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fifing t$e Incorporation of t$e journals t>(ti)erto known as “ fffjc metrical Press ”

anH “Wt metilcal Circular.”

Jl SEccklg Journal

OF

MEDICINE AND MEDICAL AFFAIRS.

FROM JULY TO DECEMBER.

1907 .

LONDON: 8 HENRIETTA STREET, STRAND; DUBLIN: 16 LINCOLN PLACE.

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Jan. i, 1908.

INDEX.

INDEX.

VOL. LXXXIV NEW SERIES. (VOL. CXXXV OLD SERIES.)
JULY TO DECEMBER 1907.

ARTICLE! (LEADINQ).

Accuracy of thought in medicine,
»34

Alleged crisis in the medical pro¬
fession, 404

Anaesthetics m hospitals, 433
Bristol infirmary, deadlock in, 433,
459

Burns, Mr. John, on the nobility
of the medical profession, 309
City methods of philanthropy, 135
Clifford v. Timms, 567
Cult of the child. 160
Dabbling with human ailments, 653
Deaths under anaesthetics, 3
Do medical men assist in the sale
of proprietary medicines, 366
Feeding of school children, 679
Fires in hospitals, 484
General Medical Council, a portent

General Medical Council and Dental
Companies Bill, 52
" Grip of the specialist, the,” 405
Health, public, in India, 183
Hospital funds and local hospital
practice, 78

musing problem in Dublin, 37
Industrial dangers, some, 184
King Edward's -hospital fund for
London, 36

Lister, Lord, and the freedom of the
City of London, 3
London University crisis, 634
Medical department in the Board
of Education, 398
Medical officers’ report to the Local
Government Board, 51a
Midwives in default, 678
Plurality of hospital appointments
35*

Poor-law, medical, 335

Quack medicine, campaign against,

• 104

Quackery, a blow to, 513
Rights of hospitals in compensation
and other claims, 538
Sanatoria for consumptives, ra¬
tional economy of, ao8
School medical inspection, experi¬
ment, in, 33*

Sheffield Union Infirmary, deadlock,
378

Supreme national health authority,
*» 3*4

Trypsin treatment of cancer, a
claim to priority in, 593
Tuberculosis problem in Ireland,
458

Vivisection, third report of the
Royal Commission on, 379

ARTICLES (SPECIAL).

British Medical Association, annual
meeting, 134, 151, 176
Dublin hospitals, 431
General Medical Council, 609
Imperial cancer research fund, 45
Kent practice since 1690, a, 231
Local Government Board for Ire¬
land, 1906-7, report of, 303
London medical exhibition, 434
Memorandum on Medical Inspec¬
tion of school children, 644
Royal College of Surgeons, annual
meeting of Fellows and Members,
588

Royal College of Surgeons, annual
report, 304

Royal College of Surgeons, election
of president, 68

Royal Sanitary Institute, meeting
of, 19

Royal visit, R.C.S.I., 63

Territorial force, proposed medical
service for, 504

Tins, destructor of disused, in the
tropics, 477

Tuberculosis Exhibition in Dublin,
4*4

Vital statistics of Ireland, 315

LINK

rURES.

E.

TITLES.

Adhesions, intra-abdominal,
Percy Pa ton, 30
Cancer of the rectum, R. Atkinson
Stoney, 30a

Carcinoma of great intestine, treat¬
ment of, Seton Pringle, 56
Deformities of the foot associated
with abduction, Edred M. Corner,
516

Disorders of sleep, Dr. Purves
Stewart, 82

Epilepsy, traumatic, treated by
operation, Thomas Sinclair, 488
Exophthalmic goitre and myx-
cedema, R. W. Philip, 55)8
! Bye, congenital anomalies of,
Sydney Stephenson, 328, 356
i Fractures at the wrist, JJ'Arcy
1 Power, 656

I High blood pressure, some of the
! organic consequences of, Dr.
1 Leonard Williams, 6
i Infantile diarrhcea, Dr. G. F. Still,

| 312

Laceration of the female perineum,
consequences and treatment of,
j Dr. R. J. Kinkead, 188
1 Lingering labour, Dr. James Morri-
| son, 370

Liver, enlargements of, Dr. W. Hale
White, 408

Otosclerosis, Macleod Yearsley, !>28
Ovaries, belated, value and fate
of, J. Bland-Sutton, 108
Puerperium, prevention of fever in,
Dr. H. O. Nicholson, 462
Serum treatment of typhoid fever
Dr. Chantemesse, 682
Sphygmomanometer in medicine,
Dr. R. Saundby, 382
Tabes, abortive forms of, Prof. F.
Raymond, 236

Treatment of the insane, Dr. G. H.
Savage, 164

Treatment of suppurative otitis,
Dr. R. H. Woods, 138
Tubercular diseases of the knee-
joint, &c., R. L. Swan, 342
Uremicmeningitis, Prof. R. Lepino,
436

AUTHORS.

Bland-Sutton, belated ovaries, 108
i Cnantemesse, Dr., serum treatment
I of typhoid fever, 682
; Comer, Edred M., deformities of
! the foot, 316

Kinkead, R. J., female perineum,
I laceration of, 188
1 Lepine, Prof. R., uraemic menin-
! gitis. 436

Morrison, Dr. James, lingering
labour, 570

Nicholson, Dr. H. D., puerperium,
I prevention of fever in, 462
1 Paton, E. Percy, abdominal ad-
; hesions, 30

| Philip, Dr. R. W., exophthalmic
t goitre and myxoedema, 598
j Power, D’Arcy, fractures at the
wrist, 636

! Prmgle, Seton, carcinoma of great
■' intestine, 56
Raymond, Prof., tabes, 236
' Saundby, Dr. R., sphygmomano-
: meter in medicine, 38a

Savage, G. H., treatment of the
insane, 164

Sinclair, Thomas, traumatic epi¬
lepsy treated by operation, 488

Stewart, Purves, disorders of sleep,
82

Stephenson, Sydney, congenital
anomalies of the eye, 328, 356

Still, Dr. G. F., Infantile diarrhoea,
212

Stoney, R. Atkinson, cancer of the
rectum, 302

Swan, R. L-, Tubercular diseases of
the knee-joint, &c., 542

White, Dr. W. Hale, enlargements
of the liver, 408

Williams, Leonard, high blood
pressure, 6

Woods, R. H., suppurative otitis,
138 «

Yearsley, Macleod, otosclerosis, 628

EOORDi.

Acute nephritis and scarlatina, 390
Belfast Hospital for Children, cases,
663

Cyst of the clitoris, 90
Fibro-myoma of the vagina, 89
Ovaries and vermiform appendix,
malignant disease of, 118
“ Siamese twins,” case of birth of,
38

OORRE8PONDENOE FOREION.

Austria—

Aggression and toxin, 122
Angioma arteriale racemosum,
669

Aorta, obliteration of, 392
Atoxyl and syphilis, 42
Atoxyl in relapsing fever, 420
Balantidium coli, typus malm-
sten, 367

Bier's suction treatment, 696
Bigemina, spontaneous, 313
Cancer, origin of, 421
Cardia-cardnoma of the stomach,
66

Cardiac insufficiency, 383
Cataracta compliesta, 17
Caustic soda, erosions from, 121
Cerebellar tumour, 041
Circulation, physiological and
pathological, 17
Cirrhose bronz^e, 585
Cirrhosis, experimental and
tubercle, 150

Collum anatomicum humeri, 323
Concurrent antagonistic bodies,
3 i 3

Congenital cerebral motor de¬
fects, 249

Cranio-plastic operations, 669
Crystal, curious, 421
Diagnosis of cerebro-spinal me¬
ningitis, 366

Displacement, abnormal, 641
Embolism of pulmonary artery-
696 ’
Female structure, 421
Fistula gastrocolica, 615
Foreign body in_trachea, 613
Gall-stone colic, 121
Giant growth, a, 556
Glaucoma, 529
Hematoma. traumatic, 6x3
Hernia, radical cure of, 393
Hirschsprung’s disease, 43
Hypertrichosis, 556
Hypoplasia of the aortic system,

585

Icterus, pleiochromic, 294
Inguinal glands and tubercle,130,
Injury to the neck with paralysis,
199

r Ischialgia and infiltration, 69b
Lead poionning, 696
Lipoid, bactericide, 248 .,

j Lipomatosis, 122

Loew, Dr. Anton, death of, 367
Lymph and glycosuria, 669
Lymphatic leucbcvthiemia, 392
Monoplegia, simulated, 94
Meningococci serum, 174
Mental moral weakness, 313
Mongoloid idiocy, 392
Necrosis of bone, 556
Optic aphasia, 383
Osteopatny, 640
Pancreas, a new function of, 199
Paralysis, stationary, 313
Pempnigus contdgiosus, 069
Perl-cyst, 615
Pes varus, 17
Phosphorus necrosis, 223
Physiological lines on nails, 130
Poliomyelitis, 641
Politzer, retirement of Professor,

Polyneuritis and bacterium coli,
420

Quadrigemina region, disease in,
174

Radiation and necrosis, 333
Radio-tnerapy of tne iscnias, 669
Scapular rhombus, 17
Sclerosis, multiple, and urinary-
trouble, 385

Spondylitis infectiosa, 43
Squint, hereditary, 249
Stomach, contractional pheno¬
menon of, 66

Stomach, histological changes of,
121

Swimmers and albuminuria, 342
Syphilis and valvular disease,
615

Tenia cucumerina, 669
Tar and nephritis, 130
Therapeutics, cerebro-spinal, 314
Thrombosis arterie vertebralis.

Tulal pregnancy with melcna,
34*

Tubercle, diagnosis of, 43
Tuberculosis, 448, 500, 330
Ureters, cystic, widening of, 17
Uterus, carcinomatous, extirpa¬
tion of, 223

Vaccination, secondary, 174, 556

France—

Abortion, 347
Adenitis, cervical, 311

Anglo-American Medical Society,
the Continental, 498
Artificial abscess, 554, 614
Astuma and atropine, 640
Bier, the method of, 221
Broncho-pneumonja in young
children, 554

Cancer of the stomach, origin and
treatment of, 447
Colloidal silver, 039
Coryza in infants, 366
Diazo-reaction, 341
Dilatation of the stomach, 419
Diphtheria, paralysis of, 65
Drainage in gynecology, 365
Exophthalmic goitre, 173, 197
Gastric ulcer, treatment of, 583
Gonorrhoea, treatment of, 391
Hemoptysis, treatment of, 584
Hyperemia of the pharynx, 391
Infantile eczema, 16
Intertrigo in the adult, 222
Malpraxis, sued for, 120
Metritis, treatment of, 41, 65
Mushroom poisoning, 366
Obesity, 293

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iNDEX

fKdcma, acute, o the lungs, 498
Ostrich stomach. 120
Pain, origin of, 65
Peruvian balsam, 391
Pnlegmasia alba dolens, 328
Pregnancy, extra-uterine, 03
Procreation of sexes at will, 121
Retention of urine, treatment of
acute, 474

Rheumatism, acute, and the
thyroid gland, 93
Rontgen rays in malignant tu¬
mours, 499

Sea-water treatment, 341
Syphilis, treatment of, 16
Thiosinamin in heart disease, 614
Thiosinamin, injections of, 420
Thyroid insufficiency, 528
Tongue, atrophy of, 31X
Typhoid fever, early diagnosis
of, 120
Unemia, 667

Vegetations on the genital organs,
16

Vomiting, treatment of, 448
Warts, 312

Germany—

Abdomen, injuries to by blunt
force, 555

Atresia, multiple intestinal, 198
Bence-J ones, albuminous bodies,
669

Bladder, contracted, and its
treatment, 198

Bladder, intraperitoneal rupture j
of, 420

Buttermilk, feeding of infants ;
with, 94

Cerebral arachnitis, circumscribed (
adhesive, 121

Cerebrospinal meningitis, epi- j
demic, 448

Cerebro-spinal meningitis, throat |
affections in, 248

Chlorate of potash, poisoning by, ■

Cystfc disease of the bones, 312 ^
Dagger thrust, extraordinary re¬
sults from, 16

Diapnragmatic hernia in a f etus,
69s

Displacements of the uterus
backward, treatment of, 322
Education, report, 392
Bscarine, 93
EwakL, Professor, 615
Fundus oculi and middle-ear
symptoms, 640

Gout, treatment of by hydro¬
chloric add, 6x4

Guinea-pig infected with human
tuberculous sputum, 695
Haemorrhages, recurrent, 121
Immunisation in tuberculosis,

584

Immunisation of guinea-pigs
against tuberculosis, 341
Laryngeal tuberculosis in preg¬
nancy, 392

Lymphatic tumours of the sto¬
mach, 93

Metals, influence of, on gastric
secretion, 3x2
Midwives, 668
Mikulicz's disease, 312
Mineral waters ana the digestive ;

tract, 448
Neuronal, 294
Ochronosis, 341

(Esophagus, dilatation of, opera¬
tive treatment, 65
Operations for perforated ulcers
of the stomach, 420
''-Opium in acute peritonitis, 499 1
Otitic pyaemia, 294
Pancreas, acute inflammation of,
420

Percussion of the lungs, 366
Periarteritis nodosa and syphili¬
tics, 669

Plethora vera, 366
Pulsating exophthalmos, 695
Pylephlebitis complicating peri¬
typhlitis, 420
Rectum, tumours of, 615
Resection of stomach, complica¬
tions after, 66

Reversion in embryonal blood,
formation and the origin of
malignant tumours, 3x3
Skull, serious injury to, 640
Sleep of school children, 668
Syphilis and serum, 614
Tetanus, treatment of, 474
Tonsils, physiology of, 439
Transplantation of tendons, 17

| Treatment of neuralgias by in¬
jection, 695

Tuberculosis immunisation pro¬
cess, 392.

Tuberculosis, etiology of, 500
Tuberculosis investigation, 42
Urinary bladder, total extirpa¬
tion of, 149

Wounds' penetrating, of gastro¬
intestinal tract, 640

Hungary—

Appendicitis, internal treatment
of, 641

Cancer of intestinal tract, 122
Chronic nephritis, chemistry of,
670

City poor, care of, 314
Clean milk movement in Buda¬
pest, X22

Erysipelas serum, efficaciousness
of. 641

French doctors in Budapest, 249
Laceration of the perineum,
immediate repair of, 3x4
Negligence, gross, of two forensic
doctors, 249

Paralysis progressiva juvenilis,
*75 . . .

Physosttgmine in intestinal pa¬
resis, 641

Pulmonary embolism, 314
Purpura, Henoch’s, 314
Pyramidon in tuberculosis, 670
Sclerosis multiplex congenita, 175
Small-pox, public lecture on, jox
Spastic spinal paralysis, 173
Sterility of women, 641
Stricture of the msophagus, 670
Swellings of the testis and epi¬
didymis, X22
Syphilis on cheek, 173
Syphilis, hereditary, symptoms
of, 501

Theophyllin, 301
Tubercular reaction, value of, 314
Tuberculosis, acute miliary,
origin of, 670

Typhoid sera, agglutination of,
301

OORRESPONDENOE—HOME.

Aberdeen University graduation
ceremonial, 123

Annandale, the late Professor, 696
Assault on Dr. Carswell, Glasgow,
x8, 43

Ayr asylum, 224

Ayrshire, consumptive sanatorium
for, 421

Bangor Nursing Society, 200
Belfast District Lunatic Asylum,

314

Belfast, report of the medical officer
of health, 421

Burnett, Dr. Richard, 642
Carswell, Dr., presentation to, 502
Cerebro-spinal fever, Belfast, 617
Cerebro-spinal meningitis, Belfast,
476

Centenary of the Edinburgh Royal
Asylum, 93

Chicne, reminiscences of Professor,
449

Clinical surgery teaching in Edin¬
burgh, 421

Clinical teaching, Glasgow, 556
Consumption, prevention of, Ire¬
land, 476

Corporation and Local Government
Board, Belfast, 43
Corporation and physical degenera¬
tion, Belfast, 173

Corporation and treatment of con¬
sumption, Belfast, 393
Defective children, training of,
Edinburgh, 301
Derry County Infirmary, 449
Edinburgh Medico-cnirurgical So¬
ciety, 642

Edinburgh Royal Infirmary, 18,
4 *i. 530

Edinburgh University, three term
session in, 199

Edinburgh University, new physical
laboratory, 421

EdinburghUniversity.Lord feector's
assessor, 556

Edinburgh University, women gra¬
duates and, 585
Falkirk Fever Hospital, 696
Fatal attack on an asylum atten¬
dant, 449

Feeble-minded children in Glasgow,
care of, 501

Glasgow medical officer and the
| plague, 585

Glasgow milk supply and tubercu¬
losis, 585

Glasgow University graduation,
rowdiness. 30, 536
Glasgow University graduation
ceremonial, 122

Health of school children, Ireland,
586

Incipient insanity, treatment of,
Scotland, 641

Inebriate home, proposed, for the
North of Ireland, 586
Inebriates, problem of, Glasgow,

367

Infectious diseases, notification of
deaths from, Belfast, 224
Insane, problem of, Scotland, 393
Irish University problem, 386
Irish University question, 556
Larbert Asylum, 449
Late Dr. Howden, Haddington, x8
Lurgan and public health, 642
Macphail, Dr., complimentary din¬
ner to, 421

Medical and Dental Defence Union
of Scotland, 697

Mental disease, incipient treatment
of, Edinburgh Infirmary, 6x6, 696
Milt supply, Belfast, 557
Mullan, Dr., of Ballymena, death of

368

Mumey, Dr. Henry, death of, 249
Notification of births, Belfast, 302
Notification of Births Act,Scotland,
476

Nursing Society, Banbridge, 393
Paintings by a medical man, Bel¬
fast, 175

Plague in Glasgow, 530
Public health, Belfast, 368.330, 670
Public health posters, Belfast, 342
Queen’s College, Belfast, 342, 642
Refuse, house, Belfast, 368
Registrar-General and Registra¬
tion districts, Ireland, 586
Royal Crichton Asylum, Dumfries,
476

Royal Medical Society, Edinburgh,
501

Royal visit to Edinburgh, 95
Royal Victoria Hospital, Belfast,
449

Royal Victoria Hospital, Edin¬
burgh, 475

Rutherford, Dr., resignation of, 367
Sanatorium for Consumptives,
Dublin, 401

School cnildren, medical inspection
of, Belfast, 642

Scottish Exhibition, proposed model
hospital for, 642
Scottish orphan homes, 616
Sidlow Sanatorium, Dundee, 18
Simpson, Sir A. R„ compliment to,

95 .

St. Andrews University, rectorial
election, 502

Trinity Hospital fund appoint¬
ments, 616

Tuberculosis Exhibition, Belfast,
393 . 586, 642

Typhoid fever at Peterhead, 200
Ulster Medical Society, 530, 616
Visit of Lord Lieutenant and Lady
Aberdeen, Belfast, 50a
Woodilee Asylum, annual report,
586

EDUCATIONAL SUMMARY FOR
1S07-S.

ENGLAND AND WALES.
English Colleges—

Royal College of Physicians, 269
Royal College of Surgeons, 269
Society of Apothecaries, 269
English Universities^
Birmingham, 263
Cambridge, 262
Durham, 263
Leeds, 267
Liverpool, 265
London, 262
Oxford, 262
Sheffield, 267
Victoria, 264

Examining Board, Conjoint, Eng¬
land, 268

Extra-Academical Institutions in
London, 273

Hospitals with no medical school,
London, 274, 275

Hospitals with no medical schools,
principal provincial, 276
Introductory remarks, 260

_Jan. i, 1 908.

London Schools—

Guy’s, 270
King’s College, 271
Middlesex, 272
St. Bartholomew's, 269
St. George's, 270
St. Mary’s, 271
St. Thomas’s, 272
University College, 272
Westminster, 273
Women, 273

Post-Graduate Institutions
Metropolitan, 276
Wales, University of, 267

IRELAND.

Hospitals—

Belfast, 285
Cork, 285
Dublin, 281
Galway, 286
Licensing bodies, 277
Medical schools, 280
Public services, 286

SCOTLAND.

Carnegie trust, 288
Colleges—

Royal Colleges of Physicians and
Surgeons, Conjoint Board, 291
Faculty of Physicians and
Surgeons, Glasgow, 291
Introductory remarks, 287
Schools, &c., 292
Universities—

Aberdeen, 290
Edinburgh, 288
Glasgow, 289
St. Andrews, 290

health “WORT*-® 0 " 71 *

RENTAL.

Chatel-Guyon, 223

Nice and the French Riviera, 613

LABORATORY REPORTS, NEW
PREPARATIONS, SURQMAL
APPUANOES, At.

Allsopp’s lager, 226
Cervix uteri, new cupping instru¬
ment for, 506
Gingamint tabloid, 202
Lemonade, 226
Muscatol, Roger's, 202
Plasmon biscuits, 69
Post-nasal curette, 532
Red marrow, Armour’s extract of.

69

Slippery elm tabloids, 532

LETTERS TO THE EDITOR.

Anesthetics for unqualified den¬
tists, 503

Anti-tuberculosis dispensaries, 357
Appeal to the medical profession,

* S V

Apology, an, 423
British Medical Association, 697
“ Brown Dog " disturbances, 642,
670, 697

Cancer problem, 331
Cocaine in the morphia habit, 225
Collection of debts by debt-collec-
tors, 124, 175

Congress of school hygiene, inter¬
national, a new advance at, 200
Dental and cosmetic quacks, 67
Dental caries in childhood, medical
aspect of, 225, 295
Do medical men assist in the sale
of proprietary medicines? 617
01 i™" 3 ’ 557, 587

England and Germany, a contrast,
95

English local government, Is it a
failure ? 44

Etiouette, professional, 503
Exclusion of Scotch and Irish
diplomates from London hospi-

Eye, congenital anomalies of, 394,

General practitioner, the, 123, iso
Guild of St. Luke, 295
Harrogate waters, therapeutics of,
66

Hot water operating tables, 558
Humanitarian abattoirs, 671
Inebriates Act, 295, 343
Introductories, the, 394
Is cancer curable ? 225
Law for druggists and law fo
quacks, 276

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INDEX.

Jan. i, 1908.

Livings tone College and medical I
missionaries, 18
Maguire, the late Dr., 450, 618
Medical law, 643
Medical law and quackery, 422
Midwives’ Act, 643
Milk and tuberculosis, 176, 200,
225, 230

New era in medicine, 394
Notification of Births Bill, 394
Profession and the public, 450,671
Proprietary medicines, 643
Protection for beast, not for man,

„ 394

Quack dentists and a Royal Com¬
mission, 96

Quack medicines, the disclosure of
trade secrets, 476
Quack methods, 644
Quackery and practice by com¬
panies, 44

Quackery m drugs, 201
Quackery of quacks, 697
Royal Commission on cancer, pro¬
posed, 44

Royal Commission on quackery,

. 558 , 387

Sandow as a physician, 617
Sanitary administration, 230
Si* brothers doctors, 423
Soul, the nature of, 672
Southend and Cheltenham, 502
Southend and its medical officer of
health, 230
Spinal analgesia, 343
Teaching of physiology, 19
Therapeutical Society, 672
Trypsin treatment of cancer, latest
phase of, 586

Trypsin, who introduced ? 643
Unqualified medical practice,
Government scheme for the pro¬
motion of, 430
Vivisection Commission, 303
Voyage d'ltudes medicales, 44
Where are the police ? 368
Why let scarlet fever spread ? 587

MEDIO AL MEWS IN BRIEF.

Abortion, charge of attempted, 478
Accident, an unfortunate, 179
Action for damages by a medical
man, 129

Apothecaries’ Hall, Ireland, 373,
533

Apothecaries' Society, London, 479,1
701 '

Alltymynydd Sanatorium, 179
Army and Navy Mate Nurses
Association, 675
Assault on a medical man, 389
Asylums Board and bacteriology,
589

Bath Mineral Water Hospital, 363
Bequest, disputed, hospital, 398
Bristol, pathology in, 399
Bristol Royal Infirmary, 373
“ Brown Dog ” Memorial, Batter-
sea, 589

Caledonian Medica Society, annual
dinner, 205

Cancer Hospital, Brompton, 23
Cape doctors censured, 563
Cholera nostras In St Petersburg,
>79

City medical officer’s bereavement,
428

Conjoint examinations in Ireland,
533 .

Contamination of town milk, 701
Coombe Hospital, Dublin, 701
Cork Medical and Surgical Society,
56a

Davos Sanatorium, 74, 563
Death under anaesthesia 348, 398,
428, 646

Death under chloroform, 233, 6t8
Death under ether, 253
Death under nitrous oxide gas, 533
Dental Association, prosecution by,
45 *

Dentistry practice of and joint
stock compan es 100
Dentists, bogus in Ireland, 507
Dentists, unregistered, fined 307
Deportation of an English lady
from America, 373
Devon man's divorce, 56a
Disputed claim, 646
Dublin Hospital Sunday Fund, 333
Educational health and food cam¬
paign, 22

Epsom Col ege, annual meeting of
governors, 47

Evidence medical, conflict of,
engineer's death, 306
Exhibition, medical, 433

Expensive medicines and Poor-law j
medical officers. 589
Faculty of Physicians and T Sur-!

geons, Glasgow, 479, 533 ;

Freedom of City of Lindon con- j
ferred on Lord Lister, 23
General Medical Council, 333 1

Great Northern Central Hospital, :
428

Happy hunting ground, a, 678
Haslar Hospital, 433
Hunterian collection, 563
Inebriety, Society for the Study of,
253

Infantile Mortality Congress, 319
Infantile mortality in Poplar, 701
Inquest on Malvern medical man,

, 333

Institute of Hygiene, 129
International Congress of School
Hygiene, Second, 129, 178
Irish Medical Schools and Gradu¬
ates' Association, 563, 618
Irish University question, 562, 675
King’s visit to Ireland, 74
King and India, 205
Limerick Union medical officership
election, 362

Liverpool School of Tropical Medi¬
cine, 100

London ambulance service, 647
London Consumption Conference,

London County Council Scholar¬
ships, 429

London Hospital, 647
London hospitals entrance scholar¬
ships, 399

London Medical exhibition, 397
London Society of Apothecaries,
229

Manifesto, medical, yet another, 319
Maternity Hospital case, 348
Meath Hospital, Dublin, 429
Medals, award of for tropical re¬
search 318

Medical man accidentally shot, 307
Medical man shot by patient, 253
Medical Sickness ana Accident
Socety, 349, 563
Metropolitan Asylums Board, 348
Metropolitan Hospital, 136
Midwifery teaching in Ireland, 701
Midwives Act, 1002, 157
Midwives' Board, General, 179
Mortey, Mr., and the Indian
k Government, 229
Morphia poisoning, medical man’s
death by, 220
Motorist, a medical, 428
Murderous attack on a medical
man, 674

Normyl treatment of inebriates, 619
North east London Post-graduate
College, 101

Notification of Births Act, Dublin,
647

Oyster merchant fined, 228

Plague in India, 6x9

Prizes at London hospitals, 23

Prizes for mothers, 375

Public medical service, Birmingham,

647

Queen’s College, Belfast, 348
Queen's College, Cork, 349
Royal Academy of Medicine, Ire¬
land, 373, 4*8. 673
Royal Army Medical College, 47,

• 56 . 507 . 589

Royal College of Physicians, London
5°7

Royal College of Physicians, Edin¬
burgh, 479, 701

Royal College of Physicians, Ire¬
land, 433

Royal College of Surgeons, Edin¬
burgh, 453, 479. 7 °i
Royal College of Surgeons, Eng¬
land, 427, 561, 563, 074 . 675
Royal College of Surgeons, England,
annual election of Council, 46 ;
vacantexaminership, 47 ; Fellow
ship examination notice, 74 ;
ordinary meeting, 129
Royal College Surgeons, Ireland,
* 3 . 3 * 9 . 452 , 453 . 563 , 619 ;
Fellowship examinations, 101
Royal Hospital for Incurables,
Dublin, 74

Royal Medical Benevolent Fund in
Ireland, 619

Royal University, Ireland, 375, 453,
507

Sanatorum for consumptive chil¬
dren, 398

Sanitary Committee, 374
Sanitas, Okol, 398

Scarlet fever spreading, 533
Schools, medical inspection of, 229
Sea-water cure, 373
Sheffield midwife, 398
Sleeping sickness, 619
Society for the Relief of Widows
and Orphans of Medical Men, |
xoo, 479

Society of Apothecaries of London, :

589 I

Society of Physicians and Surgeons
of South Africa, dinner, 46
Status lympbaticus, 179
Statute of Limitations, 618
St. Bartholomew's, 349, 374, 647 :
St. George's Hospital, changes at.
675

St. John’s Hospital for Diseases of
the Skin, 47

St. Mary's Hospital, 37a.

St. Thomas's Hospital, House
appointments, 229, 619
St. Vincent’s Hospital, Dublin, 479
Struggle on a liner, medical man's,
?74

Suicide, doctor's, 74
Supreme national health authority,
a. 373

Trinity College, Dublin, 479. 507 ,
563, 589, 619

“ Tuberculosis Exhibition ’’ in
Dublin, the proposed, 319, 399,
452

Tragic death of a medical man, 136
Treatment of lunatics, 429
Tropical Medicine, School of, fur¬
ther grant to, 205
Tuberculosis in Ireland, 228
Turner, Dr. W. B., presentation to,
205

Ulster Medical Society, xot
United Services Medical Society,
101

University of Birmin4ham, dental
department, 74
University of Durham, 375
University of London, pass list, 647
University of London, the Rogers
prize, 179

Vegetarian manifesto, a, 232
Westminster Hospital, 428
Women doctors in Austria, 248
Women's National Health Associa¬
tion, 618

Workmen’s compensation case, in¬
teresting, 362

NOTES AND COMMENTS.

Academic and scientific, 593
Alcohol and cirrhosis, 566
Almost manslaughter, 393
Anti-quackery legislation in New
Zealand, 623

Apprenticeship of medicine, 257
" Art and Mystery, the,’’ 352
August congresses, 159
Australia and quack medicines, 377
Barr, Sir James, at Douglas, aj
Board of Education and its medical
staff, 297

Boot ou the other foot, 332
British Association and alcohol, 159,
160

“ Brown Dog ” and the students,
565. 593 . , , ,

Brutality, the school of, 624
Burns, Mr. John, and the birth
certificate, 258

Cheltenham and its medical officer
of health, 431

Cholera, the approach of, 259
Chops v. logic, 323
Christian science to medicine, 457
Climate and diarrhoea, 351
County Courts and debt collecting,
103

Curzon, Lord, and the plague, 183
“ Daily News ” and student dis¬
turbances, 651

Death of Sir William Broadbent,
Death of William Rae, 134 7 52
Deceased wife's sister, 29
Dentistry a la “ Daily Mail," 298
Doctor, the, as parson, 52
Doctors as dictators, 2
Dragooning versus peaceful per¬
suasion, 25

Dressed like a medical student, 51
Drink cures, 624

Education, administrative provi¬
sions, 231

Esperanto and the natural sciences,
>59

Evans Brothers, 1
Examinations for wives, 323
Financial aspect of practice, 237
Flower cure and fruit cure, 483

Fly, the shortcomings of, 331
Fraser, Sir Thomas, redivivus, 103
General Medical Council and penal
powers, 623

German legislation and its conse¬
quences, 432
Homoeopathic spas, 351
Homoeopaths again, 537
Hounslow and out-patients, 183
Hygienic sheets, 298
lei on parle francais, 431
Infant culture, 25
Inquisitorial methods at Manches-
ter, 484

Juvenile smoking, 311
Kilkenny cat position, 312
King and the School Hygiene Con¬
gress, 160

Knee, a valuable, 183
Law and logic, 208
Lawyers and collectors, 104
Limericks and insanity, 677 j
Lister, Lord, and the City, 1
Livingstone College, 2
London University election, 511
Manual skill, acquiring 1 238
Materialism v. medicine, 483
Medical boycott of duelling, 324
Medical men and sanitary officials,
51a

Medical referees and the Home
Office, 77

Medical referees and the Workmen's
Compensation Act, 26
Medical socialism and medical im¬
perialism, 77
Medical thrift, 283
Melbourne Hospital staff election,
403

Metropolitan Asylums Board and
its matrons, 458
Midwife, the triumph of, 311
Missing link, a, 26
Mulligan, Judge, and debt collect¬
ing, 184

Mulligan, Judge, and paid agents,
104

Municipalised medical man, the,
and the municipal hospital, 133
Museum specimens, property in,
537

Nose, a, not ducal, 394
Notification errors, 677, 678
Notification of Births and other
Acts, 232, 403
Official mind, the, 78
One inspector, one microbe, 51
Opinion and practice, 208
Other side of the lantern, 77
Pittsburg and appendicectomy, 207
Plea for justice, a, 438
Politzer, retirement of, 432
Precipitation, abundant, 207
Public Health Acts, 231
Radium for everything, 377
Referee, the medical, begins, 183
,, Return” case, a, and its result,
.133

Rice treatment, 677
Roll of Merit, 677
Rosy side, the, 258
Royal order of motherhood, 207
School Hygiene Congress, 133, 160
Science ana British citizenship, 1
“ Self protection,” 565
Silica in infinitesimal doses, 331
Small holdings, 231
Snobbery ana abuse, Star, 652
Socialism and medicine, 403
Southend v. Dr. Nash, 323, 431
Speed limit, the, 437
“ Standard ” and medical butchery
651

Surgeon and butcher, 51
Tact, 258

Temperance research, 378
Tomato putrifiee, sit
Triplets and trouble, 207
Unenglisb, libellous, and provoca¬
tive, 65a

Usque ad aras, 438
Vivisection Commission's difficul
ties, 437

Vivisection horror, 404
Whooping-cough parties, 78
Wisdom, manifestations of, 298
Worcester C.C. and medical inspec¬
tion, 538

Work cure, the, 103
Wyrley outrages, 232

NOTES ON CURRENT TOPICS

Adequacy of fines, the, 54
Alcohol and mountaineering, 233
Alcohol manifesto, an echo of, 28
Alternative drink for alcohol, 680

OteMlu.

INDEX.

Jan. i, 1908.

A ma l gama tion of the Obstetrical
• ana Gynaecological Societies, 79
Anesthetic fatalities in London
1 -^hospitals, 406

Aiuesthet cs, administration oi for
unqualified persons, 487
Aiuesthet cs for unqualified
“ dentists,” 460
Anti-vaccinist mare's nest, 137
Anti-vivisection Hospital and the
, .Sunday Fund, 354
Appendicitis and plum pudding, 634
Army medical training and civilian
doctors, 626

Army reform and the medical
profession, 434
Asylums report, a costly, 584
Athletics, college, 407
Bacteria and the tram ticket, 5
Belated ovaries, efiects of, 103
Birrell, Mr., and the tuberculosis
problem, 485
Birthday honours, 514
Bishop, a, upon toothache, 485
Bob Sawyer redivivus in Paris, 341
Bowls, tne beatitude of, 353
Breathing appliances in mines, 136
Bristo Infirmary dispute, 539, 567
British Medical Association and its
Charter, 654

British Medical Association and the
General Medical Council, 103,161
“ Brown dog ” disturbances, bSi
Bums, Mr John, and gratuitous
medical service, 162
Butchers and tuberculous meat, 406
Camphor eating, 136
Candour between physician and
patient, 623

Cardigan cancer “ curers,” an
Carnegie’s, Mr., gift, i6x
Cerebrospinal meningitis in London
notification of, 233
Cheltenham, victory at, 625
Chicago in England, 300
Childlessness, a prescription for, 183
Colonial appointments, 395
Consultants and specialists, lists of,
28

Consumption, a new remedy for,
595

Consumption in West Wales, 486
Consumption and breach of promise
of marriage, 326

Consumption in the Hebrew race,
3*7

Copper in spinach, 681
Dakhyl v. Laboucbere, 340
Deaths under anesthetics, 234
Dearth of medical men, the alleged,

434

Deficient mortuary accommoda¬
tion, 380

Dentistry, economical Poor-law, 300
Dirty Dublin, 596
Disinfecting dangers, 137
Divorce, specific cruelty in, 433
Drilling in schools, 80
Dublin hospitals and tuberculosis,
541

Earth fertilisation by seed inocu-
Klation, 339

Easton's syrup, death from, 210
Engine drivers and medical exami¬
nation, 460

Englishman’s, an, breakfast, 79
Eskimos, the extinction of, 653
Fainting fit in criminal assault, 334
Fees for certicates under Work¬
men's Compensation and Educa¬
tion Acts, 106
Finger licking by clerks, 161
For London or for the United
Kingdom, 53

Fourth of July fatalities, 105
Fungi, edible, 326
Germany and patent medicines, 323
Gladstone, Mr., and alcohol, 210
Haflkine, »Mr., and the Indian
Government, 135, 301
HalifaxHospital controversy ended
8° .
Hammersmith and lady health
visitors, 486
Heroism, medical, 461
Hospital building craze, 186
Housing problem in Ireland, 4
Housing Reform Congress, 5
Hygiene of the swimming-bath, the

i°6 ,

Inaccurate prescriptions, 680
Indian methods for delirious pa¬
tients, 369

Inebriates’ homes, 233
Infantile mortality in Durham, 313
Infantile mortality at Hudders¬
field, 634

Infection, emotional theory of, 300
Infection from old bottles, 210
Ingenious milkmen, 54
Instruction for mothers, 53
Irish Local Government Board and
consultants' fees, 439
Irish Poor-law reform, 655
Irish University question, 627
Japan leads the way in school in¬
spection, 162

King Edward Fund bill, 4
Kippers, incriminated, 680
Koch, Professor, and the croco¬
diles, 486

Lead as an abortifacient, 162
Leadless glaze, 106
Local Government Board and
medical salaries, 187
Lord Mayor and Cripples’ Home,
326

Manchester epileptic colony, 681
Manifesto, an echo of a famous, 299
Maternity homes and syphilis, 325
McKenna, Mr., and school hygiene,
80

Medical arrangements on American
liners, 136

Medical examination of children for
factory work, 626
Medical man shot dead, 234
Medical papers and the lay press,
186

Medical officers of health and
security of tenure, 354
Medical practice by companies, 34
Medical referees and women, 163
Medical referees and Workmen's
Compensation Acts, 106
Medical service, a public, 681
Medical student of to-day, 568
Memorandum of the medical de¬
partment of the Board of Educa¬
tion, 567

Midwives' Act, the, 380
Midwives’Act, defaulters under, 635
Milk contamination, 433
Motor cars and dust, 27
Motor club, a medical, 486
Motoring and the opsonic index, 107
Mountain sickness, 625
Nightingale, Florence, O.M., 596
No man's ground of the milkman ,

379

Norman Kerr memorial lecture, 461
Notification of disease, the, 137
Open-air school-room, an, 105
Patent medicines in the Antipodes,
568

People and the hospitals, 397
Performing lions and their per¬
formance, 162

Pharmacy prosecution, a, 136
Plague in Glasgow, 314
Plague in India, 80
Poison epidemic in Essex, 325
Poisons m sweetmeats, 360
Police and the medical profession,

380

Police-court psychology, an ad¬
vance in, 81
Pollution of rivers, 314
Premature burial, 28
Prime Minister, the, and the Royal
Commission on Cancer, 3
Property in dead bodies, 569
Public health parliament, proposed,

Pu^Uc Health Act, the new, 186
Public health in Ireland, 239
“ Quarterly Journal of Medicine,"
461

Radium, a substitute for, 29
Railwaymen, the long hours of, 3
Rayner, mental condition of, 354
Register 1 Register 1 Register 1 355
Research scholarships on eSects of
alcohol, 406
Roof gardens, 211
Rotunda Hospital, Dublin, opening
of new wing, 234
Round robin, a, 340
Royal College of Surgeons, annual
election to the council of, 27
Royal Commission on scarlet fever,
suggested, 653
Sandow as physician, 368
Sanitary Committee, a model, 314
Sanitation in Irish schools, 340
Sarcoma and the Compensation
Act, 368

Sausages, boric acid in, 483
Scarlet fever and sanitary science,
353

School Board medical certificates,
460

School Hygiene Council, a per¬
manent international, 187, 333

Science, value of in Montgomery,
233

Scotch judge, a, on the liabilities of
chemists, 29
Sea-water cure, a, 486
Sheffield Infirmary trouble, 354,433
Shrewsbury railway accident, some
medical aspects of, 434
" Siamese twins," 28
Sign of the times, a, 339
Slums and coroners, 653
Smoke and disease, 327
SouL the nature of, 627
Spotted fever as a test of local
sanitation, 434
: Spurious sports, 396
I State medical attendance, 186
j Strait jacket in the workhouse, 381,

Sylvester's method v. Schafer’s, 340
Teaching of hygiene in elementary
schools, 4

Town water supplies, 626
Tradesmen’s wrappers, 368
Tropical medicine, certificates in,

Tuberculosis and the Irish Govern¬
ment, 596

Tuberculosis in pigs,a source of, 326
Tuberculosis ana work on farms
*34

Tuberculosis Exhibition in Dublin,
*35. 407, 315

Typhoid epidemic at Peterhead, 209
Unvaccinated teachers, 406
Urticaria and military service, 210
Vaccinationist, an imperial, 299
Veterinary College ana unqualified
practice, 379

Workhouse scandal, a, 680
Workmen’s Compensation Act re¬
ferees as witnesses, 381
Year’s trade accidents, a, 54

OBITUARY

Ann an dale. Prof. Thomas, 698
Beiiham, R. Fitxroy, 539
Bennett, E. H., 45
Bradbury. Arnold F., 343
Broadbent, Sir W. H., 67
Brown, W. H., 201
Carter, R. W., Deputy-Surgeon-
General, 477

Clark, Charles Mackinnon, 313
Davies, Thos. Glasbrook, 672
Day, Dr. W. H., 277
Dolan, Thomas Michael, 477
Drysdale, Dr. Chas. R., 644
Dunsmure, James, 96
Elliott. Dr. G. F., 423
Forsball, Francis Hyde, 96
Gairdner, Sir William Tennant, 19
Gamer, John, 559
Gray, Andrew, 251
Harrison, John M., 19
Harvey, Fleet-Surgeon Frederick,
558

Hudson, Dr. Arthur C., 393
Hutchinson, Sir Charles F., 338
Jenkins, Josiah Robert, 343
Latham, Charles, 43
Lochrane, Dr. Frank, J., 368
Logan, Thomas, 313
Margrave, Malcolm L., 201
McDowell, Edmund G., 123
Naime, Stuart, 315
Owen, Alfred Lloyd, 96
Paton, Dr. Robert J., 388
Pirie, John, 151
Pirrie, Dr. A. Mac Tier, 358
Preston, Alexander Francis, 123
Scott, William, 45
Settle, Robert, 45
Stewart, Prof. Charles, 368
Stolterforth, Dr. H., 423
f rotter, R. de Bruce, 644
Watson, Sir P. Heron. 698
Whitchurch, Major H. F., 226
Wilders, John St. Swithin, 343
Williams, Charles, 201
Williams, John, 230
Williams, Dr. J. L., 698
Wright, Dr. E. A., 4*3
Wrigley, William Sugoen, 19

on

iu

Great Northern Hospital—
Cystotomy, 8tc., 495
Double osteotomy of the femur,
9 °

Fracture of lower end of humerus,
221

Pelvic and subphrenic abscess,
418

Kensington General Hospital—

• Nephropexy, spinal analgesia, 17c
King's College Hospital—
Encephalocele, 443
“ Haemorrhagia Necrosis " of can¬
cellous bone, 340
Ruptured gastric ulcer, 197
Hospital por Sick Children,
Great Ormond Street—
Supra-pubic cystotomy, 379
North-West London Hospital—
Maxillary antrum,chronic abscess
of, 3*5

Royal Free Hospital—
Appendicitis, 63
Bronchial cyst of neck, 13
Cholecystectomy, 243
Hydrocele, radical cure of, 331
Intestinal obstruction, 390
(Esophagus, malignant disease of,
47 i

PirogofTs amputation, 364
Thoracotomy, 39
Tumour of breast, 699
Royal Southern Hospital,
Liverpool—

Intestinal obstruction, recurrent,

St. Metre's Hospital—

Partial excision of the bladder,
148

St. Thomas's Hospital—
Amputation of thigh for senile
gangrene, 311

Victoria Hospital por Children .
Peritonitis and sloughing of
appendix, 663
West London Hospital—

Iliac colostomy, 635
Westminster Hospital—
Cholecystectomy, 472
Nerve transplantation, 119
Removal of rectum, 603

ORIQINAL PAPERS

Anti-putrescent medication by spe¬
cially selected lactic organisms,
Dr. M. Dutour, 1x7
Auto-deformities of the foot, Dr.

Paul Gallon, 169
Beginnings f disease, Lione 1 Tayle r,
336

Blindness in children, definition of,
Dr. A. Bronner, 239
Calcium salts, use of, Dr. S. J.
Ross, 2391

Cancer and its treatment. Dr. J. A.

Shaw-Mackenzie, 61
Children, physically defective, &c.,
R. C. Elmslie, 415
Circulatory and muscular systems,
Dr. Alex Good all, 634
Contagious diseases and school
attendance, Sir Shirley Murphy,
306

Death from hemorrhage. Professor
Hendrick, 401, 318, 347
Dental caries m childhood, medical
aspect of, Dr. G. F. Still, 170
Dilatation of the cervix, artificial,
Dr. Robert Jardine, 303
Diphtheria and schools, Dr. James
Niven, 632

Disinfection, chemical and bacterio¬
logical, S. Rideal, 192
Diseases and displacement of the
testicle in childhood, D'Arcy
Power, 333

El. uvation and sparking, high-
frequency, for malignant tumours
Dr. J. A. Riviere, 601
Evian, mineral waters of, treat¬
ment of urinary disorders by
Dr. J. Grisel, 217
Eye strain, H. C. Mooney, 687
Feeding infants on sterilised whole
milk, Dr. M. P. Kerrawalla, 464
Fractures of the shaft of the feinut^
Sir Thomas Myles, 35
Friedreich's ataxia, and syphilis,
George Pernet, 60
Gastrojejunostomy and regurgitant
vomiting, K. W. Monsarrat, 602
Gelatins, choice of, for bacterial
culture media, T. Thorne Baker,
60

General practitioner, J. Lionel
Tayfer, 34, 38, 85
Government scheme to promote the
unqualified practice of medicine,
Dr. J. C. McWalter, 36a
Gynaecological progress, twenty
years of, W. D. Spanton, 88
Headaches and their causes. Prof.

Friedrich Pineles, 113
Infant mortality, reduction of, Dr
Henry Kenwood, 194

Jan. i, 1908.

INDEX,

ntfle paralysis, recumbency in
the treatment of, Dr, A. B.
Judson, 494

Interstitial keratitis. Dr. Sydney
Stephenson, 684'

Intestinal obstruction, post-opera*
tive, R. T. Johnstone. 438
Intracranial tumour, indications
for operation in, Dr. J. S. Rtsien
'•Russell, 191

Lieamentum pectinatum iridis, &c„
Dr. Thomson’Henderson, 343
Medical service, new, for territorial
■^armv. Sir Alfred Keogh, 66a’
Medical supervision of secondary
schools in Sweden, Gottfrid
TorneH, 335

Middle-ear, suppurative disease of,
B. Malcolm Stockdale, 34a
Milk in relation to human tubercu¬
losis, Henry B. Armstrong, 145
Mucous membranes, colour of.

Dr.’A. Haig, 630
Nasal polypi, determining cause of
the formation of, Dr. Eugene S.
Yonge, 143

Neurasthenia, a birdseye view of,
Dr. M. Marc, 307
Notification of diseases, suggested
improvements in, Dr. J. C.
Mewalter, 115

Observation of disease, Dr. J. O.

Affleck, sax .

Operation for oblique inguinal
hernia, G. L. Chiene, 52a
Paralysis, progressive, Dr. Karl
Heilbronner, 338

Physiological sins and a health
conscience, Dr. J. C. McWaher,

344

Plea, a. for accuracy of thought in
medicine. Dr. W. Hale White, 139
Pleural effusion and its treatment,
Sir James Barr, 489
Poor-law and sanitary administra¬
tion in Ireland, Sir Charles A.
Cameron, 86

President’saddress,annual meeting,
British Medical Association, Dr.
Henry Davy, 111
Profession of medicine, its future
work and wage, Dr. W. Ewart,

Puimtomy, Dr. Thomas Wilson,

Public medical services, co-ordina¬
tion of, Dr. Arthur Newsholme,

Pseudo-rheumatism of toxic origin
Dr. M. S. Lassange, 384
Rashes, haemorrhagic, George Per-
net, 440, 463 _ , _

Rheumatoid arthritis, Dr. Arthur P.
Luff, 167

Rhinorrhoea in faucial diphtheria
Dr. J. D. Rolleston, 10
Rontgen rays, Dr. Emil Epstei n .
688

School ’attendance and ill-health
Dr. F. J. Poynton, 218
Spinal Analgesia. E. Canny Ryall.

659 ,

Spinal curvatures, some medica’
aspects of, Dr. G. W. F. Mac-
naugh ton, 437

Sodo-keratosis, Dr. R. W. Brima-
combe, 413

Syphilis, abortive treatment of.

Prof. R. Duhot, 573
Syphilis, treatment of. Dr. E.
Lesser, 661

Syphilis, treatment of tertiary, Dr.

M. Von Zeissl, 414
Thoracic lympho-sarcoma. Dr. Job-
son Home, ais

Trypsin, a word for, A. K. Matthews
363

Tuberculosis and Irish death-rate,
W. R. Macdermott. 690
Tuberculoais in Ireland, R. F.
Tobin, 386

Tuberculosis, limit of mortality j
from, W. B. MacDermott, 333
Tuberculosis, prevention of, m
Ireland, R. B. Matheson, 369
Tuberculous children, care of. Dr.

T. N. Kelynack, 14a
Tuberculosis in childhood and its
relation to milk/Dr. John' M’Caw,
57 *

Typhoid fever, treatment of, Dr
B. SUdebnann, 8
Uremia, Dr. Alfred E. Russell, 13
Urinary calculi, the spontaneous
fracture of, Dr. T. R Bradshaw,

I 38*

OUT PATIENTS’ ROOM

Children's Hospital,Paddington
Grken—

Inguinal hernia in an'infant, 603
Thumb, habitual dislocation of,

364

French Hospital—

Columnar carcinoma and white
1 swelling at the wrist, aao
Great Northern Central Hos¬
pital—

Congenital elevation of the sca¬
pula, Sprengel’s deformity, 119
King's College Hospital—
Pott's fracture, 635
Metropolitan Hospital—
Chlorosis and early tuberculosis,
310

Minor degrees of shock, 578
Royal Free Hospital—
Colotomy for intestinal obstruc¬
tion, 171

Epithelioma of the cheek, new
operation, 551

Osteo-periostitis .congenital
syphilitic, 443

Thboat Hospital, Golden Square
Foreign body in the nose, 417
* Foreign body in'the larynx, 418

PERSONAL NOTIONS

Pages 3, 29, 35. 8r, 107, 137. *63.
187, 211, 235. *59. 301. 3*7. 355,
381, 407. 435. 461, 487. 5*5. 54*.
569, 597, 6 7. 653. 381

REVIEWS OP ROOKS AND
LITENARY NOTES

Alcohol and mankind, Sir V.

Horsiey and Mary D. Sturge, 345
Anesthetics, Dudley W. Buxton, 69
Anesthetics, practical, H. E. G.
Boyle, 370

Analysis of water. Dr. J. C. Thresh,
226

Anatomy, applied, surgical, Sir F.
Treves, 339

Anatomy, manual of, Dr. A. M.
Buchanan, 395

Antiseptic methods, H. Upcott, 531
Auscultation and percussion, Dr.
Samnel Gee, 396

Blood stains, &c., W. D. Suther¬
land, Major, I.M.S., 531
Brain surgery, C. A. Ballance, 70
Canadian Journal of Medicine and
Surgery, 478

Children, disease in. Dr. G. A.
Sutherland, 33a

Clinical surgery, lectures on, C. B.
Lockwood, 370

Consumption, pulmonary, modem
treatment of, Dr. A. Latham, 332
Dermatology, Dr. W. Allen Pusey,
4*5

Dictionary of medical diagnosis,
Dr. H. L. McKisack, 344
Digestive system, the, Dr. J. L.
Salinger, 396

Drink problem, the, Dr. T. N.
Kelynack, 344

Everybody’s doctor (illustrated
serial), 478

Eye, diseases of, Samuel Theobald,
97

Eye injuries. Dr. Maitland Ramsay,
369

Functional nervous disorders in
childhood. Dr. L. G. Guthrie, 698
Gem-cutters’ craft, Leopold Clare¬
mont, X34

General surgery, Dr. Gustavus P.
Head, 3x8

Gout, Dr. A. P. Luff, 370
Hair and its diseases, Dr. David
Walsh, 559

Health, laws of, Dr. C. C. Douglas,
506

Hio disease, treatment of. Dr. P.

Bruce Bennie, 395
Household emergency and reference
chart, Major R. J. Blackham,
672

Human physiology, R. Tigerstedt,

ln& x catalogue, Surgeon-General's
office, U.S.A., 359
Inflammation, Adams on, 178
International clinics, 395
Intussusception, C. P. B. Clubbe,
53*

Larynx, diseases of, Harold Bar-

well, 4*5

Leamington Spa, 478

Massage, M. D. Palmer, 371
Materia medica and pharmacy, Di.

W. Hale White, 371
Medical annual, Wright’s, 371
Medical electricity, H. Lewisjones,
*54

Mind and the nervous system,
Auguste Forel, 178
Nerve diseases, Dr. L. A. Clutter-
buck, 559

Nose and pharynx, diseases of,
James B. Ball, 69
Nursling, the, Pierre Budin, 317
Organic nervous diseases, diagnosis
of, Dr. Christian Hester, 699
OrthopaBdic surgery. Dr. Royal
Whitman, 317

Pathology, text-book of, A. Stengel,
20

Pathology, Guthrie McConnell, 154
Physical diagnosis, Howard Anders,
97

Physician as naturalist, Sir W.
Gairdner, 478

Pneumonia, Dr. D. W. C. Hood. 672
Pneumonia, acute, Dr. Seymour
Taylor, 478

Poisoning, what to do, Dr. W.
MurreU, 505

Polypus, Dr. E. S. Yonge, 306
Post-graduate studies, Dr. H. H.
Scott, 505

Prescription writing, Dr. M. Mann,
506

Prevention of infectious diseases,
Dr. J. C. McVail, 6o8
Rectal diseases, Harrison Cripps,

369

Rontgen rays, R. Higham Cooper
226

Royal Academy of Medicine, trans¬
actions, 531

Royal College of Surgeons calendar,
478

Sanitary engineering and water
supply, L. F. Vernon-Harcourt,
70

Self-synthesis, a means to perpetual
life, Cornwall Round, 672
Sigmoidoscope, P. Lockhart Mum¬
mery, 371

Skin diseases, Dr. H. G. Adamson,
3*7

Skm diseases, Arthur Whitfield, 70
Some successful prescriptions, Dr.

Herbert Hart, 559
Surgical instruments in Greek and
Roman times. Dr. J. S. Milne, 646
St. Thomas’s Hospital reports, 345
Tics and their treatment, Henry
Meige and E. Teindel, 318
Travels through France and Italy, j
Smolletx. 646

Treatment, on, Dr. Harry Camp¬
bell, 344

Tuberculosis, the reaper, Dr. F.
Barbary, 370

Tumours, books on, W. Sampson
Handley, Charles W. Cathcart,
J. Bland-Sutton, 123, 126
Ulceration of the cornea, Angus
Macnab, 369

Urinary surgery, diagnosis in, Dr.

E. Deansfey, 506
Ventilation, 478

Wife, the. her book, Haydn Brown,
478

Worry, philosophy and pathology
of, C. W. Saleeby, 71

TRANSACTIONS OP SOCIETIES.

British Balneological and
' Climatological Society—
Blood pressure in Spa practice.
695

British G yn-ecolocicalSociety—
Myoma of unusual interest, 92
Specimens, 91

Valedictory address of the pre¬
sident, 92

Central Midwives Board—

Fees of medical men, 639
Disease in Children, Society for
the Study of—

Acute arthritis, 38a
Alopecia, generalised, 497
Amaurotic idiocy, 497
Associated movements of upper
eyelids and jaw, 497
Dislocation of hip, 582
Fractured jaw, 38a
Genu recurvatum, 497
Heart disease, congenital, 498
Inherited syphilis, 692
Intention tremor, 382
Lymph adenoma, 382

I Lupus vulgaris of the face, 497
Lupus vulgaris, multiple, 497
j Obesity, 582
CEdcma, 582

Osteogenesis imperfecta, 497
Paralysis, Infantile, 497
Paralysis, facial, 582
Ptosis, congenital, and Motais's
operation, 497

Rheumatic hyperpyrexia, 582
Synostosis, 497

Tuberculosis of the iris and
ciliary body, 497
Tumour of pons, 382
Vaccinia, 382

Edinburgh Medico-Chirurgical
Society—

Animia, tuberculous, 638

Buddisation, 637

Cases, 40, 5*7

Formic acid, 638

Herpes roster, 638

Movable kidney, shelf below, 40

Muirhead’s bacillus, 41

Novocain, 638

Oblique hernia, operation, 527
Vaccines and antisera in G. P.

and tabes dorsalis, 40
Valedictory address, president's
5*7

Liverpool Medical Institution—
Ataxia, an unusual case of, 553
Births, notification of, Act, 609
Bladder, extroverted, 473
Clinical cases, 693
Diet, 473

Hodgkin s disease, acute, 473
Kroenhein’s operation, 553
Levey-Dom orthodiagraph, 553
Natural colour photography, 608
Paraplegia treated by operation,
609

President’s address, 447
Roth-Drager oxygen-chloroform
apparatus, 354
Uric acid calculus, 473
North of England Obstetrical
andGyn-pcologicalSociety__

Exhibits and cases, 582
Hemorrhage, post-climacteric,

445

Intraligamentary bladder, 445
Ovarian tumours, solid, patho¬
logy of, 445

Ophthalmological Society op
the United Kingdom—
Cases, 6a

Eye conditions, treatment, 64
Interstitial keratitis from ac¬
quired syphilis, 552
Ligamentum pectinatum iridis
55 *'

Optic nerve, tumour of, 446
Optic neuritis, acute uni-ocular,
64

President's address, 446
Tay-Saehs, infantile retinitis, 667
Royal Academy op Medicine in
Ireland—

Cancer of the bladder, 637
Carcinoma of the mouth, 667
Carcinoma, 636
Card specimens, 608
Exhibits, 582, 607, 608
Innominate artery, ligature of
, 55 * .

Intrameningeal hemorrhage, 665
Laryngeal specimens, 637
Metabolism, nitrogenous, 528
Mucous colitis, 66b
President's address, 607
Sarcoma of tibia, 637
pome unusual abdominal cases
55 i

Spastic paraplegia, functional.
581

Thrombosis of arm. 637
Vaginal surgery, 607
Villous tumour of bladder, 636
Royal Society of Medicine—
Clinical section, 419, 526, 664
Medical section, 606
Neurological section, 495, 636
Obstetrical and gyiuecologica
section, 444, 380, 691
Therapeutical section, 64
Sydenham Society, New, 246
Ulster Medical Society—
Clinical meeting, 636
West London Medico-Chirurgi-
cal Society—

Appendicitis in women, 694
Clinical evening, 553
Presidential address, 447
Uterine nbroids, 694

, y Google

INDEX.

Jan. i, 1908.

uSttrs*

•Bdcinvter.

WEEKLY SUMMARY OF MEDI-
OAL LITERATURE, ENQLISH

Abscess, paranephritic, 648
Apomorphin in bulbar affections,
631

Amaurotic family idiocy, 5^1
Acid intoxication a factor in dis¬
ease, 181

Addison's disease in children, 509
Agglutination, some new facts
about, 48

Albuminuria of adolescence, 73
Alcohol in midwifery and gynaeco¬
logy. 455

Amputation, inter-scapulo-thoracic,
649

Ankylostomiasis, 700
Antigonococcic serum, an, 373
Anti-rabic treatment at the Pasteur
institute, 155

Aphasia, cerebral localisation of,
401

Appendicitis and pregnancy, 138
Appendicitis during pregnancy, 560
Asepsis during abdominal opera¬
tions, 31

Asphyxia, traumatic, 648
Atheroma, causation of, 373
Atoxyl and syphilis, 187
Arthritis deformans, metabolism in,
355

Bacterial inoculation, treatment by,
>55

Balsam of Peru in scabies, 400
Beneficial effect of one disease on
another, 331

Beri-beri, pathology of, 155
Bladder, tumours of, 481, 535
Blood changes subsequent to ex¬
cision of the spleen, 509
Blood formation in the liver and
spleen, 373

Blood, the, in rheumatoid arthritis,

Blood pressure in athletes, 355 ; in
tuberculosis, 591

Blood and urine in appendicitis,
important change in, 436
Blood transfusion in puerperal sep¬
ticaemia, 45*

Casarian section when the uterus is
infected, 455

Calculus, renal, etiology and treat¬
ment of, 304

Calmette’s ophthalmo-reaction to
tuberculin. 700
Cancer, histogenesis of, 136
Cancer, implantation of, 355
Cancer of the stomach, 400, 500
Cancer, primary, of the appendix,
436

Cancer, primary, ol the vagina,
with auto-inoculation, 481
Cancer problem, the, 700
Carcinoma, recurrence of, 337
Central retinal vien, obstruction of,
99

Cephalic tetanus, 373
Cerebro-spinal meningitis, bacterio¬
logy of, 48

Chlorosis in infants, 355
Cholecystectomy, 534
Chorea during pregnancy, 31
Chorion epithelioma, 481
Chorio epithelioma, 337, 637
Circulation, fcetal, 480
Caeliac axis, anomaly of, 481
Colour vision, a theory of, 49
Coloured lights and blood pressure,
49

Creatinin and uric acid excretion,
of, 509

Cystopexy, 533

Cysts of the corpus luteum, 674
Dependence of respiration on pres¬
sure conditions, 355
Detachment of the retina, treat¬
ment of, 303

Diabetes, treatment of by drugs, 73
Diarrhoea, summer, of infants,
bacteriology of, 155
Diet in kidney affections, 401
Diphtheria bacilli in normal throats
*55

Diphtheroid organisms in general
paralysis, 481

Diseases of women and disease of
the intestine, relationship, 360
Dorsal, foot reflex, 181
Enema, starch and opium, 401
Enlarging the pelvis, operations, 33
Epidemic pneumonia, 590
Epilepsy, emotional, 73
Epilepsy and pregnancy, 435
Erythema nodosum, 630
Extracts, organ and tumour, hamo-
lytic properties of, 48
Faroes, examination of, for occult
blood, 508

Fat and fatty acids, deposition of,
480

Fat embolism, 700
Fibrolysin in abdominal adhesions,
330

Forceps, high, 138
Formamint in septic affections of
the oro-pharynx, 509
Fracture of the neck of the femur,
new treatment of, 436
Fractures, punctured, at the base
of the skull, 99

Gastric adhesions, treatment of, by
fibrolysin, 73

Gastric secretion in nephritis and (
dechloridation, 308
Gestation,ectopic and tubal rupture I
137

Glaucoma, chronic, production of a .

filtering cicatrix in, 437
Glycosuria, transient, prognosis in,
7*

Hemorrhages at the beginning of
puberty, 138

Hemorrhages in Bright's disease,
630

Headache, physical therapy of, 401
Heart, examination of, in the
Trendelenburg position, 181
Heart, valvular disease of, in preg¬
nancy and labour, 137
Hebosteotomy, 560
Herpes facialis in diphtheria, 630
Howell’s granules, 373
Hyoscine anesthesia in obstetrics,
**7

Hyperemia, Bier s, 509
Hyperemesis gravidarum and its
relation to eclampsia, 137
Hysteropexy, ventral, 454
Hysterotomia vaginalis anterior,
338

Immunisation against inoculated
cancer, 590

Infections, acute pelvic, scope of
treatment, 561
Kidneys, mobility of, 534
Lactic acid bacilli to combat intes¬
tinal fermentation, 73
Leukemia, atypical, 49
Lipjemia, diabetic, 49
Lipoma, retroperitoneal, 534
Liver cirrhosis in children, 480

Liver, rupture of, 534
Lung suction mask; Kuhn’s, 181
Lupus erythematosis, fatal case of,
3*1

Lupus of face, nasal origin of, 631
Lupus, treatment of, 99
Lupus vulgaris secondary to tuber¬
cular lymph glands, 331
Luteum, the corpus, 137
Lymphocythamia, acute, patho¬
logy of, 480

Massage and movement in the
treatment of fractures, 98
Meningococcus, mode of spread, 48
Menstrual function, 673
Metabolism in leukaemia treated by
X-rays, 590
Microbic cyanosis, 400
Micturition in women, frequency of.

648

Mobile kidney, new operation for,
4*6 , .

Moser's syrup in scarlatina, 355
Movable kidney, 648
Myomata, neurosis and suppura¬
tion in, 674

Nipples and breasts during preg¬
nancy, Ac., care of, 337
Nucleinate of soda in peritoneal in¬
fections, 508

Oblique inguinal hernia, 649
Obstetrical literature, 346, 347
Obstructive jaundice, 534
(Edema of the lung, acute in ether
narcosis, 73

Opsonic index for streptococci in
scarlatina, a00
Orthostatic albuminuria, 373
Ovarian cysts, relation of, to abdo¬
minal and pelvic pain, ta 7
Ovariotomy during pregnancy,
labour, and the puerperium, 138
Pain and blood pressure, 590
Paralysis, infantile, 73
Parathyroid glands, 400
Pelvic inflammation in the female,
700

Perforation, partial, of the bowel,
simulating appendicitis, 304
Peritoneal wounds, treatment of,
561

Phagocytic action of the alveolar
cells, 373

Phlebitis following abdominal opera¬
tions, 673

Phthisis, influence of heredity, in
the prognosis of, 180
Pigment spots, Mongolian, 180
Plumbism following bullet wounds,
330

Podalgia, case of, 304
Post-partum hemorrhage, treat¬
ment of, 31

Pregnancy, prolonged, 138
Pregnancy, disappearance of, 338
Prolapsus funis, 361
Prostatectomy, post-operative re¬
sults of, 436

Puerperal peritonitis treated by
abdominal section, 31
Puerperium, treatment of, 673
Pus tubes, ruptured, 434
Pyelitis, suppurative, treatment of
by lavage of the renal pelvis, 304
Pyelonephritis and methylene blue,
181

Pylorus, congenital stenosis of, 436
Reaction, a new cutaneous, in
tuberculosis, 330

Regeneration of bone, role of the
various elements in, 98
Rcgulin in chronic constipation, 330

Retention in utero of separated
after-coming head, 434
Retroflexio uteri, 433
Rheumatism, acute, and constric¬
tion hyperaemia, 631
Rhinoplasty by means of one of
the fingers, 304
Rodent uker, origin of, 373
Sarcoma, inoperable, 303
Scoliosis, its prevention and.trcat-
ment, 303

Sea-sickness, cause of, 180
Skin grafting, 437
Smoking, influenoe of on circula¬
tion, 355

Sodium phosphate in neurasthenic
conditions and in exophthalmic
goitre, 73

Staphylococci in furunculosis, 590
Stomach, acute dilatation of, 180
Stomach, contraction of in, poly¬
serositis, 49

Stovain in spinal analgesia, 98
Suprapubic delivery, 433
Suprarenal haemorrhage, 331
Surgical literature, 347
Surra in Indo-China, 390
Sweating, hysterical, 631
Syphilis, treatment of by intra,
muscular injections of mercury-
99 . 180

Syphilis, new infection of, 401
Syphilitic heart diseases, diagnosis
of, 630

Tachycardia, paroxysmal, 6ao
Tetany, 331

Thiokol and myrtol, 331
Thrombosis and embolism after
gynaecological operations, 560
Thyroid extract and toxaemia of
pregnancy, 561

Toxicity of therapeutic sera, 590
Transvesical operation for prosta¬
tism, 330

Tubercle vaccine, preparation of
homologous, 156

Tuberculin treatment in children,
700

Tuberculosis and heredity, 181
Tuberculosis, miliarv, 648
Tuberculosis, early diagnosis of, 400
Tuberculosis, muscular, 48
Tuberculous peritonitis, treatment
of, 631

Tuberculous skin affections, dia¬
gnosis, Ac., of, 631
Tumours of central nervous system,
treatment of, 648
Typhoid agglutinins in a non-
typhoid case, 591
Typhoid fever, diagnosis of by the
conjunctival reaction, 391
Vaccine treatment and opsonic con¬
trol, 354

Vaccino treatment and diagnosis,
59 > ,

Vaginal ovariotomy during preg¬
nancy, 560

Valvular disease of the heart,
chronic, 400

Vaquez disease, 373, 630
Varicocele, symptomatic, 99
Veronal as a hypnotic, 331
Visceral tuberculosis and intestinal
infection, 631

Vomiting, habitual, of nursing
infants, 508

Weak or flat foot, treatment of,
4*7

Wood-tick and spotted fever, 480
Yellow atrophy of the liver, acute,
and chloroform anesthesia, 508

Digitized by

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The Medical Press and Circular.

"SALUS POPUU SUPREMA LEX."

Vol. CXXXV. WEDNESDAY, JULY 3 , 1907 . No. 1

Notes and Comments.

The presentation of the Freedom
Lord Lister °* City of London to Lord

aa d Lister last Friday cannot but

the City. give rise to some reflections on
the position which the repre¬
sentatives of medical science hold in the esti¬
mation of their contemporaries. Lord Lister is
well over eighty years of age; for twenty-five
years he has been recognised all over the civilised
world as the greatest benefactor to humanity
that this age, or perhaps any age, has produced ;
he has been honoured in every civilised country
by the conferment of such dignities as each could
bestow ; moreover his eminence is only surpassed
by his modesty, his disinterestedness, and his
sterling honesty. It is no exaggeration to say
that for a quarter of a century Lord Lister has
been the worthiest and most distinguished British
subject in the kingdom, and he may fairly be
claimed as a Londoner to boot. In his brief and
modest speech on receiving the freedom Lord
Lister spoke of it as “ the highest civic honour
in the world,” and though medical men are duly
.grateful to the City for having bestowed it on
Lord Lister, they cannot but wonder how it is
that it has so long been withheld, and whether
it would have been granted at all but for the fact
that a medical man who believes in his own
profession is Senior Sheriff for the year. Every
year the freedom of the City is conferred on
some Royal person, often from some quite second-
rate country and from the point of view of
humanity quite undistinguished, or on some
victorious admiral or general who has doubtless
rendered great service to his country, but whose
achievement will frequently not be deemed of
sufficient magnitude to require mention in a
history-book of a hundred years hence, or on
some person whose exploits are making good
" copy ” for the newspapers of the moment.
On such occasions the streets are lined with
troops, flags and banners adorn every building
on the route, and all the most distinguished
officers of the State are assembled to welcome
the hero.

On Friday a bare handful of
S ience and gentlemen, mostly medical men,
British assembled in the Guildhall to
C. zeaship. receive Lord Lister, there were
no soldiers, and we are bound to
be'ievo that not ten persons in the City knew
that any unusual event was toward.. Most of.
the newspapers considered half a column on an

inside sheet sufficient to record the event. Thus
shall be done to the man whom the world delighteth
to honour! There is no gainsaying the fact
that in America and on the Continent Lister is
a name to conjure with, and we believe if a vote
were taken as to who was the greatest living
Englishman, he would be easily first; yet in his
own country in his old age he is fobbed off with
semi-private presentation of the Freedom of the
City without a cheer from his fellow citizens in
the streets. It is true that Lister is the first
and only medical man on whom a peerage has
been conferred, but that peerage is only a barony,
whilst a politician, soldier, or wealthy brewer
will often despise anything below a Viscountcy
or Earldom; and the bare idea of a public
pension or money grant, such as the politician
or soldier receives, and the brewer does not
need, would raise a smile. But perhaps the
truest honour and highest reward is for a man
to be loved, respected and unenvied by those of
his own calling, and Lord Lister has passed
through the storm of controversy to the haven
of honoured old age, enshrined in the hearts of
medical men as their worthiest and noblest
comrade. Perhaps for that reason they would
wish all the more for his name to be a household
word and his portrait a household possession
throughout the land.

The carpenter cancer-" curing ”
The Evans brothers at Cardigan continue to
Brothers. attract an enormous number of
patients, and from accounts it
appears that the lodgings in the
town are full of sufferers seeking the aid that
has been so widely advertised. Indeed, in a
letter which would be comic but for the under¬
lying pathos of the circumstances, the Evans have
addressed the public through the Press asking
patients not to come without special appoint¬
ment, as they have already more work than
they can adequately cope with. They say, " We
find it impossible to give proper attention to the
large number under our care. . . . This is
a great disadvantage to us, and seriously injurious
to those who are ill.” One special correspondent
reports that probably over five hundred patients
are already being dealt with, so that we may
safely conclude that a pretty good thing is being
made out of this " secret.” It seems that cancer
is not the only disease to which the method is
applied, for not only are scirrhous carcinomas of
the breast and epitheliomas of the face reported.

259525

2 The Medical Pusi

LEADING ARTICLES.

July 3 . 1907.

but lupus, necrosis oflthe nasal bones, and (save
the mark!) polypus of the nose are specifically
noted. The treatment, however, seems to be
the same for all. Some of the “ secret ” fluid is
painted on to the diseased part, an application
of fresh leaves applied, and a dressing placed over
all. These wonder-working brethren describe
themselves as “ herbalists,” but it would not be a
very hazardous guess to assert that this mysterious
fluid contains arsenic as a prominent ingredient.
The arsenical treatment of external cancer, is
always cropping up in one form or another, and
the improvement which follows the separation
of the slough produced by the caustic has been
the stock-in-trade of cancer-quacks innumerable.
From the published accounts it seems that the
patients are not so universally satisfied as was
at one time given out. That is as might be
expected; the denouement in these matters is
seldom as sudden as in a play.

A curious but not unsympathetic
Doctors article on “ Doctors as Dictators ”
aa appeared in The New Age, a

Dictators. Socialist organ, last week. In¬
deed we may congratulate the
writer on possessing a considerable amount of
acumen and some working knowledge of the
conditions of medical practice. It may not be
flattering to us to be told that “ essentially the
doctor nowadays is an upper servant,” but as the
writer wishes to deliver us from this thraldom
he at least deserves the gratitude of those who
groan in the bondage of their masters. But what
we are glad to learn is that Socialists have no
quarrel with medicine or medical men, but rather
that they acknowledge the benefits of medical
science and would like to promote them. At the
same time they consider that scientific merit and
personal worth are only factors in a practitioner’s
success, and that his advice has to be adapted to
the whim and social position of the patient.
The writer in The New Age considers that the
cry of “ Doctors as Dictators ” is a bogie, and
that on the contrary the doctor is very much
dictated to by the State and by his circumstances
and patients. We may say with little hesitation
that if the Socialists would release the profession
from the painful necessity of having to do as
they are bid, and would allow them to act on
the scientific ideal in all cases, they would achieve
immense popularity with the profession, but till
old things are passed away and a new age is firmly
established, we fear that men will t still have
their weaknesses and failings, and these will
continue to cause the doctor frequently to sub¬
ordinate his theoretical ideal to the practicabili¬
ties of the situation.

We publish in another column a
Livingstone letter from Dr. Charles F. Har-
College. ford, Principal of Livingstone

Medical College, commenting on
some remarks in The Medical Press and
Circular of June 19th, with regard to that
institution. While cordially appreciating the
tone of Dr. Harford’s letter, and sympathetically
entering into the difficulties of the position, we
still feel inclined to repeat what we then said,
namely, “That we find it difficult;.to recom¬
mend a system of unqualified practice among
natives which we would condemn if pursued at
home, and we notice from the report that some

of the Livingstone alumni seem to practise quite
extensively.” We gladly accept the statement
that students at the College sign a declaration
that they will not represent themselves as medical
missionaries or assume the position of qualified
medical men ; that is certainly as it should be,
but does the child of nature draw the line very
accurately between registered and unregistered
practitioners ? The only logical solution of the
difficulty would be for all missionaries to be
medical men, or to act only as assistants to a
medical man ; but presumably that is an ideal
which the Church Missionary Society cannot
practically fulfil at the moment. Still it is the
one that should be aimed at, and if Livingstone
College marks a transition in that direction, we
should not be so churlish as not to wish it God¬
speed.

LEADING ARTICLES.

LORD LISTER AND THE FREEDOM OF
THE CITY OF LONDON.

On Friday last, June 28th, Lord Lister was
formally presented with the Freedom of the City
of London in the ancient and historic Guildhall.
The auspicious event took place, with appropriate
ceremony, in the midst of an assemblage of
distinguished men. The scroll of the freedom
was enclosed in a gold casket of elaborate design,
surmounted by a figure of Hygeia, and having
at opposite ends of the base two figures, one
representing London offering the scroll of freedom,
and the other symbolising medical science holding
out the torch of Fame. In making the presenta¬
tion the City Chamberlain, Sir Joseph Dimsdale,
remarked that Lord Lister, by blending the
antiseptic treatment with modem surgery J had
made possible what previously seemed impossible.
In acknowledging the presentation Lord Lister
said simply that the work in which it had been
his great privilege to be engaged had brought its
own reward. At the end of a brief speech he
made a pathetic allusion to the consideration of
the Court which permitted him to attend at his
own convenience. Had it been otherwise the
state of his health would have prevented his
personal acceptance of their gift in that historic
building. Of all the great events that have
been dignified in this centre of English history it
may be questioned if any more worthy of civic
and national honour has ever been celebrated
therein. Unquestionably Lister’s name will be
for ever one of the greatest and most revered in
the world of medicine. The Corporation of
London may be congratulated upon their action
in conferring the highest dignity within their
power upon the man who has probably done
more than any single man for the advance of
medical science and the relief of suffering
humanity.

DEATHS UNDER ANAESTHETICS.

The question of deaths under anaesthetics has
vexed the minds of medical men ever since the
introduction of the great boon of general anaes¬
thesia. As years go by and experience accumu-

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CURRENT TOPICS.

_ The Medical Press. 3

CURRENT TOPICS.

lates, the conclusion appears to be more and
more inevitable that there must always be an
unavoidable margin of accompanying fatalities.
True, some drugs used for the purpose are less
dangerous than others, but, unfortunately, the
safer ones are otherwise unsuitable for any but
minor operations, while not a single one is abso¬
lutely safe. Yet it would be contrary to the
spirit that animates the student of modem scien¬
tific medicine were he to accept the position as
one incapable of further improvement. On the
contrary, he is bringing to bear upon the problem
every ray of light that may be obtained from the
chemist, the physiologist, the pathologist, the
surgeon, the anaesthetist, or from any other avail¬
able quarter. Recently the introduction of spinal
anaesthesia has opened up a novel departure in
this highly technical branch of work, and it may
even be that the final solution will be found
somewhere in that direction. Meanwhile it seems
not altogether impossible, in the light of recent
enquiries, that some additions to our knowledge
of fatal anaesthesia may be gathered from a
systematic examination of all cases on certain
clear and well-defined lines. The Coroner of the
City of London, Dr. F. J. Waldo, has recently
paid a great deal of attention to enquiries of this
kind, and has gathered a mass of information
that cannot fail to be of interest, and may possibly
prove of real value. By drawing up exhaustive
tables of the proportion of deaths to administra¬
tions under various anaesthetics, it is possible
to compare the accompanying conditions. It
seems to be a fact that with a given anaesthetic
there are proportionately more deaths in one in¬
stitution than in another. By investigation there
is an obvious possibility that contributory causes
may be detected in the peculiar conditions of the
administrations where the greater fatality exists.
One particular point worthy of careful enquiry is
the exact chemical composition and source of
origin, as well as cost, of each anaesthetic drug or
combination of drugs. For some reason or other
this aspect of anaesthetics has never been as fully
dealt with as its importance certainly appears to
demand. The matter, of course, touches delicate
ground and would have to be dealt with tactfully.
If handled without due caution, a serious injury
might inadvertently be inflicted upon this or that
medical charity. We should decline to believe,
however, that such a suggestion would for a
moment prevent any great modem hospital from
lending its utmost aid to any enquiry that might
help to lessen in any way the sum total of deaths
under anaesthesia. There is no apparent reason,
for that matter, why all enquiries should not be
strictly impersonal. The statistics could be
drawn up readily enough without giving the name
of any institution, by resorting to the simple
artifice of reference numbers. So important is an
investigation of the sort to the welfare of the com¬
munity that we would suggest a Governmental
enquiry by a competent scientific body as a pro¬
position requiring little argument in favour of its
desirability. To avoid so plain a duty in deference
to timid or hostile interests would be to reverse
the outspoken and fearless candour which is one
of the chief characteristics, as it is the foundation,
of progressive medical science.

The Long Hours of Railwaymen.

It is an old story that many railway accidents
are directly due to the fatigue of over-worked
servants. This fact has been once again empha¬
sised in a White Paper issued last week by the
Board of Trade. Since the year 1900 there were
thirty-four such accidents, five of them being
in Ireland. A particularly bad record comes
from Goolc, where four accidents took place,
involving the death of one railway servant and
injury to three others. In the first instance a
shunter was killed after working 14} hours con¬
tinuously. In the three injuries the men had been
on duty 13J, 14} and 16 hours respectively. A
fireman killed at Clapham Junction had worked
1 7\ hours. The record number of hours appears
to have been that’of a platelayer killed at Notting¬
ham, who had worked 23 J out of 30 J hours, when he
was run over and killed. A collision between two
passenger trains at Broad Street, London, in
1904, was due to the mistake of a signalman
who had been on duty 12 hours daily for the
three preceding days. The whole matter is one
that urgently demands legislative action in the
interests both of the railwaymen and of the
travelling public. As a plain statement of fact
the economic loss must necessarily fall, in the
long run, upon the community from whom the
railway companies draw their revenues, including
that portion which has to be paid away as com¬
pensation for accidents and fatalities. Clearly
the public that thus pays the piper should be
entitled to a voice in the conditions of employ¬
ment that have been shown to be fraught with
such disastrous consequences.

The Prime Minister and the Royal
Commission! on Cancer.

Medical officialism has again prevailed against
medical opinion. In the House of Commons last
week, the Prime Minister in reply to a ques ion
asking for the appointment of a Royal Commission'
on cancer, said “ he had made inquiries of the-
authorities who were best qualified to express an
opinion, and he was advised that it would not be
expedient at present to recommend the appoint¬
ment of a Royal Commission to inquire into the
causes of the disease . . . and he was advised
that much remained to be done before any facts;
could be brought before a Royal Commission;
with any likelihood of their making such an in¬
quiry fruitful for the public advantage." In formu¬
lating this reply reference was made to the Imperial
Cancer Research Fund ; it is therefore not difficult
to infer that the “ authorities who were best
qualified to express an opinion,” implied the
Executive of this Fund, and that the strange
opinion expressed by the Prime Minister on this
matter was due to them. The opinion certainly
was an extraordinary one, on the face of the evid¬
ence which has guided the profession generally in
arriving at the conviction that such an inquiry
would, as the Medical Press and Circular
stated last week, prove “ of enormous educative

Dior

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CURRENT TOPICS.

July 3, 1907.

value.” The force of circumstances, however,
having placed the Imperial Cancer Research Fund
in the position of arbiter, as between the pro¬
fession, the public, and the Government of the day,
it is only due to those who subscribe to the Fund
to be informed upon what grounds the Executive
of the Fund have advised the present Government
that an inquiry is unnecessary. Doubtless, having
practically been appointed arbiters, the Fund are
waiting to substantiate their position as such, and
this view of the case is more than likely to be the
correct one, seeing that the Fund have been
singularly neglectful in showing what they have
done in advancing our knowledge of the disease.
The fitful outbursts of cancer “ booms ” in the
lay press are simply due to the lordly scientific
silence which the Fund persists in observing
whenever any matters regarding the disease
obviously demand official refutation. Lay editors
would hardly dare to continue to publish “ facts ”
about cancer after having been officially informed
that such “ facts ” were merely impossible crea¬
tions, and not worthy of credence. Before
long, however, public opinion will demand a Cancer
Inquiry ; already the lay press are beginning to
direct attention to its necessity, and then “ those
best qualified to express an opinion ” against
it will find themselves powerless to resist the
demand. Thus will Nemesis fall upon them for
failing to recognise in the past that they have a
duty to discharge towards the public in correcting
statements in the Press which to the medical
man are obviously inaccurate.

The Teaching of Hygiene in Elementary
Schools.

The reply of Mr. McKenna to the deputation
which waited on him recently in reference to
the above subject was, like replies given on other
occasions by his predecessors, sympathetic but non¬
committal. The deputation urged the import¬
ance of giving instruction to children in the sub¬
jects of hygiene and temperance, of training
teachers in these subjects, and of their being
reported on by H.M. Inspectors of Schools. Mr.
McKenna declared himself in full agreement with
the desires of the deputation, but he confessed
himself unable at present to find means of carrying
them into effect. He hoped, however, that after
hearing the views to be put forward at the Inter¬
national Conference in August, he might be in a
position to suggest a solution of the difficulties.
We confess we cannot see that the obstacles are
so great as they appear to the official mind. It
is true that the teachers must themselves be in¬
structed before they begin to teach the children,
but this could easily be done in a few carefully
planned holiday courses. Within the course of
a few years, the Department of Technical Instruc¬
tion in Ireland has found it possible to train a
sufficient staff of teachers in experimental and
natural science, not for the primary but for the
secondary schools of Ireland. The task facing
Mr. McKenna is by no means more difficult. His

complaints, too, as to the difficulty of compiling
a syllabus for instruction in hygiene seems like
making a mountain of a mole-hill. It was
unfortunate that Mr. McKenna should haw
been ruffled by what he considered the
“ peremptory ” manner adopted by some of the
members of the deputation.

The Housing: Problem in Ireland.

Of the many problems facing the sanitary re¬
former in our cities and towns, one of the most
urgent is that of providing proper housing for tha
poorer classes. It stands, indeed, in the forefront
of many questions intimately dependent on it.
In the struggle against tuberculosis, in the battle
against intemperance, in the extermination of all
filth diseases, the providing of proper housing is
all-important. In dealing with the question,
economic as well as sanitary considerations have
weight, and some method must be found by which
houses in large numbers can be supplied without
an economic loss. In the discussion on the subject
at the meeting of the Royal Sanitary Institute in
Dublin last week, two ways of finding a solution were
put forward. Either large blocks must be erected
in the heart’of great cities, or improved communica¬
tion with the suburbs must be established, so as to
permit of cottages being built on cheaper sites.
The latter plan has many points in its favour. It is
more economical, in that land can be bought at
cheaper rates, and it has the further advantage
that the cottages can be placed in healthy sur¬
roundings where their inhabitants can have the
benefit of fresh air and sunlight. It has the
drawback that it takes workmen to a distance from
their work and puts them to the expense of a
tram or rail journey morning and evening. With
improved means of conveyance, however, it is to
be hoped that the chief of these inconveniences
may disappear.

The King Edward Fund Bill.

On Monday, July 2nd, the King Edward Hos¬
pital Fund Bill passed the Commons.. The
amendment brought forward by Dr. Rutherford
in favour of representative control was ultimately
withdrawn under strong pressure from high
quarters on both sides of the House. As a matter
of fact, the original Bill has been considerably
altered since attention was first publicly drawn by
the medical journals to its autocratic constitution.
The Prime Minister reminded the House that the
Council of the Fund included the Lords-Lieutenant
of London and Middlesex, the Bishops of London,
Southwark, Westminster, the President of the
Free Churches, the Chief Rabbi, Chairman L.C.C.,
Governor of the Bank of England, and the Pre¬
sidents of the Royal College of Physicians and
Surgeons. It will be noted that the main mass of
the medical profession, the hospitals and the
public are unrepresented. Above all, the small
hospitals, who already complain of injustice at the
hands of the Funds, are without a single represen¬
tative. Under these circumstances the Fund can
hardly wonder if it has occasionally to face the fires
of searching criticism.

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July 3, 1907.

PERSONAL.

The Medical Peess. 5

PERSONAL.

The Housing Reform Congress.

For the first time in history the International
Congress on Housing Reform will meet in the
United Kingdom. It is to be hoped that the
great gathering to be held in London early in
August will do something to educate the nation
generally upon a matter so vital to their well¬
being. It seems probable that in no country
in the world does the jerry-builder flourish with
greater impunity than in our own long-suffering
realm. The absence of stringent building acts
from our Statute book constitutes a standing
reproach to a nation that prides itself on its
practical handling of public health matters.
Over the whole face of the land houses are springing
up like multitudinous mushrooms in the suburbs
of towns, both small and great. A brief inspection
of these speculative dwellings will reveal the
fact that they are more or less riddled with
appalling structural and sanitary defects. Of
late it has been the fashion to raise sensational
outcries on the question of impure food. Clearly,
however, the provision of sound and sanitary
housing is of no less importance to the sturdiness
of our race. Let us hope that the forthcoming
Conference will teach the man in the street
what the law should empower him to demand
from his landlord.

[Bacteria and the Tram-ticket.

The public mind is being agitated at the
moment about the possible dangers to health
incurred by accepting a tram-ticket from the
conductor of the car. Indeed, a question on the
subject was recently put to the Home Secretary.
An ingenious French bacteriologist lately examined
a number of these tickets and found them to
contain germs innumerable and those of the
deadliest character. Far be it from us to decry
scientific research or bacteriological methods,
but let us at least remember we live in a practical
world. Desirable as the sterilisation of tram-
tickets may be, it would be quite useless unless
the conductor dealt them out with aseptic hands,
and however aseptic the conductor’s hands
might be when he started out in the morning,
they would certainly be freely infected by the
first fare he received from a passenger. In a
Utopian tram it might be possible for a conductor
to wear a sterilised overall and to serve out
sterilised tickets with sterilised hands, but in
order to complete the requirements of hygiene
he would have to deal only with sterilised passen¬
gers paying sterilised fares. At present the
chief danger to be apprehended from the tram-
ticket is the creation of hysteria in those who
have yet to learn that the doctrine of the imman¬
ence of bacterium. With the ’bus-ticket there
need be no difficulty as there is no obligation
on the passenger to preserve it, and it may be
thrown away as soon as it has been handed to him
The ’bus companies cannot demand that a
ticket shall be produced for inspection, although
they would fain have people believe they can
Let us, however, take our tram-tickets with
thankfulness, asking no questions for conscience
sake.

The following medical men had honours con¬
ferred upon them on the occasion of the official cele¬
bration of the King’s Birthday last week:—

To be Knight Bachelors—

Horace Rosborough Swanzy, Esq., M.D., President
of the Royal College of Surgeons of Ireland.

Mr. Alderman Thomas Boor Crosby, M.D., Sheriff of
the City of London.

To be K.C.B. (Military Division)—

Inspector-General Herbert Mackay Ellis, R.N.,
Honorary Physician to the King.

To be C.B. (Military Division)—

Deputy Inspector-General Thomas Desmond Gim-
lette, R.N.

Surgeon-General Francis Wollaston Trevor, Principal
Medical Officer, Western Command, India.

Colonel George Deane Bourke, Administrative
Medical Officer, Southern Command.

To be Hon. C.I.E.—

Dr. Jean Etienne Justin Schneider, Principal Doctor
of the First Class, French Army, late Chief Phy¬
sician to the Shah.

To be C.I.E.—

Surgeon Lieut.-Colonel Warren Roland Crooke-
Lawless, M.D., Coldstream Guards, Surgeon to
His Excellency the Viceroy of India.

To receive the Kaisar-i-Hmd Medal—

Rai Bahadur A. Mitra. L.R.C.P. and S. Edin., Chief
Medical Officer, Kashmir.

To be G.C.M.G.—

Sir William MacGregor, M.D.. K.C.M.G., C.B.,
Governor and Commander-in-Chief, Newfound¬
land.

The King has also specially appointed to the Order
of the Bath the following veterans, who served in the
Mutiny :—Surgeon-General Thomas Tarrant, Honorary
Physician to the King; Deputy Surgeon-General
Edward Malcolm Sinclair, late Army Medical Staff ;
Deputy Surgeon-General Alfred Eteson, late Indian

Medical Service.-

We have to congratulate Sir James Blyth, who has
done so much to help forward the investigation of
tuberculosis, on his being raised to the Peerage.

Dr. D. C. Watson was elected Assistant Physician,
and Mr. W. J. Stewart, Assistant Surgeon, to the Edin¬
burgh Royal Infirmary, on June 24th.

Dr. J. Odery Symes has been unanimously elected
Physician to the Bristol General Hospital to fill the
vacancy created by the death of Dr. Markham Skerritt.
Dr. Carey P. Coombes has been elected Assistant
Physician to the same institution.

Dr. R. H. Kennan, Senior Medical Officer of Sierra
Leone, is acting as Principal Medical Officer of that
Colony during the absence on leave of Dr. R. M. Forde,
who has arrived in England.

Professor Osler will present the prizes to the
successful students at the London School of Medicine
for Women, at 4 p.m. to.morrow. The gathering will
be held at the Royal Free Hospital, with Mrs. Garrett
Anderson in the chair.

Mrs. Russell Sage has contributed £60,000 towards
the foundation of an Institute of Pathology in connet-
tion with the City Hospital and City Home on Black¬
well’s Island, New York. The main objects of the
institution include the prosecution of researches into
the diseases of old age.

Dr. J. J. Pursel has been elected Anaesthetist to
Dr. Stevens’ Hospital, Dublin, in room of Dr. J. L.
Bell, resigned.

The honorary degree of M.D. was last week conferred
by the University of Dublin on Dr. Conolly Norman and
Dr. Philip Henry Pye-Smith.

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6 The Medical Press.

CLINICAL LECTURE.

July 3. 1907-

A Clinical Lecture

ON

SOME OF THE ORGANIC CONSEQUENCES OF HIGH
BLOOD PRESSURE («>.

By LEONARD WILLIAMS, M.D., M.R.GP-
Physician to the French Hospital) Assistant Physician to the Metropolitan Hospital.

These five patients are here to illustrate some
of the many morbid conditions which are associ¬
ated with high blood pressure. In the minds of
a great number of people high blood pressure
suggests one morbid condition only, namely,
granular disease of the kidneys. Such, however,
is a very restricted view of the matter which, in
the light which the manometer has afforded us,
is no longer justifiable. Arterial hyper-tension
is now very generally admitted to exist as a primary
condition ; it is only when it has been in operation
for a considerable length of time that organic
changes supervene. Something, of course, must
give rise to the hyper-tension itself, and this
something in the majority of cases is the absorption
of toxins from the gastro-intestinal canal. The
stages through which the process passes, therefore,
may be described as auto-intoxication; high
arterial tension, arterial degeneration. Arterial
degeneration, as we know, is of two kinds : (1)
that which affects the larger arteries and is called
atheroma; (2) that which affects the smaller
arteries and arterioles and is called arterio¬
sclerosis. The burden of atheroma is borne by
the aorta and the heart. In the former it provokes
aneurysm, in the latter it gives rise to aortic val¬
vular disease, and, by involvement of the coron¬
aries, to angina pectoris and myocarditis. It is well,
then, to remember that if we can recognise and
arrest hyper-tension in its functional stage we
may save our patient from these dread maladies.
Arterio-sclerosis being a degeneration of the
smaller vessels, it may of course appear in any
tissue or organ, and when it is more marked in
certain particular organs than it is in the system
generally, a distinctive name is given to the con¬
dition, and we are in consequence apt to lose sight
of the fact that hyper-tension may be at the bottom
of the disease so designated. Thus it is that
granular disease of the kidney and hepatic cirr¬
hosis are often considered primary events, arterial
hyper-tension being regarded as a result rather
than as the cause of the disease. If we learn to
look at the matter from the other point of view,
and consider the sclerosis of the organ as a part
of a general arterial sclerosis which has been in¬
duced by long continued high tension, the nature
of these processes becomes very much more com¬
prehensible. The functional stage of hyper¬
tension is one to which very much less importance
is usually attached than its gravity merits. This
is partly because its symptoms are very indefinite
(breathlessness on slight effort being the only one
which is at all prominent), and largely because
its detection can only certainly be effected by the
use of a manometer, an instrument the use of
which is still unfortunately confined to the few.

The use of the manometer is certainly liable to
be irksome, and as none of the reliable instruments
are very portable, it may still be a long time before

la) Delivered at the Medical Graduate*' College and Polyclinic.

I it vindicates its real value. In the meantime, in
your endeavours to form an estimate of the state
of the blood pressure without such assistance, I
cannot insist too strongly upon the danger of
trusting to mere palpation of the radial artery.
Here, for example, is a man aet. 50, whose pulse,
when felt,will be found to be perfectly compressible,
whose radial artery seems to present nothing
strikingly abnormal, who nevertheless has a very-
high blood pressure. The history of my association
with him is interesting and instructive. He was
admitted into the hospital with a profuse haemop¬
tysis, on the subsidence of which my house
physician very properly examined his chest, and
thought he detected some signs of tuberculosis.
When I came to confirm this diagnosis, I found
myself quite unable to do so. The lungs seemed to
me to be quite free from any serious disease. The
question then naturally arose : how was the un¬
doubted haemoptysis to be explained ? There
was no phthisis, there was no mitral stenosis,
the size of his heart was normal, there were neither
casts nor albumen in his urine, and although he
has a little emphysema, it did not seem to me
to be a sufficient cause for the profuse haemorrhage
from which he had suffered. I therefore took his
blood pressure with Dr. Oliver’s new instrument,
and found it registered 190 mm. Hg. This I re¬
garded as a sufficient explanation of the haemo¬
ptysis. My house physician wanted to know¬
how high blood pressure in the systemic circu¬
lation could give rise to a haemorrhage from the
vessels in the pulmonic, the lesser, circulation.
That is a very pertinent question, for it is obvious
that the interposition of the capillaries, the veins
and the valves of the right heart, render the pres¬
sure in the two systems absolutely independent
of one another. It is of course true that if from,
any cause there is hyper-tension in the pulmonic
circulation, there must inevitably be hyper¬
tension in the systemic circulation, because the
pressure on the systemic side must always rise
higher than the pressure on the pulmonary side.
This is only another way of saying that arterial
pressure must always be higher than venous,
pressure. As soon as this ceases to be the case
the medulla is starved and the patient dies. It
is also true that the same cause which produces
hyper-tension in one system may produce it in
the other, that is to say, the toxins acting on the
interior of the vessels so as to bring about their
contraction, may act as powerfully in the pulmonic
circulation as they do in the systemic. This,
however, though theoretically true, is uncommon,
and need not therefore detain us. But the im¬
portant point to remember is that haemoptysis
may, and very often does, occur even when the
pressure in the pulmonary circulation is low. We
are rather too apt to think of haemoptysis in terms
merely of the lesser, the pulmonary circulation ;
we are rather too apt to forget, that is, that the

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July 3, 1007. CLINICAL

lung substance itself is supplied with blood from
the systemic system through the bronchial arteries,
which are of course branches of the thoracic aorta,
and that when there is hyper-tension in the
systemic system, one of these arteries or their
branches are liable to rupture. Such, I believe
to have been the cause of the haemoptysis in this
man’s case, high arterial tension with rupture of
one of the branches of the bronchial arteries. The
arteries in the lung, though better supported than
those in the brain, are not as well supported as
those in the ordinary systemic circulation. We
do well, therefore, to remember that, after the brain
the lung is perhaps the most frequent site for the
rupture of a systemic artery.

This next man shows a different stage of high
blood pressure, for he has, I think, without doubt
granular disease of the kidney. Unlike the first
patient he has albuminuria and definite cardiac
involvement. His heart’s apex is outside the
nipple line, and he has a reduplicated first sound,
the sound which is very aptly described as a
“ bruit de galop.” Now, these bruits, which are
created by the interposition of an extra sound, are
sometimes very difficult to distinguish the one from
the other, but this sound, a true galop rhythm,
which is as much apparent to the palpating hand
as it is to the ear, is characteristic of definite
cardio-vascular involvement. I do not ever re¬
member to have heard it, in the form in which it
is here present, except in a case of arterio-sclerosis
or renal cirrhosis, which, as I have said before,
are in reality but two different names for the same
thing. A true “ bruit de galop ” consists of two
short sounds and one long, and is best appreciated
at the apex. The doubling of the second sound for
which it ought not to be mistaken, though it
sometimes is, consists of one long and two short,
and is best heard at the base. This doubling of
the second sound is due to asynchronous closure
of two sets of basal valves, and is not in reality
a “ bruit de galop.” The true “bruit de galop ”
is a pre-systolic sound, and is therefore very easily
confused with the pre-systolic doubling of the first
sound which occurs in early mitral stenosis. In
early mitral stenosis the valves are thickened, and
as the auricle contracts, the steam forces open
the stiffened mitral segments, thus causing the
extra sound. The French called it “ le claquement
de I'ouverture de la milrale.” In arterio-sclerosis,
the mechanism is somewhat similar. The auricle
contracts and forces the stream of blood through
the unimpaired valve, so that it impinges against
the wall of the left ventricle, before the latter is
fully dilated. The tardiness of the left ventricle
in accomplishing its diastole is due to the fact that
it is no longer purely muscular, that its substance
has become invaded by fibrous tissue. This
degenerative myocarditis represents the final stage
of the process which beginning as functional high
tension, leads progressively to arterial degenera¬
tion and cardiac involvement.

Inasmuch as these two conditions, chronic
degenerative myocarditis and mitral stenosis, are
both characterised by dyspnoea, that in both
there may be haemoptysis and oedema, and that
in both the systemic blood pressure is liable to
be very high, it is not surprising that in certain
cases confusion may creep in. The importance,
therefore, of ascertaining the real size of the heart
by careful percussion cannot be over-estimated.
In mitral stenosis the enlargement is to the right,
in myocarditis the enlargement is to the left.

LECTURE._ The Ml dicai, Press 7

Where the mitral stenosis is accompanied by
mitral regurgitation, the left ventricle may indeed
be enlarged, but even so, the bulk of the
enlargement wall be on the right side, whereas
in arterio-sclerosis the bulk of the enlargement
is always on the left.

This next patient came to hospital complaining
that though he could point to nothing which was
definitely wrong with him, he had been feeling
out of sorts for several weeks. When I came to
examine him I found that he had a blood pressure
of over 200 mm. Hg., and that his liver was en¬
larged, practically to the level of the umbilicus.
His heart sounds are very difficult to hear, especi¬
ally the systolic sound at the apex, but his aortic
second sound is definitely accentuated. He has
no murmurs or interpolated sounds, and his urine
is free from albumen and casts. The case I believe
to be one of hepatic cirrhosis of the alcoholic
type, and I believe it to have been induced by
high arterial tension whose long continuance
unchecked has caused a sclerosis in the vessels of
the liver. The subject of the causation of hepatic
cirrhosis is not one which invites to dogmatism,
but I submit that this view, which is very generally
taught in France, serves to explain a good deal
which on all other hypotheses must remain obscure.
Moreover, cirrhosis of the liver of the alcoholic
type is admittedly associated with general arterio¬
sclerosis and degenerative disease in the kidneys
and heart. The hepatic manifestation may be
regarded then as a part of a general toxaemia,
the first physical sign of which has been a func¬
tional hyper-tension, leading insensibly to degener¬
ative disease in the arterioles of the organ.

The two remaining patients are both women,
and, characteristically enough, they display the
results of their hyper-tension in the domain of the
nervous system. This woman comes to us with
the story of an attack of unconsciousness followed
by a loss of power on the left side of the body—in
point of fact a hemiplegia. There seems no reason
to doubt the accuracy of her statements, because
in out-patient practice we are familiar with numer¬
ous cases of a similar kind. These people have
attacks of unconsciousness followed by paresis
of one side of the body. They are admitted to
the wards, and a short time afterwards they are
discharged perfectly well. In the cases to which
I refer, although the loss of power is quite definite,
there are never any subsequent signs to indicate
the existence of descending degeneration in the
spinal cord. If you will examine this woman you
will find that she has no ocular phenomenon, that
her tongue is protruded mesially, that her grasps
on both sides are equal, that her knee jerks are
present, moderate in extent, and equal on the
two sides, and, further, that she is free from ankle
clonus, and that her plantar response is flexor.
Now what is the explanation of these cases?
The causes of hemiplegia are haemorrhage, throm¬
bosis, embolism and new growths. But it is
obvious that any one of these, if sufficiently severe
to give rise to an attack of unconsciousness must
destroy a certain portion of the brain substance
and give rise to permanent impairment of function.
In this woman nothing of the kind has happened.
We are justified therefore in assuming that what¬
ever the cause of her hemiplegia, it was not one
of the four classical causes which are generally
recognised. There was in our grandfather’s time
a condition which used to be spoken of as “ serous
apoplexy ” and I am strongly inclined to believe

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8 Thz Medical Piess.

ORIGINAL PAPERS.

July 3. * 907 -

that the physicians of those days were right in
their contention that such a condition can exist.
If, for instance, we suppose a greatly increased
fulness in the cerebral vessels, the inevitable result
would be a filling of the ventricles and a pressure
applied in all directions to the substance of the
brain. Why that pressure should affect one side
more than another, it is no more possible to explain
than why it is that one artery should rupture in
preference to another. When this woman came
to see us, I thought I would test this view of the
question by measuring her arterial tension, and I
found that it was no less than 190 mm. Hg. Now
if it stands at that figure generally, to what height
must it rise in states of excitement or in such other
conditions as we know to be capable of increasing
the inter-vascular tension ? And if in such con¬
ditions it rises, as we may assume that it does,
another 20 or 30 mm., it is not very difficult to
believe that the pressure within the cranium may
be such as to cause an effusion into the ventricles,
and so press upon one of the internal capsules as
to give rise to a passing hemiplegia. For we have
to remember that the vessels in the brain are
endowed with a power of contraction so slight
that some competent observers still doubt its
existence. A general rise of blood pressure would
therefore certainly give rise to an overfulness of
these arteries.

This last case is one of ordinary Bell’s palsy,
that is to say, a paralysis of the left side of the
face unaccompanied by any condition which would
lead us to suppose that the seventh nerve inside
the cranium is organically affected. I need not
remind you of the methods at our command for
determining the exact seat of the lesion which
may cause a facial paralysis of the peripheral
type. The points are dwelt upon in the text¬
books and are beloved of examiners. The ana¬
tomical fact to which I want to direct your atten¬
tion is well shown in this diagram of the cerebral
arteries at the base of the brain in “ Quain’s
Anatomy.” There you will see that the anterior
inferior cerebellar artery is given off by the basillar
as soon as the latter has passed from the medulla
to the pons. The branch as it passes outwards
threads its way between the 6th, 7th, 8th, 9th,
10th, and nth cranial nerves, and it is a remark¬
able fact that it passes over them all except the
7th and 8th, which two it passes under.

Now these cases of Bell’s palsy are, as you know,
described as “ rheumatic ” in origin, which is
merely another way of saying that we have not
the slightest idea as to their cause. “ Rheu¬
matic ” to the aetiologist is an even more blessed
word than ever Mesopotamia was to the theologian.
I suggest that the anatomical distribution of this
anterior inferior cerebellar artery may supply us
with the explanation of this condition, whose
cause has hitherto seemed so obscure. This
woman, for example, has no rheumatic or “ chilly”
history, but she has a very high blood pressure.
Her artery as it crosses these two nerves is there¬
fore presumably distended. If, by emotion or
“ chill ” or what not, this distension becomes
augmented, it is not difficult to imagine that the
vessel might exercise sufficient pressure upon the
seventh and eighth nerves to give rise to serious,
if temporary, embarrassment of function. In
support of this explanation is the fact that
this patient had a certain amount of deafness
which accompanied the onset of her palsy ; the
deafness and the palsy having disappeared co¬

incidently. In further support of facial paralysis
of the so-called “ rheumatic ” type having some
causal relationship with high blood pressure is
the fact that the only drug which hitherto has
seemed to be of any service in the paralytic con¬
dition is iodide of potassium, and iodide of potas¬
sium, as we know, is a powerful reducer of blood
pressure. The element of increased blood pressure
in the causation of this affection is therefore one
which seems to be deserving of more attention
than it has hitherto received.

In endeavouring to come to a conclusion on the
subject of the state of blood pressure when no
instrument is available, I have already pointed
out the futility of palpating the pulse at the wrist.
A far more satisfactory method of arriving at a
general conclusion is that of estimating what the
French call the stability of the pulse. The pulse
rate, we know, is normally 6-8 beats more rapid
in the upright posture than it is in the recumbent.
If this difference tends to become abolished then
the probability is strong that the pressure in the
arteries is unduly high ; and if it becomes reversed,
so that the rate in the recumbent posture is greater
than that in the upright, not only is it certain that
the pressure is unduly high, but the probability is
great that matters have progressed to the point of
producing definite organic disease. This proba¬
bility is rendered even more pronounced if, on
examining the heajft, we find the apex beat dis¬
placed to the left, a sign which by some authorities
is considered as undoubted evidence that there is
a sclerosis of the arteries in the splanchnic area.

Note. —A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture
for next week will be by E. Percy Paton, M.S., F.R.C.S.,
Surgeon in Charge of Out-Patients to Westminster
Hospital. Subject: " Some Observations on Intra-
Abdominal Adhesions with Illustrative Cases."

ORIGINAL PAPERS.

THE TREATMENT OF TYPHOID
FEVER.

By E. STADELMANN, M.D.,

Hofrath Tit. Professor der Innere Medirin, and Director oft’he Stadtl.

Krankenhaus am Friedrichshain, Berlin. „ - «

The strivings after a specific form of treatment
have, unfortunately, not led us much further. A
serum, by means of which we could cut short
typhoid, or modify or shorten its course, still re¬
mains undiscovered. The preliminary report of
prophylactic inoculation appears to have given
better results. Both in the Boer war in South
Africa and in our own field-work in South-West
Africa, typhoid fever has claimed its terrible sacri¬
fices. The number of infections after preventive
inoculation with deadened typhoid cultures carried
out at home are said to have been considerably
diminished. The breadth of bearing of this obser¬
vation cannot be seen at a glance with any cer¬
tainty, and at the present time no physician is in
a position to be able to recommend preventive
inoculation to those belonging to the families of
those ill of the disease, somewhat in the same
way as is done in the case of diphtheria, and
often with good results. Wherefore the strivers
of older dates who sought for an abortive
treatment of typhoid fever have still many
adherents. Liebermeister, to this end, recom¬
mended treatment by iodine—1 part iodine, 2
parts potassic iodide, 10 parts water, of which 3

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July 3, 1907.

ORIGINAL PAPERS.

The Medical Pees*. 9

to 4 drops were to be given every four hours in a
glass of water, or potassic iodide alone in doses of
1 to 4 grm. daily. The calomel treatment had the
same aim—2 to 3 doses of 0.2 to 0.3 grm. in the
twenty-four hours for one day in tne first or
second week of the disease. It is quite conceivable
that with the copious stools following the medi¬
cine, a good deal of infectious material was
removed from the bowel, and that a certain amount
of intestinal disinfection was obtained. I have
often thought I had seen good results from this
procedure in recent cases. But, on the other hand,
I have never seen any from the administration of
naphthalin, naphthol (40 grm. in one dose), or
bismuth salicylate, which should also have a dis¬
infecting action in the bowels.

Independent of the general management of
typhoid patients (rest in bed, arrangement of the
room, &c.) that is generally understood, the diet
is of eminent importance. The food must be fluid,
easily digested and absorbable. That many body
substances, especially body albumen, are destroyed
under the influence of the re-absorbed toxines, and
of the fever, is undoubted, and it is impossible to
prevent the consequences of this destruction by
giving large quantities of albuminates and other
feeding material. It must naturally be our endea¬
vour to prevent the loss of bodily substance as
much as possible, but this can only be effected by
giving chiefly carbohydrates. The sickly organism
does not bear flesh meat even in the mildest forms,
and the patients object to taking it, and there are
great difficulties in the way of giving fats, and even
carbohydrates. In the first line in typhoid cases
we must fall back on milk, which later on we may
make more palatable to the frequently-objecting
patient by the addition of coffee, cocoa, oatmeal.
Milk soups, meat broths, soups of meal, rice,
groats, even children’s prepared foods, afford
further changes, which we can make more
nourishing by the addition of yolk of egg. The
various artificially-prepared foods mav also be tried,
but more important and more nourishing is an egg
in a glass of milk. Gelatine substances are an im¬
portant nitrogenous food material which can be
given to the patient as meat jelly, wine or fruit
jelly. Fats are, at the most, to be given in the
meals or groat gruel; cream, as whipped cream,
with sugar, should be tried. Carbohydrates are
best given in the form of sugar in the drinks, and
a trial should be made of preparations of malt,
In the feeding of typhoid cases it should be the
rule to give something every two hours. In
practice, however, when the patient is so often
opposed to it, and there is as often a tendency to
vomit, it is sometimes a very difficult thing to do.
But you must not lose patience; you must still
coax and try something new and novel.

A question as important as that of food is that
of the drinks. The fever patient, with his raised
temperature, requires a deal of water; he lies more
or less in a 6emi-conscious state with half-open
mouth, mouth, tongue, palate and fauces dried up,
and a strong feeling of thirst is the outcome. We
must not only satisfy this, but we must make the
patient drink. Pure, fresh water is in the end the
best taken by the patient, but there is no objection
to the various lemonades. An excellent drink for
quenching thirst is weak, sweetened, cold tea. A
warning must be given as regards mineral waters
that act as aperients or that distend stomach and
intestines with carbonic acid gas. There is no
objection to small doses of alcohol ; large doses,
such as were formerly given, are dangerous and
even hurtful. The stimulating action of alcohol
has not been proved, and our pharmacopoeia offers
us endlessly better and less harmful stimulants
than that agent, and it possesses no antifebrile
properties whatever.

The Antipyretic Methods of Treatment.

I. Hydrotherapeutics .—In regard to fever, there
are, as is known, two opposite views. The one,
the older, sees in it a factor destructive to the
organisms that must be combatted with the most
powerful remedies; the newer view considers the
fever as a protection to the organism against the
toxic substances that have found their way into
it. The truth here lies between the two; unusually
high and long-continued high temperatures cer¬
tainly result in serious mischief to the organism.
But the fever alone does not dictate the treatment;
the experienced physician does not judge of the
severity of the disease from the height of the tem¬
perature alone; the patient’s general condition is
of far more importance to him. Experience teaches
that cold baths, independent of the lowering of the
temperature, act favourably in quite other direc¬
tions. They make the sensorium freer, the pulse
becomes stronger and less frequent, the morbid
conditions of the respiratory tract improve, or they
are arrested at the onset, food is better taken, the
skin is properly cared for by the very treatment
itself; decubitus, that occurred so frequently in
former times, is avoided, the patients breathe more
calmly and freely, the urine and stools are no
longer voided involuntarily, &c. We have there¬
fore arrived at quite different views as to the kind
and manner of hydrotherapeutic treatment, as well
as the indications for it. I have given up the for¬
mer rule of ordinary baths at 16-12-10 (R), as soon as
the temperature in the axilla has reached 39.5 (C),
and content myself with cool or lukewarm baths at
30 to 32 (C). Here also one sees the temperature
fall 1 to 1$ to 2 degrees, and the ■ favourable in¬
fluence on the general condition manifests itself.
It is certain that in later time, even if the dangers
of typhoid fever are unchanged, the temperature
curves are undoubtedly considerably altered. The
temperature curves, with a constant high tem¬
perature lasting two to three to four weeks, I have
not seen for years. The fever has from the first
a pronounced intermitting character, and main¬
tains it through the whole duration of the fever.
The baths are begun early, and continued until the
fever ceases. Two or three a day are given gener¬
ally during the height of the disease. If the
temperature in the morning is normal one bath
only is given, and that towards evening.

Of other hvdratic forms of treatment to be men¬
tioned are cold douching, which is not advisable,
wet packings, which have onlv a slight effect,
sponging of the body with cold water (not over
12 R.I, with vinegar and water, 1 part to 4.
The procedure is a mild one and may be used when
baths, from any cause, are not allowable; the
washing, if it is to be serviceable, must be re¬
peated every two to three hours. The protracted
warm baths introduced by Riess at a temperature
of 25 to 27 R., in which the patient lies for hours,
are used especially for very excitable patients as well
as for alcoholics, and have a very soothing effect.
The bed-bath, introduced by Kronig, may also be
mentioned, of which I have no experience.

Bath treatment must be unconditionally for¬
bidden in cases of intestinal haemorrhage, peri-
tonitic irritation, as well as in peritonitis. One
must be very cautious in cases of cardiac weakness,
cardiac diseases, arterio-sclerosis, old heart
failure, tuberculosis, bronchiectasis, that is,
diseases with a tendency to haemorrhage from the
lung tissues, in emphysema of the lungs, in old
fatty people, in chlorosis, anaemia, and alcoholics.
Priessnitz packings, when baths are not available,
are quite suitable.

II. Antipyretic Medicines .—A large series of
febrifuges have been used, quinine, antipvrine,
phenacetin, antifebrin, lactopnenine, pyramidon.

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10 The Medical Press.

ORIGINAL PAPERS.

July 3, 1907.

These I practically never give, as I have become
convinced that no real advantage can be gained by
them. Antipyrin has very unpleasant bye-effects
as regards the stomach; phenacetin and antifebrin
are poisonous drugs best altogether eliminated
from the physician’s armamentarium. In regard
to lactophenine, which in doses of from 4 to 6 grm.
daily brings about a prompt reduction of fever, I
have no experience. Pyramidon is said to act in a
similar way, but I cannot join in its praise. Often,
in doses of 0.25 to 0.30, given five times a day, it
has failed to reduce the temperature for any length
of time. Vomiting often took place after it; loss
of appetite, and profuse sweating distressed the
patient very much. The salts of pyramidon do no
better. Quinine acts best given in one dose of

1 grm. to i£ grm. before the height of the fever.
But even this drug has so many disadvantages
(singing in the ears, a species of intoxication, deaf¬
ness and feeling of unwellness, tremors, and even
collapse), that I now scarcely ever use it in typhoid;
it cannot be compared to the treatment by baths.

The Treatment of the Disturbances on the
Part of the Various Organs.

The disturbances of the central nervous system
(somnolence, apathy, restlessness, delirium, sleep¬
lessness, &c.) are influenced in the most favourable
manner by the baths. With them an ice-bag may
be applied to the head. In case of great restless¬
ness and insomnia a morphia injection of 0.01 to
0.015 grm. may be given with a favourable effect
on the general condition also. On the side of the
circulatory apparatus the dangers of threatening
cardiac weakness are very great. In such cases of
collapse I have never seen any real good from
alcohol. It is much more important to make
use of the excellent excitants we nave in our phar¬
macopoeia. Digitalis does not act favourably, and
is very often badly borne. On the other hand,
early subcutaneous injections of Ol. camphoratum
and natrosalicvlate of caffeine (in heroic doses 1 to

2 syringefuls of a solution of 2 : 10 every two
hours); aether is uncertain in its action, and extra¬
ordinarily painful. The intestinal tract demands
special careful supervision and therapeutic treat¬
ment. Moderate diarrhoea requires no medicinal
treatment; on the other hand, if it is profuse I
prefer giving ten drops of tinct. opii. in a mucilage
or starch enema. Excessive meteorism is very
favourably influenced by bismuth subnitrate or
subsalicylate, the application of an ice-bag, or the
insertion of a rectal tube. If the bowels are
blocked, no aperient must be given, but a mild
enema or injection of oil.

In haemorrhage from the bowels, even if of the
slightest, absolute rest, limitation of diet and
drinks, and the baths must be stopped. If the
haemorrhage is severe, only pills of ice should be
given for the thirst. Medicinally, acetate of lead,
0.05 to 0.1, every hour or two, dialyzed ext. ergotae
2 : 10, a syringeful every half hour or every hour,
stypticine 0.03 to 0.1 several times a day by sub¬
cutaneous injection, gelatine (pure) injected in a
2 to 5 per cent, solution, at first 4 grm. at once,
then twice more in a dose of 2 grm. at intervals ol
a day or two. An absolutely reliable (sterilized)
preparation is made by Merck, of Darmstadt, the
solution being already prepared and put up in sealed
vessels. Adrenalin, 10 drops of a 1 : 1,000 solu¬
tion, every two hours for a day or two days. I
have never been able to convince myself with cer¬
tainty of the beneficial action of the two remedies
last named. In case of violent and repeated epis-
taxis, careful tamponnade of the nostril affected
from behind.

When perforation of the bowel takes place the
prognosis is almost hopeless. Absolute rest, pro¬
hibition of all foods, and even fluids. Whether

any real good is obtained by operative measures I
do not know. In addition to rest and cold applica¬
tions, opium and morphine should be given to keep
the bowels quiet, and to favour the formation of
adhesions and the relief of pain.

For the prevention of extensive catarrh of the
lungs and pneumonia, cold water treatment is the
most suitable. Decubitus must be avoided with
the most painful care; typhoid patients must be
placed from the first on a water-cushion, and in
furtherance of avoidance of the mischief, bath
treatment is still the best on account of the cleanli¬
ness and care for the skin associated with it. On
the first sign of its appearance the part must be
rubbed with spirit of camphor, boric lanolin, or
boric vaseline. If decubitus has already appeared,
a dressing of antiseptic remedies must be ordered,
amongst which a 1 in 30 dressing of balsam of
Peru is suitable. Great care must be taken re¬
garding the onset of an attack of nephritis, in
consequence of toxic material either taken into the
system or arising from the typhoid bacilli them¬
selves. If the bladder becomes paralysed the
catheter must be made use of.

Relapse and recurrence are to be looked upon as
very dangerous; their treatment does differ from
that of the original fever, but on account of the
organism being already weakened by the preceding
illness, the greatest caution is necessary, especially
as regards treatment by baths.

After convalescence has set in, the fluid diet
must still be continued for a week; not till then
may the patient take more solid food in the shape
of soaked and softened biscuit (Zwiebach) or Eng¬
lish biscuit, gruel, &c. Flesh meat must not be
given for ten or fourteen days, and then either
scraped or minced. After the third week the
ordinary diet may be given. Exceedingly strict
warning must be given against any errors in diet;
even if they cannot cause a relapse they can, at
any rate, favour the onset of one, as the virulent
bacilli still present in the intestines may, after
anv error of diet, possibly set up a new disease.

In milder cases, if the patient is not too much
run down, he may attempt to get up after the fever
has been away for a fortnight; but in severe cases
not until after three or four weeks. The time for
being out of bed may gradually be lengthened, and
if the weather is fine the patient may go out after
the fourth week. The usual vocation should not
be returned to until after another six or eight
weeks’ recuperation. The consequence of return¬
ing to work too early and before the powers have
become restored is a long lingering feeling of lassi¬
tude, inability to work properly, and general feel¬
ing of not being well.

A NOTE ON RHINORRHCEA. IN
FAUCIAL DIPHTHERIA.

By J. D. ROLLESTON, M.D., B.Ch., Oxon.

Assistant Medical Officer, Grove Hospital.

From an early stage in the history of diphtheria
the occurrence of nasal discharge preceding 01
accompanying the angina has been well known.
Misled by the fact that a nasal discharge, ap¬
parently benign in nature, may sometimes precede
very severe diphtheria, Bretonneau, who first
established diphtheria as a specific disease,
formulated the law that diphtheria always has a
nasal origin. The nasal fossae according to him
were the nest from which the membrane is carried
to the lower parts. The exaggeration of this
statement was obvious. Trousseau, between
whom and Bretonneau a controversy arose,
had no difficulty in showing that diphtheria is
not always preceded by a nasal discharge, and

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July 3, 1907.

ORIGINAL PAPERS.

The Medical Peess. II

fell into the opposite error of denying the possi¬
bility of the nasal onset of diphtheria. Mem¬
branous coryza, according to Trousseau, was
merely a complication of the angina. The
question of the nasal origin of diphtheria was soon
forgotten, and it is only within the last few years
that it has been revived by Sevestre, who states
that careful inquiry from the parents of children
affected with faucial diphtheria will often elicit
a history of a nasal discharge. More recently
Marfan has declared that while it is rare for a
child to complain of a sore throat at the very
beginning of diphtheria a mucous hypersecretion
of the nostrils at that time is not uncommon.
The pharyngeal tonsil, according to Marfan, is
probably the site of origin of diphtheria. It is
obvious that pre-existing adenoids would pre¬
dispose to diphtheria originating in such a spot.
The frequency of adenoids in fatal cases of diph¬
theria has been shown by Cottier, who in 38
autopsies on diphtheria patients found adenoids
in 50 per cent.

The great authority of Trousseau is responsible
for the erroneous doctrine that a nasal discharge
in diphtheria is invariably of bad omen. “ Coryza,
even of a slight degree, is a serious occurrence,
for it indicates that the specific phlegmasia
has invaded the nasal fossae. ... Of 20
individuals affected with nasal diphtheria 19
succumb, while of 20 affected with croup you
can save a certain number by tracheotomy.”
Two subsequent writers of the pre-antitoxin era,
Cadet de Gassicourt and Henoch, showed that
Trousseau’s statements were too absolute, both
asserting that a nasal discharge during the acute
stage of diphtheria was compatible with a mild
attack. The truth of this view is confirmed by
my own experience, as will be seen below.

The present paper is based on 1,200 consecutive
cases of diphtheria that have been under my
care in the course of the last four years. Of
these, 323, or 26.91 per cent., on admission to
hospital, or subsequently during the acute stage,
presented a discharge from the nose. There was
also a history of recent nasal discharge since the
commencement of the disease in 177 others (14.75
per cent.), though in them no nasal discharge
was observed either on admission or subsequently.
Thus a total of 500, or 41.6 per cent, of all the
cases had some nasal involvement, (a) These
figures are probably too low, for a slight degree
of nasal discharge before admission to hospital
may have escaped the notice of the patient
or his friends. Further, it must be borne in mind
that the absence of rhinorrhcea, or of visible
membrane in the nostrils, does not necessarily
imply that no nasal diphtheria exists. The nasal
membrane may, as autopsies show, be limited
to the posterior part of the nares, from which
the discharge passes down into the pharynx
instead of externally.

As only four of the 177 cases with nasal dis¬
charge prior to admission had received antitoxin
before admission, and two of the four on the same
day that they were admitted, it is obvious that
nasal discharge may cease spontaneously. This
is most likely to occur in cases which run a mild
course, as is shown by the following tables, Irom
which it is seen that, while the self-limiting
nasal discharge becomes progressively more
frequent in the milder cases, the more persistent

(a) Seven purely laryngeal cases and six purely nasal cases which
have not been included complete the 1,300 cases.

i nasal discharge becomes progressively more
frequent in the severer cases.

Table I.—Cases in which nasal discharge
occurred as a prodromal symptom, but was not
present on admission to hospital or subsequently.

Character of Faucial
Attack.

Total Number
of

Cases with Pro¬
dromal Nasal

Percentage,

Faucial Cases

Discharge.

Very severe ..

I 21

9

7-43

Severe .

225

24

io*6

Moderately severe

108

12

11. t

Moderate

305

53

17-37 .

Mild .

428

1.187(b)

79

177

18*45

Table II.—Cases in which nasal discharge
was present on admission, or developed subse¬
quently during the acute stage.

Character of Faucial
Attack.

Total Number,
of

Faucial Cases.

Number of
Cases with
Nasal
Discharge.

Percentage.

Very severe ..

121

89

73-55

Severe .

225

112

4977

Moderately severe

108

30

277

Moderate

305

48

1573

Mild .

428

44

10*28

I.I87

323

Further evidence of the greater severity of the
cases in which the nasal discharge persisted
until admission is afforded by the following
figures. Out of 92 deaths in the 1,200 cases
16, or 18 per cent., occurred in the purely faucial
cases, among which are included those which
had a history of nasal discharge prior to admission
only ; 14 or 11.1 per cent, occurred in the faucial
and laryngeal cases ; while in the faucial and
nasal cases there were 59 deaths, or a mortality
of 18 2 per cent. Intercurrent diseases were
responsible for 3 deaths, two being due to scarlet
fever, and one to congenital syphilis.

The incidence of albuminuria and paralysis,
the frequency and severity of which bear a direct
relation to the character of the initial attack,
was greatest in the nasal cases. Thus, among
the purely faucial cases there were 135 paralysis
cases (15'6 per cent.), 27 of which were severe,
while in the faucial and nasal cases there were
143 paralysis cases (44 2 per cent.), 59 of which
were severe. So with albuminuria. In the
faucial and nasal cases there were 215 albuminuric
cases (66*5 per cent.), in 32 of which the albumin
persisted for three weeks or more ; in the purely
faucial cases there were 395 albuminuric cases
(45 8 per cent.), in 19 of which the albumin was
present for more than three weeks.

In the cases of self-limiting nasal discharge
the rhinorrhcea was a very early symptom
starting as a rule at an earlier date than the nasal
discharge which persisted until admission.

This is shown by the following tables :—

Table III.—Day of disease on which a nasal
discharge was first noted in cases which on
admission and subsequently had none.

(6) Very similar figures are auotcd by Glatard, who says that 0U9
of 177 cases of diphtheria admitted to the HApital Bretooneau, 44.V
per cent, contained diphtheria bacilli in the nose. The great majoritn
of those cases showed clinical evidence of nasal diphtheria as well. It
pre-antitoxin times Gamier (quoted by Glatard) found nasal diphtheria
in 41*03 per cent., or in 39 out of 95 cases.

Digitized by > ^.oogle

12 Thk Medic At Pke's.

ORIGINAL PAPERS.

July 3. 1907.

1st day

.. 88 cases

2nd „

• • 43 »

3 rd „

.. 28 „

4 th „

.. 6 „

5 th „

.. 7 ..

6th „

.. 5 ..

177 cases

Table IV.—-Day of disease on which a nasal
discharge was first noted in cases in which it
was present on admission or subsequently.

1st day

.. 89

2nd „

.. 69

3 rd ,.

.. 68

4th ,,

.. 50

5 th „

•• 37

6th ,.

.. 6

7th „

■ • 4

323 cases

Though the self-limiting nasal discharge was
more common in young children it was not
confined to them ; 26 out of the 177 cases occurred
in patients between the ages of 10 and 36 years.

A previous history of recent nasal discharge
was more frequent in the laryngeal cases than
in those which were purely faucial. Out of 133
laryngeal cases in the 1,200, 31, or 23.3 per cent.,
had such a history; while out of 861 purely
faucial cases, 152, or 17.65 per cent., had had
a nasal discharge at the beginning of their illness.
It is interesting to note that in three out of seven
cases (42.8 per cent.), which on admission were
clinically cases of purely laryngeal diphtheria,
there was a recent history of nasal discharge.
Such cases are especially likely to occur in very
young children. The nasal diphtheria of infants
usually remains localised to the nose, but it
may spread, the membrane passing down the
sides of the pharynx, where it may easily escape
observation. In seven cases of nasal diphtheria
in nurslings recorded by Ballin there were two
in which the larynx was affected.

Summary.

1. A large percentage of all cases of faucial
diphtheria admitted to hospital has a history
of rhinorrhoea.

2. In a certain number of cases which clinically
are purely faucial, rhinorrhoea is an early symptom,
subsequently disappearing without treatment.

3. The frequency of this early and transitory
rhinorrhoea bears a direct relation to the mildness
and an inverse relation to the severity of the faucial
attack.

4. Faucial cases which are also clinically
nasal are more severe than those which are
clinically faucial only.

5. Faucial cases which are also clinically nasal
as a rule develop the nasal discharge at a later
date than those which are clinically faucial only.

6. Early and transitory rhinorrhoea is relatively
more common in laryngeal cases than in those
that are purely faucial.

Rxfvrknces.

1. Ballin, quoted by Faseuille. loc. cit.

2. Bretonneau. Memoirs on Diphtheria. New Sydenham Society,

*859-

3. Cadet de Gassicourt. Traits clinique des maladies de l'enfance,
1884.

4. Faseuille. Thbse de Paris, 1906.

j. Glatard. Thfcse de Paris, 1906.

6. Henoch. Lectures on Children's Diseases. New Sydenham
Society, 1889.

7. Marfan. Lemons Cliniques snr la Diphttrie, 1903.

8. Plottier. Laryngoscope, 1899, p. in.

9. Sevestre, in Comby’s Trait6 des Maladies de l’Enfance, Tom. 1,
1904.

10. Trousseau. Clinique Medicate, yt Edition, 1883.

URAEMIA (a).

By ALFRED E. RUSSELL, M.D.Lond., M.R.C.P., 1
Assistant Physician West London Hospital.

The purpose of this paper is to put forward the
proposition that there is evidence to show that the
cerebral manifestations of uraemia are dependent
upon cerebral anaemia, produced by an increase in
intracranial tension resulting from cerebral oedema.
In other words, the old and abandoned hypothesis of
Traube will be reconsidered in the light of recent
experimental and clinical work on conditions of
increased intracranial tension with their associated
alterations of blood pressure.

(1) The Physiological Results following In¬
creased Intracranial Tension.

This question has been studied experimentally by
Harvey Cushing (6). He increased intracranial tension
in dogs by trephining and applying pressure to the
surface of the brain by means of a distensible rubber
bag, communicating with a burette containing mercury.
He showed that if the intracranial pressure be rapidly
increased, “ Kussmaul Tenner spasms, evacuation
of bladder and rectum, practical cessation of respira¬
tion, and pronounced vagus effect upon the heart,
often with a complete standstill, lasting from ten
to twenty seconds, may develop. Then follows a
release from this extreme vagus inhibition and the
vasomotor centre exerts its influence.” With a slower
increase of the intracranial pressure a different series
of events occurred. The pressure against the brain
could be increased to the point of its equalling the
blood pressure before any symptoms referable to
the centres in the medulla were called forth. Direct
examination of the cortex through a circular disc
of glass fitting tightly into a second trephine hole
showed, at this period of equalisation of blood pressure
and intracranial tension, an abrupt blanching of the
exposed convolutions. The pulsating arteries could
be seen against the blanched background and the
dark blue veins in the sulci remained filled with blood,
but presumably little, if any, circulation passed
between them. The usual consequence was not
death but a stimulation of the vasomotor centre, which
occasioned a rise in blood pressure sufficient to overcome
the high intracranial tension ; the cerebral circulation
was re-established and the rosy colour could be seen
through the glass window in the trephine hole to
return again to the blanched convolution. With
further increase in intracranial tension the blood
pressure rose pari passu, and always to a point exceed¬
ing the intracranial tension. This process could
be repeated until the arterial pressure was forced to
two or three times its normal level, sometimes to as
much as 250 mm. Hg., without evidence of vasomotor
failure.

If by division of both vagi their influence on blood
pressure and pulse rate were cut out, the blood pressure
followed the increase of intracranial tension even more
closely. If the spinal cord were divided in the cervical
region, and thus the vasomotor control of the great
splanchnic area lost, then increase in the intracranial
tension produced only a vagus slowing of the pulse
with no rise of blood pressure ; while if both cord
and vagi were divided no alteration whatever in
either pulse or blood pressure occurred on increasing
the intracranial tension. In face of these experi¬
ments Cushing’s conclusion that an increase of intra¬
cranial tension occasions a rise of blood pressure
which tends to find a level slightly above that of
the pressure exerted against the medulla seems
absolutely justified. By this mechanism the vital
centres in the medulla and the life of the brain and
entire animal are protected.

(«) Read at a meeting of tlie West London Medico-Chirurgical Society,
December 7th, 1906.

(6) “ The Regulatory Mechanism of the Vasomotor Centre which
Controls Blood PressureMuring Cerebral Compression ."—Johns Hopkins
Bulletin, Sept. 1901. For fuller account see also Cushing's Miitter
Lecture for 1901, in the American Joum. of the Med. Sciences, Sept.,
1902.

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July 3 ,1907-

ORIGINAL PAPERS.

The Metical Press. 13

(2) Certain Clinical Conditions Associated with

an Increase of Intracranial Tension.

It is well established that many of the symptoms
of cerebral tumour, hydrocephalus, cerebral haemorr¬
hage, Ac., are dependent upon an increase of the
intracranial tension. Among such symptoms may
be mentioned headache, vomiting, coma, convulsions,
choked disc, &c. Extraordinary relief to these
symptoms is attained after the pressure is relieved
by surgical intervention. An admirable series of
cases has been recorded by Harvey Cushing (a). In
another paper Cushing ( b) gives the records of five
cases of intracranial haemorrhage, four traumatic and
one apoplectic. These illustrate from the clinical
standpoint the facts ascertained by him experi¬
mentally. As the case of apoplectic hemorrhage is
of great importance I give it in detail.

Resume .—Apoplexy with right hemiplegia, symp¬
toms of pronounced intracranial tension evidenced
by a blood pressure ranging about 300 mm. Hg. ;
threatened symptoms of medullary paralysis, major
symptoms (bulbar) immediately relieved by cranio¬
tomy and aspiration of intracerebral clot, subsequent
replacement of flap, death on the third day from
pulmonary complications.

Man, aet. 40, admitted to hospital thirty-six hours
after onset of symptoms. He was in a state of pro¬
found stupor with right-sided flaccid paralysis.
Temperature 99.6° ; respiration varied from 21 to 27 ;
pulse 50 and of high tension, registering 300 mm. Hg.
Conjugate deviation of eyes to right with nystagmus.
Pupils equally contracted and reacted to light. Veins
of forehead were greatly distended.

Operation .—A large osteoplastic flap was turned
down over the left hemisphere. The dura was tense
and without pulsation. On incising it the brain
bulged far into the opening and began to pulsate
actively. The convolutions were greatly flattened,
deeply cyanosed, and the veins occupying the sulci
were widely dilated, and their contents so dark that
the colour contrast between veins and arteries was of
an unusual degree. Blood was evacuated from the
hemisphere by means of a grooved director, about
two teaspoonfuls. The blood pressure began at once
to fall and in twenty minutes had reached the normal
level. The pulse rate during this fall in blood pressure
remained unaltered. The release from intracranial
tension was evidenced by the immediate collapse
of the bulging hemisphere. On the following day
the patient’s condition had greatly improved. The
pulse rate and blood pressure remained normal,
respiration was no longer laboured, stupor was much
less deep, and he could be roused with considerable
ease. The conjugate deviation disappeared and he
seemed to see and recognise objects. Stupor returned
on the following day, though the blood pressure only
rose to about 160 mm. Hg. ; oedema of lungs set in,
and he died two days later. Post mortem, a large
hemorrhage was found in the white centre of the
left hemisphere.

The clinical evidence as obtained, therefore, from
cases of cerebral tumour, cerebral haemorrhage, &c.,
is in complete accord with the conclusions derived
from a study of Harvey Cushing’s experiments. To
recapitulate—it is clear that a rise in intracranial
tension by the introduction of any foreign element
such as a tumour mass, blood, &c., must tend to
diminish the blood flow through the brain. If the
tension increases, a point would be reached at which
the intracranial tension equals that of the general
blood pressure. The cerebral circulation would
therefore cease were it not that by a compensatory
process the general blood pressure rises to a point
above that of the intracranial pressure, and thereby
maintains the flow of blood through the brain.

But with a great increase of intracranial tension,
certain general effects are produced apart from focal
symptoms dependent upon the position of the lesion.

(a) Surgery, Gynacology, and Obstetrics, Vol. I., No. 4, Oct., 1905.
>- * 97 - 3 « 4 -

(t>) American Joum. of the Medical Sciences, June, 1903.

Headache, for instance, is common, and is probably
attributable to tension of dura mater and tentorial
structures. It is probable that the brain tissue
itself is insensitive, and the fact that Cushing notes
that after excision of the Gasserian ganglion for
severe trigeminal neuralgia, any subsequent headache
is only felt on the side with the intact fifth nerve,
points in the direction that intracranial pain is experi¬
enced via the fifth nerve.

Optic neuritis is to be attributed, in the main, to a
passive venous congestion of the retinal veins, and
subsides or improves on relief of intracranial tension,
sometimes with extraordinary rapidity.

Finally, coma is almost invariable in the last stages
of cerebral tumour and in large cerebral hemorrhages.
Convulsions are also frequent in these conditions.
Both are remarkably improved by methods capable
of lowering the cerebral pressure, such as trephining
or lumbar puncture. And it is to be noted that, by-
lowering the intracranial tension, a free access of
blood to the brain is facilitated.

(3) Ur.emia.

In cerebral uraemia we frequently see a symptom
complex almost identical with that of cerebral com¬
pression, viz., headache, vomiting, drowsiness, coma,
convulsions, optic neuritis, &c. This symptom com¬
plex is, at any rate in great measure, dependent
upon increased intracranial tension, for many cases
are now on record in which extraordinary- relief has
followed lumbar puncture, a procedure which, by
means of allowing some of the fluid to escape,
diminishes the pressure within the cerebro-spinal
space.

IhusMM. Pierre Marie and Georges Guillain (a) record
the case of a man, aet. 20, suffering from nephritis and
epilepsy, who had suffered from severe headache for
twelve months, with a high blood pressure (200 to
210 mm. Hg.). Lumbar puncture was performed,
the cerebrc-spinal fluid being under greatly increased
tension, as it spurted out from the needle ; 6 cc. were
withdrawn. Within five minutes the headache was
materially improved, and within two hours it had
completely disappeared. Relief was complete for
two days, when the communication was read. In
the discussion which followed the paper, M. le Gendre
recorded a similar case of relief. A man, aet. 57,
painter, suffering from arterio-sclerosis and plumbism
with albuminuria. He was uraemic with headache,
my'osis and insomnia. Lumbar puncture was per¬
formed, and 13 cc. withdrawn. The pressure was
not noted. The same evening the headache was
improving, and he slept well. The headache pro¬
gressively improved, and in three days was absolutely

S 0116 - • . , , ,

In a further communication M. Pierre Mane pointed
out that lumbar puncture for uraemia had been per¬
formed for the past six years in Germany, and he
quoted three cases of cure of headache in saturnine
encephalopathy, by Seegelken, Brash and Nolke.
Marie, however, was careful to point out that other
observers had not found lumbar puncture of help
in the treatment of uraemia, and instanced as examples
Quincke, Furbringer, Lichtheim, von Leyden, Stadel-
mann, Braun and Lenhartz. But he remarks that
most of the above negative records were not accom¬
panied by details of the circumstances under which
the puncture was performed. G. Scherb(6) records a
case of nephritis with uraemia in a man, aet. 49, suffering
from very severe headache, and resisting all treatment.
He was admitted to hospital almost comatose, with
history of vomiting, auditory hallucinations and
severe insomnia. Fundi showed slight venous stasis,
lncreaised arterial tension. Incontinence of faeces.
Lumbar puncture was performed, and 20 c.cm.
removed, the fluid issuing in a spurt under considerable
pressure. Within five hours he was conscious and
could answer questions. Next day he was quite free
from headache and remained so for six weeks, when

(a) Bull, et Mem. de Us Soc. Med. dee Hopitaux de Paris, 1901, p. 4 * 7 -
(ftj Revue Neurologupu {de Paris), Vol. X., 190a, p. 19.

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14 The Medical Press.

ORIGINAL PAPERS.

July 3. iqo7-

it returned. (Edema also appeared, limited to the 1
region of the forehead, eyelids, cheeks, lips, ears,
and the skin of the scalp. Lumbar puncture was
again performed, but with only temporary relief, and
death occurred tens days later.

D. C. McVail records two very successful cases (a).
In the first case a man with acute nephritis, with
severe intracranial pain, followed by convulsive
attacks repeated during thirty-six hours, became
almost blind, and finally comatose. He was oedema-
tous. Lumbar puncture was performed, the fluid
issuing in drops, and apparently under no tension.
Within twenty-four hours there was a return of
consciousness and sight began to reappear. He slept
well, and on the next day was free from pain, with
perfect vision. This was followed by a rapid recovery
from the renal condition. The second case was also
one of acute nephritis, with moderate oedema. Within
thirty-six hours, of admission to hospital, and in spite
of all treatment, he lapsed into deep coma. One
ounce of fluid was withdrawn by lumbar puncture,
again issuing in drops. Consciousness returned in
four hours ; he slept well, and next morning was
quite rational. He also left the hospital free from
albumen. McVail attributes the symptoms in these
cases to increased intracranial pressure.

T. Arthur Helme (b), F. Proud (c) and R. N. Willson (d)
record instructive cases of puerperal} and uraemic
convulsions in which re.ief was immediately obtained
by lumbar puncture.

F. C. Eve ( e) notes the case of a man with uraemic
convulsions associated with total blindness. The
convulsions were relieved by venesection, but the
coma remained. Lumbar puncture was performed
(fluid under high pressure). Next morning the man
was quite conscious, and had recovered much of his
sight.

Remarks. —The above cases are sufficient to show
that marked relief may follow lumbar puncture in
cases of uremia. It is well known that uraemic con¬
vulsions and coma may disappear apart from such
treatment, but the promptitude with which the
improvement occurred was such as to leave no doubt
in the minds of the observers that the relation was
one of cause and effect. It is noteworthy also that
in most of the cases the cerebro-spinal fluid did escape
under considerable pressure. McVail states that in
neither of his cases was there any increase, the fluid
merely dropping away. Nevertheless, his two cases
were strikingly successful, and he attributed the relief
to the puncture, which obviously acts by diminishing
the pressure of the cerebro-spinal fluid. It would
be expected that the fluid would always issue from
the needle with force, as, indeed, the above records
show that it often does. But there are several
points to consider. The needle is necessarily a fine
one, and if its lumen became partially blocked in its
passage through the tissues of the back, the fluid
could only find its way out in drops. Another point
is that there is at present no reliable instrument for
measuring the tension of the spinal fluid. Eve’s
instrument,though very useful, only measures the height
of fluid which finds its way out of the spinal space
into a vertical glass tube connected with the needle. But
this height of fluid is not a measure of the real pressure
of the fluid in the cerebro-spinal space, for we have
to consider that space as a practically closed-in cavity
with walls of considerable rigidity. This cavity is
always full of fluid or semi-fluid substance, and to
force more fluid into such a space would necessitate
great pressure, its normal contents being very little,
if at all, compressible. Doubtless the ligaments of
the spinal column would yield slightly, but scarcely
to any great extent. It is therefore obvious that
the addition of but a little fluid would very materially

(a) “Spinal Puncture in Ur*mia.”— Brit. Med. Joum., Oct. 24th’

1903-

<') “ A Suggestion lor the Treatment of Puerperal Convulsions by
Spinal Subarachnoid Puncture."— Brit. Med. Joum., May 14th, 1904.

(c) Bril. Med. Joum, March 24th, 1906.

(d) Joum. American Med. Assoc., Oct. 8th, 1904.

(e) " A Cerebro-spinal Manometer,"— Lancet, April 22nd, 1905,
p. 106S.

raise the pressure, and that this pressure would not
be measured by the small amount of fluid which
escaped into a vertical tube in connection with a
needle in the space. To measure it, it would be
necessary to puncture the space with a needle full of
fluid and attached to a mercury manometer, the
whole of the connecting tube as far as the mercury
in the first limb being filled with fluid. Then, on
inserting the needle into the space, the mercury in
the proximal limb of the manometer would be.de-
ressed. The actual pressure would be ascertained
y pouring mercury into the distal limb until the
mercury meniscus in the proximate limb returned to
the same position it occupied before the puncture was
made. The difference in level between the two
mercury menisci would be the measure of the real
intraspinal pressure. Hiirthle’s manometer might
also be used for the purpose, as the movement of fluid
in and out of the tambour is exceedingly small.
Another difficulty is that the cerebral pressure is
relieved by removal of the Iree cerebro-spinal fluid.
If, however, the pressure is mainly produced by a
cerebral oedema, then unless a co-existent excess of
free ventricular fluid was present, the removal of the
little that would flow might not be sufficient to relieve
the pressure materially. This fact might explain
some of the cases in which relief is not obtained.

The manifestations of uraemia here considered
which are so strikingly relieved by lumbar puncture
are, as has been pointed out, so closely similar to the
pressure symptoms produced in other conditions,
such as cerebral tumour, cerebral haemorrhage, &c.,
that uraemia has not infrequently been erroneously
diagnosed as cerebral tumour, and the fact that the
cerebro-spinal fluid is often under considerable pressure
in these cases of uraemia, indicates that the under¬
lying condition of increased intracranial tension
must be responsible for the symptoms. Harvey
Cushing also suggests this.

Uramic Coma .—It has been pointed out that
cerebral compression would produce a cerebral anaemia
were it not that the blood pressure rises so as to keep
just above the cerebral pressure and so maintains
the cerebral circulation. But this compensatory
process cannot go on indefinitely, and a certain point
may be reached beyond which no amount of vaso¬
constriction and cardiac augmentation can maintain
an adequate cerebral circulation. If this point is
reached gradually and the volume of blood passing
through the brain be slowly diminished, we should
expect a comatose condition to develop, the last stage
of cerebral compression with gradual respiratory
failure ; the high tension slow pulse of the early stage
of compression changing into a soft, rapid pulse with
the developing vasomotor failure. A concomitant
toxic action on the brain is not denied; such may be
present and aid in the production of the cerebral
symptoms. But the anaemia alone should suffice
to induce the coma.

Uramic Convulsions .—Under the severe strain
imposed upon it in working against a very high blood
pressure the heart may fail rapidly in chronic nephritis.
Should this occur, or should the vasomotor centre
faillrapidly, it is clear that the cerebral circulation
must fail equally rapidly when the intracranial tension
is pathologically high. Instead of headache and
somnolence, gradually deepening into coma, a more
sudden unconsciousness would result, and if the
failure in the circulation through the brain occur
almost suddenly, convulsions would readily be pro¬
duced. It is well known that sudden cerebral anemia
is a most potent cause of convulsions, as. for instance,
in the well-known experiments of Kussmaul and
Tenner, also after severe hemorrhage, Ac. The
author has reported cases (a) in which the pulse stopped
before the onset of ordinary epileptic fits, and has
suggested that the cerebral anemia so produced
is sufficient in itself to account for the ordinary
epileptic fit. It is of great interest to note that
the onset of uremic convulsions is, in fact, very apt

(a) " Cessation of the Pulse during the onset of Epileptic tits."

I Lancet, July axst, 1906.

Digitized by L^ooQie

July 3, 1907.

to be associated with marked evidences of circulatory
failure.

According to Senator (6), “ before the convulsions
the pulse is often tense and slow, but during the
attack it is small and accelerated and often irregular ;
as a rule, however, it cannot be counted accurately
until after the attack, when it is also retarded in most
cases.” According to Strumpell (c), “ the pulse is
often very slow before the appearance of severe
symptoms, sometimes 48 or 40, but it is almost always
tense and hard. In chronic uraemia also a moderate
slowness of the pulse is not infrequent. When uramic
convulsions appear, however, the pulse usually becomes
small and very frequent, especially in cases that terminate
unfavourably." Willson’s cases are of the greatest
importance in this connection, especially as in his
six cases of uraemic convulsions the convulsions ter¬
minated in every case on the withdrawal of the cerebro¬
spinal fluid ; and it is to be noted that his best results
were obtained in those cases in which the fluid spurted
from the cannula, i.e., in which the pressure within
the cerebro-spinal space was greatest. And this
withdrawal of fluid by lowering the cerebral pressure
would allow of an immediate return of blood to the brain.

In cases of acute uraemia in acute nephritis it is well-
knowm that an increase of blood pressure is common,
and the cardiac failure may be more readily effected
owing to the more toxic character of some of the
diseases associated with acute nephritis, the poisons
of the acute infections, such as scarlet fever, materially
affecting the heart muscle. The heart would thereby
be unable to respond to the vaso-constriction above
described and the conservative rise of blood pressure
would fail to develop.

This paper revives the old and discredited hypothesis
of Traube. who considered that the cerebral anaemia
was brought about through a compression of the blood
vessels by oedema fluid. For this theory to rest on a
sound basis it would have to be demonstrated that
eedema does occur.

As regards this point, it is commonly stated that
cerebral oedema is present or may be present in people
dying of uraemia. Thus Senator, who though on the
whole an opponent of the oedema theory, states (d), ‘‘It
is quite true that oedema of the brain is frequently
found in the bodies of those who have died of uraemia,”
but he adds that “ the mere fact that this oedema of
the brain is not constantly found proves that at most
it is the cause in only part of the cases, providing, as
Bartels believed, the oedema is not the result of the
convulsions.” The writer (Senator) does not think,
however, that Bartel’s view is correct; “ for oedema
of the brain is not always found even after the most
violent convulsions produced by a great variety of
poisons. But the fact that oedema of the brain is a
frequent occurrence in uraemia does not in itself
justify the conclusion that the two conditions have a
cas.ial connection, although it lends a certain modicum
of probability to such a view. ... It may be
admitted that eedema of the brain in many cases is
partly responsible for the development of uraemia,
although other factors are probably present also.
The writer is very much inclined to regard a circum¬
scribed oedema of the brain as the cause of many
focal manifestations, particularly amaurosis and
hemiplegia, for which it would be difficult to find
another explanation. . . . The irritability of the

nervous centres is of the first importance, especially
for the onset of a typical acute uraemic attack. . . .
The immediate effect of the irritability appears to be a
contraction of the small arteries, causing acute
amemia of the brain, which is a pdssible factor in the
production of the attack, although it' is probably not
followed by cerebral oedenia, as Traube asserts.”

Senator, therefore, associates the attack- with a
cerebral anaemia whether produced by eedema or

(6) Nothna#ers " Encyclopaedia of Practical Medicine," American
Edit., “ Diseases of the Kidneys," p. 95. .

(«) Strumpell, “ Text Book of Medicine,” Third American ■ Edit.,
p. 600.

id) " Diseases of the Kidneys," Nothnagel’s “ Encyclopaedia,"
American Edit., p. 103 and iii.

The Medical Press. 15

arterial spasm, but inasmuch as in many cases at
least the intracranial tension is increased as shown by
the spurting out of cerebro-spinal fluid on lumbar
puncture, and by the extraordinary relief thereby
effected, it is very probable that cerebral oedema
with excess of cerebro-spinal fluid is commonly present
in these cases. Such eedema would of necessity
hinder the free access of blood to the brain, and the
cerebral ancemia thereby produced would, in the
absence of a compensating rise of the general blood
pressure or on the failure of this compensating rise,
account for many of the symptoms.

If this hypothesis be correct and if uraemic con¬
vulsions be due to a sudden cerebral anaemia as above
suggested, considerable support is lent to the theory
that epilepsy is produced by a sudden cerebral anremia,
for it is notorious that the convulsions of uraemia and
of idiopathic epilepsy may be absolutely indistinguish¬
able, and it is extremely probable that the factor
underlying conditions so remarkable and so identical
should be one and the same. The practical applica¬
tion that follows from the above is that lumbar
puncture should be performed in cases of uraemia,
whether coma, convulsions or merely severe headache
be the predominant feature. The presence of a high
blood pressure would be helpful as indicating the
advisability of lumbar puncture.

On the above hypothesis of the origin of uraemia it
is somewhat difficult to account for the material
improvement that sometimes undoubtedly follows
venesection, for inasmuch as venesection lowers the
blood pressure, at any rate temporarily, it would act
in opposition to the compensatory mechanism which
maintains the cerebral circulation in the face of the
high intracranial tension, and so should be a harmful
rather than a beneficial procedure. It is possible,
however, that the benefit which sometimes follows
its employment is due to the relief of the failing
heart with right sided distension. It would further
facilitate the outflow of venous blood from the brain
and so help to diminish intercranial tension. More¬
over, a free venesection removes a material fraction
of the total blood, and the present paper in no way
disputes the presence of an abnormal and toxic blood
in unemic conditions.

OPERATING THEATRES.

ROYAL FREE HOSPITAL.

Operation for Branchial Cyst of Neck.— Mr.
T. P. Legg operated on a woman, aet. 37. She had
noticed the lump for some months, and during the last
few weeks it had got rapidly bigger. Practically no
inconvenience had been caused by the swelling. She
had no difficulty in swallowing or trouble with breath¬
ing. Beneath the right stemo-mastoid, on a level with
the hyoid and upper part of the thyroid cartilage
there was a large ovoid tumour, the long axis being
placed horizontally. The tumour was as big as a
duck’s egg ; it was quite smooth, movable on the
deeper structures, and gave distinct fluctuation. The
skin was normal, and no evidence of pressure effects
on adjacent structures was found. Mr. Legg said that
a diagnosis of branchial cyst was made: first, on
account of the situation of the tumour beneath the
stemo-mastoid and on the level of the hyoid bone ;
secondly, it was apparently a fluid swelling, and he
might also mention here that the carotids were deep
to the tumour. It was unlikely to be a tuberculous
abscess due to disease of the glands, because there were
no other evidences of the glands being affected, and it
would be most unusual to find an abscess of this size
due to tuberculous disease of one gland alone. The
periphery of a tumour should always be carefully exa¬
mined for nodules or gland-like lumps; if such were
present they were a valuable aid in diagnosis. An
aneurysm of the carotid could be excluded because the

OPERATING THEATRES.

Digitized by GoOgle

16 The Medical Puss.

CORRESPONDENCE.

July 3. 1907-

swelling was fluid and did not pulsate. A transverse
incision, four inches long, was made along the axis^of
the tumour, which was dissected out without much
difficulty. The sterno-mastoid required partial divi¬
sion, as it and the tumour were closely adherent. The
carotid sheath was detached, and at the upper end of
the tumour a band-like process was tracked upwards
and ligated before being divided. During the dissec¬
tion, the cyst was ruptured, and opaque yellow liquid
containing cholesterin cystals visible to the naked eye,
escaped. The wall of the cyst was about one-eighth
of an inch thick, and smooth internally; on the outer
side it was rough. The sterno-mastoid was united by
two or three mat trass sutures, and the wound closed,
a drainage tube being put in at the posterior end bf
the incision. The fluid was examined at the end of
the operation, and contained squamous epithelium,
degenerated cells of various sorts, including leucocytes
and cholesterin crystals. Mr. Legg remarked that as
regards the operation, a transverse incision was best.
It gives plenty of room, and if made slightly curved, a
flap can be dissected up in order to increase the expo¬
sure of the deeper parts. Moreover, the scar becomes
practically invisible in the course of time. In suturing
these incisions, it was always advisable, he considered,
to put in two or three stitches which unite the cut
edges of the platysma and deep fascia. By doing so,
the margins of the skin incision were closely approxi¬
mated, and the sutures in the skin can be removed in
four or five days. Thus very often the stitch marks
are invisible. The removal of these cysts, he pointed
out, was not always as easy as in this case. They
were always in close contact with the great vessels
and nerves of the neck, and sometimes the cyst passed
between these structures. Hence, in separating the
deeper parts, the surgeon has to keep close to the cyst,
and see exactly what he is doing. The band-like pro¬
cess required tracing as far as possible and ligating.
It contained the remains of a branchial cleft from
which the cyst was derived by dilation of an unoblite¬
rated portion. Which cleft this particular cyst was
derived from was not very certain, because it was im¬
possible to make out the exact relations of the cyst to
the vessels and nerves. They were not very rare
tumours. During the last two or three years there
had been three or four cases in the hospital. One
patient was a child, set. about 13, and there had been
two other young adult patients. Subsequently a
microscopic examination of the cyst wall in the pre¬
sent case showed the lining epithelium to be squamous,
thus confirming the diagnosis.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Pari*. Jane 30 th 1907,

The Treatment of Syphilis.

In treating syphilitic patients, certain restrictions
should be observed in the employment of the mercurial
treatment. Of these restrictions, some depend on the
form to be prescribed, in which account should betaken
of the extreme susceptibility of certain organs such
as the stomach, intestines, bladder, while others concern
the dose, which should be proportioned to the resistance
of the subject, and to the permeability, more or less
diminished, of the emunctories.

The best form of application, says Prof. Beiugon, is
hypodermic injection of the soluble salts. The intra¬
muscular introduction of the drug is the most exact
and precise method, which also allows supervision of
the doses employed. The gastro-intestinal disorders

which frequently follow the use of pills or mixtures
expose neuropathic patients to danger.

As to mercurial ointment frictions, they have the
fault of being difficult to control as to the dosage.
Sometimes the patient will use too much, at others
the quantity will be insufficient.

Insoluble injections and particularly those of calomel
should be reserved for extreme cases where rapidity
is necessary, in ocular syphilis, etc., and in tabetic
patients showing symptoms of cerebral disturbance,
persistent vertigo, epileptic attacks, aphasia, and
hemiplegia.

Of the soluble salts, benzoate or bichloride of mercury
are the most easily absorbed.

The cure should be divided into three or four series
of twelve injections each with a corresponding interval
of rest.

Vegetations of the Genital Organs.

An easy method of treating isolated and pedunculated
vegetations is to place on the papilloma a small quantity
of resorcin by means of a moistened hair pencil, and
cover with a piece of gauze. The application is renewed
each day until the vegetation is dried up.

Where the vegetations are numerous and sessile the
following mixture is painted over them.

Resorcin .. .. .. .. drachms 2.

Collodion .. .. .. .. ounce 1.

Two or three applications are sufficient. To avoid a
return of these troublesome excrescences, the patient
should bathe the parts in a solution of resorcin, $
per cent, and apply the following powder :—

Carbonate of zinc
Sub-nitrate of Bismuth
Resorcin
Talc powder

drachms 2.
drachms 2.
drachm $.
ounces 3.

Infantile Eczema.

At the last meeting of the Academie de Medecine.
M. Variot, of the Children's Hospital, said that infantile
eczema was rapidly and favourably influenced by sub¬
cutaneous injections of isotonic sea-water. In three
fourths of the cases the treatment was entirely success¬
ful. After the first two or three injections the eczema
became inflamed, with abundant weeping, after which
an improvement set in, the scales became detached,
and a cure followe.i. Sometimes there is no reaction, and
in such cases the improvement is almost instantaneous,
and the lesions begin to pale the following day. One
ounce of this'sea-water is injected every two or three
days. According to M. Variot, no other treatment
gave such favourable results.

GERMANY.

Berlin, Jane 3Otto. 1907.

Extraordinary Results from a Dagger Thrust.

At the Medizinische Gesellschalft Hr. H. Hirschfeld
showed a young man who, several months before,
had received a dagger thrust in the right cheek below
the malar bone. Immediately afterwards he could
not speak, had a difficulty in swallowing, and the
right half of his face drooped. The wound healed
slowly, as a salivary fistula formed in consequence
of a wound of the parotid. Now the following changes
were noted :—The right eyelid and pupil were nar¬
rowed, the right half of the face did not perspire, the
tongue lay obliquely, the whole right half of the
cavity of the mouth was without sensation; the
larynx deviated to the right on swallowing, the right,
vocal cord was immobile in the position of that of
the dead body, the right side of the fauces and larynx
had no sensation, so tnat there was frequent swallow¬
ing. Pressure on a certain spot of the right side of
the neck set up coughing, the right stemo-cleido-
mastoid and platysma were atrophied. It was a case
therefore of injury of the seventh, ninth, tenth, eleventh
and twelfth cerebral nerves, as well as of the sympathic
at the base of the skull. Whether it was possible
to unite the nerves by suture he had not decided.

At the Congress of the German Society for Ortho-
prdic Surgery, Hr. Karch, Aachen, described his
misfortunes and successes in

tized by

Ji'ly 3, 1907.

CORRESPONDENCE.

Thk Medical Pres*. 17

Transplantation of Tendons (300 Joints).

He put forward the following conclusions:—The
positive success of the operation stands and falls
(i) with the exact indication ; (2) with the operative
technique ; (3) with the technique as regards bandag¬
ing ; (4) with the quality of the after-treatment.
Flaccid paralysis affords the most frequent indication
tor operation, and shows the finest results. The
limits of the indication are very wide. If an extensive
flaccid paralysis has existed for more than ten years
transplantation only rarely shows good results. It
is better then as regards the lower extremities to per¬
form arthro, teno. or fasciodesis. Caution is required
in the winter time if chilblains are present. Trans¬
plantation in spastic paralysis requires much experience
in knowing how far to go; an excess in yielding power
never leads to an improvement of the condition.
Simple plastic lengthening is often sufficient. In
complicated spastic paralysis of the upper extremities
the results obtained by operation are not always
satisfactory. It is hopeful that treatment with im¬
plantation of the nerve will give better result. Peripheral
paralysis and loss of power from traumatism are
satisfactory objects of treatment. Contractions with
flexion are efficiently met by exact transplantation.
Advancing cerebro-spinal affections should never
be treated by transplantation.

2. The plan of operation must be simple. Periosteal
transplantation is to be preferred ; that of tendon to
tendon along with this is proper, and is sometimes
the only way to success. Functional independence
is best assured by periosteal implantation. In trans¬
plantation from tendon to tendon some of the associated
muscle should be used to give power. Transplantation
of bone and the boring of bony canals must be avoided.
Button-hole implantation is the best, and sublimate
silk for the suture material. Of course, the limb
must be put right, and if necessary the tendon short¬
ened before the implantation is done. On the dorsum
ol the foot, in order to avoid pressure gangrene any
tense tendon bridges are to be removed from the
periosteum by means of a silk loop, so that they
run through a sort of tunnel of silk. For shortening,
folds should be made and fixed ; for lengthening, step
or surface incisions. Very poor tendons may be
shortened if they are first sutured to the tendon of an
associated muscle that is in function. “ Deshabiller
Pierre p,ur rev£tir Paul” is allowable under some
circumstances, when an important function can be
gained by the sacrifice of one less important. Stitch
abscesses were rare and did no harm. Suppuration is
very rare, and does not prej udice the result. They were
to be avoided by immaculate asepsis, arrest of bleeding,
and exact skin suture. Flat shaped muscles were
not to be transplanted.

3. At the close of the operation the joint must lie
placed in the desired position ; dressing was not
advisable during the hardening of the covering. The
dressing must be cut open if when the rubber bandage
was removed the circulation did not return promptly.
The dressing should remain on for eight weeks. There
was no change of dressing when the skin suture was
of silk and recovery normal.

4. The after-treatment is important, for a per¬
manent success conscientious massage must be carried
out. Further, active, passive and later, resistance move-
men ts would be necessary, or the wearing of a portable
apparatus, as well as the employment of physical
curative measures.

Transplantation of tendons was the most important
novelty in the treatment of paralysis. Along with
this, and sometimes taking its place, would be the
still incompleted method of nerve grafting. Both
were justifiable; for the majority of cases tendon
transplantation would remain sovereign.

AUSTRIA.

Vienna, June 30th, 1907.

Cataracta Complicata.

Konigstein showed a male patient to the " Gesell-
schaft ” with an old standing cataract which he con¬
sidered inadvisable to operate on, as the sensation of

light was probably lost and no good would result.
This case was before the members six years ago,
when the same opinion was formed.

The present condition is rather peculiar. The
anterior chamber is filled with a mass that glistens
and glitters like gold when light is thrown on it. He
considered this due to granules and scales of cholesterin
which had become deposited in the membrani Descemet
lining the interior of the cornea, or it may be blood
colouring deposited in the cornea itself. From this
it would seem that the capsule of the lens had burst,
exuding the contents which have taken on a retro¬
gressive metamorphosis forming cholesterin, or perhaps
the effused blocnl has undergone the change and
produced this phenomenal body.

Scapular Rhonchus.

Lotheissen showed a peculiar case of loud crackling
under the right scapula, which could be heard when
standing at a considerable distance from the patient.
There was no tuberculosis, or muscular atrophy in
the serratus muscle, to account for the strange pheno¬
menon. He considered the change to be due to a
dry proliferating bursa which could not be cured
without operation.

Cystic Widening of Ureters.

Kapsammer next showed a case that had been
diagnosed by the cystoscope as a morbid condition of
the urinary apparatus. Three weeks ago |he per¬
formed the abdominal section and found both ureters
distended into two cysts, which apparently were con¬
genital defects, and not morbid as at first presumed.
This wide condition extended far up the ureters,
which were healthy and otherwise in good condition.
He pointed to this as an example of an unavoidable
error.

Pes Varus.

Semeleder reported the success he has met with by
his method already described of treating talipes varus
in the paralytic form which many are sceptical about.
He exhibited photos of sixty cases before and after
treatment, which are convincing of success, whatever
the method may be by which he had accomplished it.
The idea carried out in his apparatus is to prevent
the antagonism of the healthy muscles distorting the
member by tearing the paralytic muscle too far and
destroying its functional activity, which he considers
the sole cause of the anatomical deformity. If the
paralysed muscles are physiologically checked, atrophy
commences, while the strong muscles with the weight
of the body complete the destruction. His object,
therefore, is to place the action on the paralysed
muscle and leave the strong muscle to atrophy.

Photos of two cases presented were of considerable
interest, as the original photos and the present condition
were marvellous contrasts.

Alberle challenged the method as having a special
advantage, for he has treated similar cases with a
wedge J to 1 centimetre with perfect success, and they
never required to put the patient to bed. This destroyed
Semeleder’s assurance that his boot had any influence
in strengthening the muscles of the leg. The weight
of the body is not all that is to be considered for this
correction, or Beely’s apparatus would be quite
sufficient. If the talipes is not severe, the least
painful and more effectual method is the manual
correction which can be done by the mother or the
nurse. Semeleder replied that many of the other
apparatuses required the patient to remain in bed, but
his did not, as the patient could move about with
advantage; with his apparatus the legs would be
corrected in two weeks, with other forms the patient
may wear them years without any visible improve¬
ment.

Physiological and Pathological Circulation.

Benedikt described the changes in the circulation,
remarking that cramp in both of the large crural
arteries may occur at the same time, thus showing a
homonymous pulse as if a normal condition existed.
If the carotid pulse is greater on one side than the
ot er, so is the radial pulse of the former less than
the latter, i.e., the sides are inverted. This is not a

le

18 The Medical Press. _ CORRESPONDENCE.

constant anatomical fact, but is usual. Basch found
different pressures in homonymous vessels. The
prodromal symptoms of apoplexy can be detected by
any departure from this anatomical relationship.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

The Assault on Dr. Carswell, Glasgow.—
Purvis, who assailed Dr. Carswell in the streets of
Glasgow with a revolver on April 16th last, was brought
before Sheriff Glegg on June 22nd. The Procurators
Fiscal stated that he had been examined by experts
in lunacy on several occasions since his incarceration,
and had been certified as of unsound mind, and was
therefore unable to plead to the indictment. An
agent who appeared for Purvis asked the Sheriff to
take a plea of not guilty. The Sheriff, however,
following the precedent in the Cumnock poisoning case,
reserved the matter for the consideration of the High
Court.

Edinburgh Royal Infirmary.— At their meeting
on June 24th, the managers appointed Dr. Douglas
Chalmers Watson, F.R.C.P., to be an assistant physi¬
cian, and Mr. William J. Stuart to be an assistant
surgeon to the Institution. There we. e a number of
candidates for both posts.

Sidlaw Sanatorium, Dundee.— During the year,
US patients have been treated. Of the discharges,
numbering 79, 18 were unsuitable cases; of the 61
remaining, the disease was arrested in 34, markedly
improved in 24, stationary in 3. The medical superin¬
tendent has kept in touch with the patients who have
left, and reports that at the end of the year 90 per
cent, of the arrested cases were in good health, and
70 per cent, were at work. Of similar cases discharged
last year, 85 per cent, continue well. Such results are
highly satisfactory. The sanatorium is kept up by
public subscription, a small sum being received from
the patients. The cost per patient is 38s. per week.

The Late Dr. Howden, Haddington. —The death
took place on the 25th ult. of Robert Howden, M.B.,
who represented a family of East Lothian doctors
which had been connected with the county for nearly
a century. He was the grandson of Dr. Thomas
Howden. who was a partner of Dr. Welsh, father of
Mrs. Carlyle. His own father, Dr. Thomas Howden,
died in 1900 at the age ot 89, and a brother, Dr. Thomas
Howden ( tertius ), died in 1878. Dr. Robert, who fell
a victim to pneumonia, held a number of local medical
appointments, and had an extensive practice. He is
survived by a widow and two children.

LETTERS TO THE EDITOR.

LIVINGSTONE COLLEGE AND MEDICAL
MISSIONARIES.

To the Editor of The Medical Press and Circular.

Sir,—I desire to thank you for your kind reference
to Livingstone College in your last issue, but hope
you will permit me to offer some explanation of the
system which is adopted at this College.

Let me say in the first place that I agree with you
most fully that it is in the highest degree desirable
that men going abroad as missionaries should have
the best medical qualifications. The Church Mission¬
ary Society, of which I was formerly a medical mission¬
ary, and am now physician, has sent to the Mission
Field a number of medical missionaries of the best
type, many of them possessing exceptional scientific
qualifications. This is as it should be, and I desire
to see the list of medical missionaries largely increased.

There is. however, another problem wholly different
from this which has to be considered. Many mission¬
aries are called upon to work in isolated stations far
from qualified medical or surgical help. At any
moment they or their fellow missionaries or families
may be struck down by some rapidly fatal illness or
accident, which can have but one issue unless they

July 3. 1907

possess such medical knowledge as would enable them
to identify and cope with these ailments. Living¬
stone College men hav been able in many cases to
preserve their own lives and that of other Europeans,
and I have little doubt that scores of lives have been
thus saved.

Again, men so placed often find themselves amongst
ignorant natives who suffer unspeakable tortures
from neglected wounds, abscesses and ulcers, whose
sufferings are intensified by the methods of so-called
witch-doctors. Common humanity will not allow
a civilised man, much less a Christian man, to see
such things, which simple aid can relieve, and refuse
to render that aid. Yet if these things are to be done
training must be given. Previous to the existence
of Livingstone College men attended the ordinary
hospitals and picked up what knowledge they could,
and there was great danger that they might undertake
treatment which they were utterly unfitted to carry
out. At Livingstone College students are not only
taught carefully what they may do, but what they
must not attempt, and we have never heard of any
serious mistake being made. Besides this the students
sign a declaration that they will not call themselves
medical missionaries or assume the position of qualified
medical men. What more can we do ? What less
can we do ? You in common with the other chief
organs of the medical profession have most generously
supported us in the past. I venture to hope that
we may rely upon your continued support.

I am, Sir, yours truly,

Charles F. Harford, M.D.,
Principal of Livingstone College.

Leyton, June 24th, 1907.

THE EXCLUSION OF SCOTCH AND IRISH
DIPLOMATES FROM THE MAJORITY OF
LONDON HOSPITALS.

To the Editor of The Medical Press and Circular.

Sir, —The outspoken letter in your issue of June 19th
deserves careful attention. The majority of the large
English hospitals, both in London and the provinces,
exclude both Irish and Scotch medical diplomates from
their honorary medical staffs. This disqualification
has been placed on the laws of hospitals in past
times when possibly there were not so many qualified
medical men educated in Scotch and Irish colleges
and universities. Anyway, it constitutes a standing
injustice to many honourable and highly qualified men.

What does the boycott mean ? A very slight analysis
will, I think, show that the matter is simply one of
class privilege. It is obviously advantageous to
holders of English diplomas and degrees to have a
monopoly of these valuable professional posts. It is
equally advantageous to the colleges and universities
that grant the special qualifications whereby alone the
monopolist appointments may be secured. But what
about the men and the colleges that are shouldered
out by the monopolists?

If the public were fully informed of the facts of the
case, it is hardly likely that this injustice would long
be permitted to continue. A considerable proportion
of the governors of hospitals are attended medically
by Scotch and Irish diplomates and graduates. What
would governors say if the men who are considered
good enough to attend themselves are not permitted to
attend hospital patients?

Let us, at any rate, have the full light of day upon
the situation. If the English colleges can show they
have good ground for maintaining their monopoly, by
all means let them keep their privilege; otherwise, let
us have some sort of equality of opportunity afforded
to all duly qualified medical practitioners within the
United Kingdom.—Yours faithfully,

A Scotch F.R.C.S.

Manchester, July 1, 1907.

The council of the London School of Medicine
for Women have received from Mrs. Godfrey Walker,
of Conisborough Priory, Yorkshire, the munificient
gift of 120,000 in aid of the endowment of the school.

Digitized by

Google

JPLY t, 1907.

THE TEACHING OF PHYSIOLOGY.

To the Editor of The Medical Press and Circular.

Sir, —With regard to the admirable letter from
your Dublin correspondent I trust the matter will be
discussed fnlly in your columns. It has always seemed
to me personally that it is sheer waste of time to demand
of medical students a knowledge (!) of advanced
physiological experiment and theory. The only
possible excuse for making such a demand appears to
be the intellectual training of the student, but that
could surely be obtained by other methods more
likely to help him in the after battle of professional
life.

I am, Sir, yours truly.

Duns Scotus.

Colwyn Bay, July 1st, 1907.

OBITUARY.

SIR WILLIAM TENNANT GAIRDNER.

Sir W. T. Gairdner, K.C.B., LL.D., M.D., died on
Friday last at the advanced age of 82. He had been laid
aside from active work through failing eyesight for a
number of years past, and for several years had suffered
from cardiac disease. His death, however, was sudden
in the extreme. Up till a day or two ago he was able
to take his usual drives into the country, and on the
morning of the day of his death he was able to receive
an old friend who had come into Edinburgh to attend
the Old Residents’ Dinner, and to send by him his
apologies and regrets for inability to be present at that
gathering. Before the message, however, could be
conveyed. Sir William had passed away. Deceased
was bom in 1824, in Edinburgh, his father being the
late Dr. John Gairdner, a president of the Royal College
oi Surgeons, Edinburgh. He graduated M.D. in 1845,
and for his thesis, which was on the subject of “ Death,”
he was awarded a gold medal. After graduating, he
travelled abroad as physician to the Earl and Countess
of Beverley, and returned in about a year’s time to
Edinburgh, where, at the early age of 24, he was ap¬
pointed pathologist to the Royal Infirmary in succes¬
sion to Hughes Bennet. Soon after this, in 1853, he
began to lecture on the Practice of Physic in the extra¬
mural school, and continued his class until his appoint¬
ment to the Chair of Medicine in the University of
Glasgow in 1862. Sir William Gairdner’s interests at
that time were much directed towards matters of sani¬
tation and public health. In the year of his election
to the Glasgow professorship, he published an im¬
portant work on “ Public Health in Relation to Air
and Water,” which was a record of the first course of
lectures on sanitation ever delivered in Scotland.
This attracted the attention of the municipal health
authorities to Dr. Gairdner, and the late Mr. John Ure
(afterwards Provost of Glasgow) entered into negotia¬
tions with the writer with the object of securing his
assistance in carrying out a scheme for establishing a
health department in the city. After some demur,
lest the proposed work should interfere with his
L T niversity duties, the Professor accepted an appoint¬
ment as Medical Officer of Health for Glasgow. He
was the first occupant of that office, and held the post
for nine years from 1863. During this time he success¬
fully combated several severe epidemics. These, along
with a threatened outbreak of cholera in 1866, led the
new Medical Officer to make a systematic investigation
of the conditions of housing in the slums, and he was
sent to Paris to report on the improvements then being
carried out by Napoleon III. in the French capital.
These investigations, added to his previous experience
of conditions in Glasgow, proved of valuable assistance
in connection with the first Municipal Improvement
Act. which revolutionized the sanitation of the city.
Professor Gairdner occupied the Chair of Medicine in
Glasgow for nearly forty years. He resigned in 1900,
because of failing vision, which prevented his keeping
abreast of medical literature, and also debarred him
from microscopic work and bacteriological investiga¬
tion. After Lord Kelvin’s retirement, Gairdner

ft?* Medical Press. 19

became “ Father of the Senatus.” He was greatly
esteemed as a teacher, and as a clinician he justly en¬
joyed the highest reputation. He was the recipient
of many professional honours: Honorary Physician
to the King in Scotland, LL.D.Edin., M.D. (honoris
causi) Dublin, Honorary Fellow of the Royal College
of Physicians of Ireland. He was also a Fellow of
the Royal Society, of the Royal Medical and Chirur-
gical Society, and an honorary member of many other
learned bodies. He was President of the British
Medical Association on the occasion of its visit to
Glasgow in 1888, and he also filled the position of
President of the Royal College of Physicians of Edin¬
burgh. He was made a K.C.B. in 1898. Sir William
Gairdner’s medical writings were numerous. He was
greatly interested in diseases of the heart, and his
graphic methods of recording physical signs are well
known. He published a volume on “ Clinical Medi¬
cine ” in 1862, and delivered the Morison Lectures on
“ Insanity” in 1879. “The Physician as a Natura¬
list ” came from his pen in 1889. Sir William Gairdner
was a man of varied talent; it is said of him that he
could have filled almost any chair in the University.
He never lost his interest in affairs medical, and even
his own last illness afforded him matter for professional
study. He married in 1870, and is survived by his
widow, four sons, and three daughters.

JOHN M. HARRISON, M.R.C.S., L.S.A.

It is with deep regret we announce the death of
Audlem’s oldest medical practitioner, Mr. John Mare
Harrison, M.R.C.S., on June 18th, at his residence,
after several months’ illness. The deceased gentleman
was born at Leek, Staffordshire, on November 6th,
1817, and was the youngest son of the late Dr. Galli-
more Harrison. Previous to going to Audlem, Dr.
Harrison practised for several years in Burslem. His
practice in Audlem extended 50 years, and during
that time he was a kind friend to the poor, and highly
esteemed by all. He was a staunch Churchman, an
ardent supporter of the schools, and always lent a
helping hand to further any good cause. Much sym¬
pathy is felt for the two daughters, Mrs. Jackson and
Mrs. Greaves.

WILLIAM SUGDEN WRIGLEY, M.B., Ch.B. Vict.

We regret to announce the death on June 22nd, of
Dr. W. S. Wrigley, of Rawtenstall, at the age of 27.
Two years ago he took up practice in Nelson, and he
had only recently been married. He was educated at
Owen’s College, and graduated M.B., Ch.B. in the Vic¬
toria University, with first-class honours, in 1902,
and -he later served as House Surgeon in the
Manchester Royal Infirmary.

SPECIAL ARTICLE.

MEETING OF THE ROYAL SANITARY
INSTITUTE.

The Royal Sanitary Institute held its annual meet¬
ing last week in Trinity College, Dublin, with Sir Charles
Cameron as President.

In his inaugural address the President detailed the
development of sanitary administration in Dublin
during the past half-century. Thirty-seven out of
every 100 families in Dublin occupied each a single
room. In many English towns not 10 per cent, of
the families were occupiers each of a single room. The
poverty of a large proportion of the people was shown
by the fact that whilst about 16 or 18 per cent, of
deaths in English towns occurred in workhouses,
hospitals, and other institutions, more than 40 per cent,
of the deaths in the City of Dublin take place in these
institutions. It was not fair to compare a city which,
as in the case of Dublin, contained an abnormally large
poor population, with cities like London, in which there
were higher standards of wealth and comfort. In
1906 the expenditure of the Public Health Committee
amounted to 3^15,593. A large proportion of the ex¬
penditure was in relation to the maintenance of fever

SPECIAL ARTICLE.

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20 The Medical Pbess.

REVIEWS OF BOOKS.

July 3. 1907.

patients, payment for notifications of infectious dis¬
eases, fees to the registrars of Cemetery Boards, work¬
ing the Act relating to the street trading of children,
contributions towards the maintenance of open spaces,
proportion of law agents’ and accountants' expenses,
expenses in connection with the Contagious Diseases
(Animals) Acts, and in providing dwellings for the
working classes. The Corporation had expended
^485,000 in clearing unhealthy areas, and a very large
sum in the erection of baths, wash-houses, refuse
destructors, abattoirs, &c. The Corporation of Dublin
had expended ^345,000 in providing dwellings for the
working classes, and a large sum in the erection of
baths and wash-houses, abattoirs, and a disinfecting
house refuge for persons whose residences were under¬
going disinfection or who had been in contact with
cases of infectious disease. A sum considerably over
half a million had been expended in main drainage
works, designed to free the River Liffey from pollution
and to prevent the blocking of the street sewers.

The various forms of tuberculosis caused a large
proportion of the deaths which occurred in Dublin.
In 1906 there were 937 deaths from tuberculosis of the
lungs, or in the ratio of 3.15 per 1,000 of the popula¬
tion. The deaths from all forms of tuberculosis num¬
bered 1,386, or in the ratio of 4.71 per 1,000 persons
living. It was remarkable that whilst all other
diseases, of which the materies morbi consisted of
pathogenic micro-organisms, had greatly declined in
Dublin, tuberculosis, which belonged to that class,
continued unabated. The three great problems
demanding solution are : How was the terrible mor¬
tality of children to be lessened ? How were the
ravages of tuberculosis to be minimised ? How were
the very poor to be provided with healthy dwellings ?

The paper was discussed by Mr. H. O. Searles Wood
and Sir John Moore.

On the 26th, the President read a paper on “ Sanitary
Science and Preventive Medicine.”

Mr. C. L. Birmingham, M.D., denied that they in
Ireland were in the rear as regards the laws of public
health. He denied also that the sanitary laws in some
places were practically a dead letter. The sanitary
laws were being carried out instinctively by the people.
He had never known a people so ready to follow advice
on sanitary matters, but they would not be driven.
He had no difficulty in establishing a system of volun¬
tary notification of tuberculosis. The vaccination
laws were carried out with the greatest promptitude.
So great was the burden thrown on the medical officers
that they were bound to close their eyes to a great
deal. He was obliged absolutely to ignore the Home
Office queries.

Among those who took part in the discussion were
Drs. Magennis, Agnew, and Flinn, Mr. S. G. Moore,
Mr. J. Lindsay, and the Registrar-General for Ireland.

The following resolution was passed :—“ That this
Conlerence is of opinion that it would be desirable to
have county medical officers of health with a sufficient
staff of qualified sanitary inspectors appointed for
Ireland, and that the Council of the Royal Sanitary
Institute be requested to take steps to urge this opinion
upon the consideration of the Government.”

Dr. McWeeney read a paper on ” The Role of
Sanatoria in Checking Tuberculosis,” which was dis¬
cussed by Sir Charles Cameron, Drs. Hanaford, Antony
Roche, and Willoughby, and Mr. E. T. Hall.

On June 27th, discussions took place on “ Housing
of the Working Classes,” and “ Sewage Disposal,”
the subjects being introduced by Mr. P. C. Cowan and
Mr. W. Kaye Parry respectively.

On the 28th, Sir John Moore read a paper on “ The
Climatology of Ireland in Relation to Public Health,”
in which he maintained that the climate of Ireland,
generally, is the most temperate in the world, and the
most conducive to health and longevity, and with
efficient sanitary organisation and cleanliness in the
homes, the island would rank as one of the healthiest
countries on earth.

Sir Charles Cameron said there were very few climates,
on the whole, superior to that of Ireland. The prin¬
cipal feature was its equability. There was only aDout

ten degrees difference between the mean winter and
summer temperatures. A low death-rate was usually
co-incident with a cool summer and a mild winter.

He dreaded a hot summer and a cold winter, for there
was no greater fallacy than that a green Yule makes
a fat churchyard.

Mr. Rideal, D.Sc., F.I.C., read a paper on "Dis¬
infection Considered from a Medical, Chemical, and
Bacteriological Standpoint.” Both he and Mr. A. E. 1
Moore, M.B., B.Ch., R.U.I., Queen’s College, Cork,
agreed on the necessity for the standardisation of
commercial disinfectants ; and Dr. S. G. Moore, M.D.,
Medical Officer of Health, Huddersfield, said that the
great majority of the disinfectants sold under fancy
names, and, of course, at fancy prices, were, to a large
extent, ineffective. Ordinary daylight, fresh air,
high temperature secured by means of steam, and soap
and water were agencies which without any chemicals
at all were absolute and complete disinfectants.

The Registrar-General for Ireland (Mr. Matheson)
quoted some interesting statistics showing the relation
of earth temperature to deaths from diarrhoeal diseases, ,
and also spoke of the close relation between the de¬
crease of temperature and increase of mortality from
diseases of the respiratory organs.

The Chairman said if the natural agencies of dis¬
infection, such as sunlight, heat, &c., were extensively
utilised, tuberculosis would have disappeared from the
country in fifty years.

At the conclusion of the proceedings votes of thanks
were passed to the Lord Lieutenant and the Countess
of Aberdeen, to the Provost and Fellows of Trinity
College, to the Lord Mayor, to the directors of Guinness’s
Brewery, the trustees of the Iveagh Trust, to the
Dean of St. Patrick’s Cathedral, to Colonel Plunkett,
Director of the Science and Art Museum, Alderman
Cotton, and others, to Surgeon-Colonel Dr. Edgar
Flinn, and Mr. W. Kaye Parry, and also to Sir Charles
Cameron.

REVIEWS OF BOOKS.

TEXT-BOOK OF PATHOLOGY, (a)

The value of this text-book is well shown by the 1
fact that in the nine years since it first appeared, five
editions have been issued. The author has succeeded
in introducing many new facts, and in revising the text
in many instances without materially adding to the
size of the book—a matter of some importance in a
volume of this character. The chapters on “ Inflam¬
mation and Immunity,” have been carefully revised,
but the author’s determination to avoid any lengthy
details of pathologic physiology, while doubtless un¬
avoidable, necessitates the omission of many important
researches. This particularly refers to the recent
experimental work on the pathology of cancer, which
hardly receives adequate treatment in this work.
Many of the chapters are excellent, particularly that on
*' Diseases Due to Bacteria,” that on “ Animal Para¬
sites,” which has been largely re-written, and the
chapter on " Urines.” As is perhaps unavoidable,
one finds unexpected omissions. For instance, there
is no mention of the pyloric stenosis of infants, the
pathology of which has been so much in question, and
little is said of some other important subjects, e.g..
carcinoma of the kidney is dismissed in a few lines,
gastric carcinoma is discussed very shortly, and
“hernia” and “peritonitis” (particularly the latter
in the pathology of which much work has been done
of late) are hardly up to the level of much of the rest.
An admirable appendix containing details of patho¬
logical and bacteriological laboratory work is intro¬
duced, and will be found of great value. The book
is well got-up and printed, although the proof-reader
has passed many misprints in the article on “ Endo¬
thelioma.” Many illustrations and seven full-page
colour plates add to the value of the edition, though
it is to be hoped that such an illustration as that of
“ syphilitic cirrhosis of the liver ” (page 611) may be
eliminated in future editions *

. - — -- *

(a) *' Text-book of Pathology.” By Alfred Stengel, M.D. Fifth
Edition. Pp. 935. Philadelphia: W. B. Saunders and Co. 1906.

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July 3, 1907.

WEEKLY SUMMARY.

The Medical Puss. 21

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for The Medical Press and Circular.

RECENT OBSTETRICAL LITERATURE.

Cborea Daring Pregnancy. —Shaw Journ. Obst. and
Gyna., 1907).—This is a report of eleven cases of
chorea of pregnancy. The first two cases were treated
on traditional lines with unsatisfactory results. It was
then decided to try anti-toxin treatment, by which
patients were put on a milk diet and elimination in¬
creased. In nine cases so treated the best results were
secured. The idea underlying the experiment was that
the tox?emia of pregnancy lowers the resistance of the
nervous system, and puts it in a state of heightened
irritability, so that it responds to stimulje, chemical
and emotional, &c., which would not otherwise produce
any result perceptible by ordinary clinical methods of
observation. Based on this hypothesis, the treatment
aims at (1) removing the pre-disposing cause; (2)
removing the determining cause; (3) treating the
symptoms, if necessary. The author's conclusions are :

(1) The chorea of pregnancy, like other choreas is due
to a toxin which appears to be identical with, or closely
to resemble, that of acute rheumatism ; (2) it affects
human subjects under two circumstances, both of these
being characterised by instability or irritability of
the nervous system, namely, childhood and pregnancy;
(3) the cause of the instability or irritability of the
nervous system in pregnancy bringing it down to the
level of childhood, is the toxaemia of pregnancy; (4)
in the chorea of pregnancy, therefore, it is more im¬
portant to remove the pre-disposing cause than to
apply merely symptomatic treatment; (5) the treat¬
ment must be eliminative as in the other toxaemias of
pregnancy ; (6) the pregnancy should not be arrested,
as a rule, as this is generally unnecessary and harmful
to the patient, as well as to the child. F.

Puerperal Peritonitis Treated by Abdominal Section.—

Gordon (Journ. of Obslet. and Gyna., June, 1907). —
This is a report of ten cases treated in the Monsell
Fever Hospital, Manchester. All the patients were in a
very critical condition when admitted to hospital and
operated on, and many were regarded as being in a
hopeless state. Of the ten cases four died and six
recovered. The conditions found on opening the abdo¬
men consisted of general peritoneal infection, dis¬
charging pus tubes and abscesses of ovary or uterine
wall, abscesses in Douglas’ space, cellulitis, and decom¬
posing placental remains inside uterus, most of these
conditions were present in each case ; the discharging
pus tubes being common to all. Cultures made from
the peritoneal fluid showed streptococci alone in four
cases, streptococci with bacilli coli communes in three,
streptococci and gonococci in two, and in one case
cultures taken from the blood during life showed strepto¬
cocci only, while those from the uterus gave strepto¬
cocci, bacilli coli and staphylococci. In only one case
was flushing of the peritoneal cavity resorted to, but
jn this case the writer attributes the patient’s recovery
to it. However, he is of opinion that, as a rule, it is
best not to flush or even sponge the peritoneal cavity
at all, but to rely rather on free drainage at the most
dependent part, with subsequent propping up of the
patient in a sitting position, and the subcutaneous
injection of saline solution with or without anti¬
streptococcic serum and adrenalin. Calomel is almost
invariably administered on the second or third day.
Cases where placental masses remained in the utenis,
■were curetted with a large sharp curette, swabbed with
pure izal, or corrosive sublimate solution and packed
with gauze. F.

The Treatment of Post-partam Haemorrhage, with a
,New Method of Hemostasis.— Stowe (Surg., Gyn.,
and{Obstet., June, 1907).—After reviewing the prophy¬
laxis of post-partum hemorrhage, the writer says that

in cases where massage of the uterus and expulsion
of clots with emptying of a distended bladder fail to
control haemorrhage, and where from atony of the
uterus, the organ lies in the pelvis like an empty sac,
with its walls soft and offering no resistance to the
hand, he has with great satisfaction tried a new method
of hemostasis. As the patient is bleeding profusely at the
time something must be done immediately so he grasps
and firmly kneads the fundus with one hand at the same
time pressing it down into the*inlet. The other hand,
encased in a sterile glove, is passed into the vagina up
to the cervix, the fingers seizing as much of the cervix
and lower uterine segment as possible. The hand is
then forced far into Bandels ring until the fundus is
reached. The internal liand remains thus outside the
uterine cavity throughout the operation. If sufficient
pressure be used the internal hand can be forced well
into the fundus and past the contraction ring, pushing
the cervix and lower uterine segment before it against
the walls of the fundus. This obliterates the cavity of
the uterus and brings direct pressure and compression
to bear against the sinuses and open vessels. The
position of the internal hand or fist in the fundus, yet
outside the uterus, has a marked effect in stimulating
contraction, especially when aided by brisk massage
and by inverting the lower portion of the uterus into
the upper direct pressure is brought to bear by the
hand against the uterine arteries, and the supply of
blood is in a great measure shut off. If arrest of haemorr¬
hage is in great part obtained, and the uterus contracts
poorly, an intra-uterine douche at 115 F. is given. If
the bi-manual compression and the douche produce only
temporary lucmostasis further delay is dangerous and
recourse should be had to the utero-vaginal tamponnade.

Asepsis daring Abdominal Operations.— Fritsch,
at the meeting of the German Gynaecological Congress
at Dresden (Zentralblatt fiir Gyn, 1907, No. 25) said
among other remarks on this subject that the efforts
to produce asepsis through the course of an operation
may be divided into the following parts (1) The
sterility of the hands ; (2) The sterility of the field
of operation ; (3) The prevention of pollution during
the operation. The importance of preserving the hands
has led the author to give up the hot-water—alcohol-
sublimate disinfection for the soap—spirit disinfection
of v. Mikulicz. Rubber gloves are necessary. Further
it is most important whenever an unclean wound
is touched or during a rectal examination or vaginal
exploration when there is discharge, for example,
carcinoma, that rubber gloves should always be worn.
Operating with perforated or torn gloves is careless
and irrational. Repeated rinsing of the hands during
operation in sublimate and sterilised water is to be
recommended. As regards the asepsis of the field
of operation we have to deal with three regions,
(a) The skin of the abdominal wall; ( b) the vagina,
and (c) the vulva with the anus. For this also the
soap-spirit disinfection is admissible. The speaker
has now adopted Doderlein’s proceeding, not because
his results formerly were bad, but because one is
ready sooner without allowing the patient to become
cold. The abdomen is first rubbed over with benzine,
then with a gauze wipe, soaked in tincture of iodine,
and after this has dried it is smeared evenly all over
with a solution of rubber Doderlein’s “ Gaudanin.”
with the apparatus which has been constructed for
this purpose. When the rubber is powdered over
with sterile chalk the preparation is finished. The
bacteria deep in the skin are best overcome with the
tincture of iodine, while they are kept away from the
wound by the rubber membrane. Further, in

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22 The Medical Press.

MEDICAL NEWS IN BRIEF.

July 3. 1907.

order that the tissues may preserve their vitality
and their power of re-acting to infection, it is necessary
that they should be protected ; therefore the operating
should be quick and skilful. The speaker also recom¬
mended Stceckel’s speculum for protection of the
abdominal wound. The finger should be employed
for the separation of intestinal adhesions, adherent
cysts and tumours. The intestines should never be
allowed to come outside the abdominal cavity. This is
easily prevented in the pelvis high position by putting
in a large compress. This absorbs blood and even
pus so well that after its removal wiping out the
cavity may be omitted. To prevent ileus and adhe¬
sions it is necessary to cover over every raw surface
in the peritoneal cavity. Pfassuensti'ri’s incision
combines all the advantages of ventral laparotomy
with the advantages of the vaginal operation; for
example, the good prognosis which is associated with
the small vaginal opening into the peritoneum. The
injuries to the bladder which so often make patients
permanent invalids after vaginal coeliotomy do not
occur with tfassuenstiel’s incision. For suture material
silver wire should be abandoned; silkworm is
much better. When buried it remains definitely
unaltered; further, owing to its smoothness it may
be easily and painlessly removed. For subcutaneous
sutures and ligatures catgut only should be used.
The speaker prefers iodine to Cumol catgut. He uses
catgut exclusively for vaginal plastic operations.
For closing skin wounds he recommends silkworm.
Finally, to keep the wound completely dry Dermato
vioform or phenyform shall be used. As regards
vaginal asepsis he recommends repeated antiseptic
douching and cleansing before operation, and before
vaginal hysterectomy the uterine cavity must also
be thoroughly washed out. One often finds in a
uterus an accumulation of pus behind a mass of
cancer. From the moment of the first incision anti¬
septic or, in fact, any douching must not be employed.
Blood must be mopped up with dry wipes and its
source controlled with catgut ligatures. Purgation
and douching out of the lower bowel must be thoroughly
employed before operation. G.

Indication, Technique and Remits of Opera¬
tions for Enlarging the Pelvis. — During the
introduction of this subject at the Congress, Doderlein
(Zentralblatt fur Gyn., 1907, No. 24) said as regards the
mortality from hebosteotomy, the open method
of operation seems to be followed by the same mortality
as symphysiotomy. Subcutaneous hebosteotomy with
four times the number of cases has less than half the
mortality of the open method, and is therefore un¬
doubtedly superior. The improvement in results is
therefore not so much due to cutting the bone as to
the subcutaneous manner of doing it. The cases in
which the genital tract was infected before operation
account for the greater part of the mortality. A
special danger lies in lacerations of the vagina commu¬
nicating with the wound when the genital tract is
already septic. Injuries to neighbouring organs,
especially the bladder, increase the danger to life.
It is not certain how dangerous thrombosis of the
larger vessels at the seat of operation with resulting
emboli may be. It seems they are not to be feared
when there are no other complications, for example,
injuries to the bladder. The danger of hmmorrhage
and of death from hemorrhage requires that this
operation shall be performed with every means ready
to stop such haemorrhage. Special attention must
be given in cases of severe haemorrhage to the corpora
cavernosa clitoridis. As regards injuries to the
bladder he says that the most frequent cause is per¬
foration of the bladder wall with the hebosteotomic
needle, particularly when the latter is sharp. In
these cases the saw will also injure the bladder. The
bladder may also be injured when there are extensive
lacerations of the vagina. Injuries to the bladder
are dangerous to life, and have a very evil influence
on the convalescence in every case. The supporters
of subcutaneous perforation method have the problem
of divesting the technique of this danger. As regards

lacerations of the vagina communicating with the
wound, their occurrence is especially to be feared
among primiparae with forced delivery. To prevent
them spontaneous delivery must be waited for when¬
ever possible, When the vagina is narrow a deep incision
into the vagina and perineum must be made at the
side opposite the hebosteotomy. The haematomata
which more or less arise in the majority of cases are
of no importance. They only suppurate when com¬
plicated with bladder injuriels. In the arfter-treatment
adhesive plaster or a pelvic binder is not necessary.
As regards the infantile results three children were dead
when bora among fifty-five cases of the open hebosteo¬
tomy, and twelve among one hundred and seventy
of the subcutaneous method. The most frequent
causes of death are cerebral injuries, such as intra¬
cranial hemorrhages usually associated with forceps
deliveries; less frequently with version and extraction.
The speaker advised 6.7s cm. as the lowest measure¬
ment at which hebosteotomy may be performed. G.

Medical News in Brief-

Aa Educational Health and Food Campaign.

The Lord Mayor presided recently at the London
Mansion House over a largely attended meeting con¬
vened by the Bread and Food Reform League for the
purpose of inaugurating an educational health and
food campaign.

The Bread and Food Reform League, an educational
and purely uncommercial and non-political association,
is organised to direct attention to the great importance
of the food question and promote the healthy nutrition
of the people, and in the proposed campaign it purposes,
in connection with representatives of other societies, to
disseminate information which will tend to promote
health and diminish many of the diseases produced by
ignorance of dietetic laws. Without advocating any
special system of diet, it is desired to show the nutritive
and economic value of much-neglected staple ioods, the
more general adoption of which would benefit the
health of all classes of society and lessen suffering among
those of limited means. As ignorance about food tends
directly and indirectly to produce infantile mortality
and physical deterioration, the council of the league
decided to organize the campaign, which will consist of
a series of conferences, lectures, and cookery demon¬
strations with distribution of literature and foods.
These will be held in poor districts with the co-operation
of public health and other local societies, clergy, and
medical men. The King has already expressed his
sympathy with the objects of the League.

After the I.ord Mayor had opened the proceedings.
Miss Yates outlined the objects of the proposed cam¬
paign.

Sir James Crichton-Brown moved the following
resolution :—“ That an educational health and food
campaign be held to stimulate societies and indi¬
viduals interested in the welfare of the people, to make
systematic co-ordinated efforts to remove this igncr-
ance, strengthen local health committees, and influence
public opinion, so that health visitors may be estab¬
lished to work in conjunction with medical officers of
health in spreading plain practical information among
the people." He said that he was not present to advo¬
cate any special system of diet, and he particularly
repudiated any vegetarian tendencies, for he had no
doubt that animal food as an element in the diet of the
people had largely contributed to the vigour, energy,
and success of our race. By establishing conferences,
holding meetings, and distributing literature, it would,
it was hoped, arouse general interest in food questions
and hasten the day when dietetics would be regarded
as an important part if the school curriculum, and when
instruction in cookery would be thorough and practical.
By bringing pressure to bear on the Legislature the
League would, it was hoped, promote measures cal¬
culated to check the adulteration and sophistication
of food at present rampant, and with reference to
certain articles to establish a standard of value, w that

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July 3. 1907-

MEDICAL NEWS IN BRIEF.

The Medical Pu«. 23

doctored or deteriorated stuff might no longer be palmed
off on the public. Sir James spoke of the necessity of
educating mothers in the feeding of infants, and of
the necessity for a pure milk diet, and then dwelt upon
the question of the feeding of children, particularly in
its relation to education. With regard to those who
could feed as they would, he said that they would do
well to revert to a greater simplicity of treatment
than was now customary.

Dr. Heron seconded the motion, which was supported
by Dr. J. F. J. Sykes, Professor W. R. Smith. Dr.
David Walsh, Mr. Pearce Gould, and Dr. A. W. Mayo
Robson, who dealt with various aspects of the question.
Freedom of the City conferred oaJUrd Lister.

More than a century ago the Corporation of London
presented the Freedom of the City to Dr. Jenner in
recognition of his work in the prevention of small¬
pox. On June 28th, in conferring the same honour
on Lord Lister, the Corporation showed appreciation
of another great name whose work marks an epoch in
the history of medicine. The ceremony took place in
the Council Chamber at the Guildhall, where, besides
the Lord Mayor and Aldermen and members of the
Common Council, several representatives of Lord
Lister’s profession were present, These latter included
the President of the Royal College of Physicians, the
President of the Royal College of Surgeons, Sir Henry
Roscoe and Dr. Charles Martin (representing the
Lister Institute of Preventive Medicine), Sir Norman
Lockyer, Sir Victor Horsley, Professor Howard Marsh,
Dr. L. W. Darra Mair (representing the Chief Medical
Officer of the Local Government Board, who was un¬
avoidably prevented from attending), and members
of the medical staffs of several of the London hospitals.

After the City Chamberlain’s Clerk had read the
Declaration of Compurgators, Alderman Guthrie and
Alderman Hanson, on behalf of the Merchant Taylor’s
Company, presented Lord Lister for the Freedom.

Sir Joseph Dimsdale, the City Chamberlain, then,
delivered an address.

The City Chamberlain offered the new Freeman the
right hand of fellowship, and presented him with the
certificate of freedom in a gold casket amid the applause
of the assembly. The casket, which has been designed
and manufactured by the Goldsmiths’ and Silversmiths’
Company, is supported by four scroll feet in the inter¬
spaces of which are emblems relating to science and
learning. The box itself bears the arms of the recipient
and views of London in enamel, and is also decorated
with emblems relating to Lord Lister’s distinguished
career. It bears the following inscription : “ Presented
by the Corporation of the City of London with the.
Freedom of the City to the Right Hon. Lord Lister
O.M., M.D., F.R.S., D.C.L., &c., in recognition of his
eminence as a surgeon, and of the invaluable services
rendered to humanity by his discovery of the antiseptic
system of treatment in surgery. Guildhall, June 28th.
1907.” The lid is surmounted by a figure representing
Hygeia, and at the ends of the base are other figures,
one representing the City of London offering the scroll
of freedom and the other Medical Science holding out
the torch of fame.

Lord Lister spoke as follows in reply : I thank you,
Sir Joseph Dimsdale, from the bottom of my heart for
your overpoweringly kind words. The work which it
has been my great privilege to be engaged in has been
its own all-sufficient reward. Perhaps I need not say
that I value in the highest degree this, the greatest
civic distinction in the world. If it were possible to
enhance the honour you have conferred on me to-day,
this has been done by the extraordinary consideration
shown by you, my Lord Mayor, and your Court,for my
personal convenience. Had it not been for this your
extreme kindness it would have been impossible for
me in my very infirm state of health to have received
your gift here in this historic building.

After some customary formalities the proceedings
came to an end.

The Cancer Hospital Bromptora.

A conversazione was held last night in the buildings
and grounds of the Cancer Hospital. The guests,
among whom were a large number of the medical pro¬

fession, were received by the President of the hospital.
Lord Ludlow, accompanied by Lady Ludlow. Two
large marquees had been erected on the lawns, and in
these light refreshments were served. The grounds
and buildings were suitably decorated, and the string
band of the Coldstream Guards rendered an excellent
musical programme. The medical and surgical staff
and other officials assisted Lord Ludlow in conducting
the guests through the wards and the various depart¬
ments of this institution, where the facilities both for
treatment and research were fully explained. The
hospital was founded in 1851 by the late Dr. William
Marsden, whose wife had previously died a Victim to
cancer. It at first contained 20 beds, but these were
increased in 1883 to over 100. There are now 114
beds available, and as the hospital is quite free, “ letters
of recommendation ” are not needed. The wards of
the hospital presented a very cheerful aspect in spite
of the fact that the patients were suffering from
cancer. Here every form of treatment which appears
to offer any possible hope of relief is given an exhaus¬
tive trial. Special beds are set apart for the treatment
of cancer by remedies that are from time to time
vaunted as being of use in the treatment of this terrible
malady. Every case is thoroughly investigated and
careful records are kept, which provide invaluable
material for the study of the disease. This close asso¬
ciation of the clinical and pathological work of the
hospital is a most important factor in the investigation
of cancer, for it is only by the combined study of the
disease at the bedside and in the laboratory that we
may expect to obtain a solution of this very difficult
problem. During the last year, 817 in-patients and
17,376 out-patients were treated, and as the hospital
is solely dependent on voluntary support, funds are
urgently needed to meet increasing expenditure.

The Royal College ol Surgeoni In Ireland.!— Barker
Anatomical Prize for 1908.

A prize of £2 1 is offered for competition, and is
open to any student whose name is on the anatomical
class list of any school in the United Kingdom. The
preparations entered must be placed in charge of the
Curator on or before April 30th, 1908. The prize is
offered for dissections to illustrate the muscular and
ligamentous anatomy of the shoulder-joint. The pre¬
paration must be sent to the Curator of the Museum,
Royal College of Surgeons, each being marked with
a fictitious signature, and accompanied by a sealed
envelope bearing outside the same signature, and
containing within (a) the full name of the competitor,
and (6) a declaration to the effect that the work of the
preparation has been carried out by himself. The
printed form necessary for this declaration can be ob¬
tained on application to the Curator. The dissections
are to be mounted in vessels fitted with glass covers, but
the covers must not be sealed down. Earthenware
basins and plaster of Paris settings are not compulsory
if the specimens can be equally well displayed and pre¬
served by other means. No prize will be awarded
unless sufficient merit be shown. Those competitors
who enter dissections for which prizes are not awarded,
but which show sufficient merit, may be refunded such
amount of the cost of production as the Examiners
deem fit. The costs and risks of transport must
be borne by the student. The College will not be re¬
sponsible for any damage the preparations may sustain ;
but those of unsuccessful competitors residing at a
distance will be carefully re-packed and handed to the
carriers for delivery at such address as may be specified
by the student.

Distribution of Prizes at the London Hospitals.

The season for annual distribution of prizes at many
of the Schools of the London Hospitals has now begun.
At the Westminster Hospital yesterday, the Right Hon.
Alfred Lyttelton, K.C., M.P., presided ; Sir Arthur
Rucker, D.Sc., LL.D., F.R.S., will present the medals
and Prizes to the successful students at Guy’s to¬
morrow at 3.15; whilst Professor Osier, F.R.S., will
fulfil a similar function on July nth, at 3.30 p.m. at St.
Mary’s. Mr. Rider Haggard took the chair at a similar
gathering at St. Thomas’s last week.

zed by Google

24 Tins Medical Press. NOTICES TO CORRESPONDENTS.

NOTICES TO
CORRESPONDENTS,

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Rstrixts—B eprinU of articles appearing In this Journal can be had
at a reduced rate, providing authors give notice to the Publisher or
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returning proofs.

Original Axtiolxb ox Lkttxks intended for publication should
be written on oneslde of the paper only and must be authenticated
with the name and address of the writer, Dot necessary for publica¬
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SUBSCRIPTIONS.

Subscriptions may commence at any date, but the two volumes
each year begin on January 1st and July 1st respectively. Terms
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must be paid in advance. For India, Messrs. Thacker, Spink and Co.,
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ADVERTISEMENTS.

Fox Oxx Ixbbetiom Whole Page £5; Half Page, £2 10e.

Quarter Page. £1 5s.; One-eighth, 12s. 6<L
The following reductions are made for a series:—Whole Page, 13
insertions, at £3 10s.; 26 at £3 3s.; 52 Insertions at ^3, and pro
rata for smaller spaces.

Small announcements of Practices, Asslstaneles. Vacancies, Books,
Ac.—Seven lines or under (70 wards), 4s. 6d. per insertion ; 6d.
per line beyond.

Txjtdo.—M elanotic sarcomata are moat frequently derived from
pre-existing pigmented spots, such as moles, and even where the
growth appears to be primary or spontaneous it may frequently be
traced to some unsuspected and obscure lesion, such as a pigmented
spot in the rectum or vagina. But some of the melanotic growths
are in all probability primary, not derived from pre-existing
pigmented structures.

W. H. M. (London, W.).—We might possibly publish the com¬
munication you send if the formulte of the preparations could be
also published. If the gentleman ia actuated by philanthropic
motives—which we do not doubt for a moment—he will surely
appreciate the argument that no medical man could take the
responsibility of prescribing a remedy for a patient unless he
were acquainted with its composition and the effects likely to
arise from idiosyncrasy or other causes through its employment.
Ingredients 1, 2 and 6 would require careful watching m certain
cases. We do not think that the arrangeihent you suggest would
meet the wants of the case, as it would tend to bring us under
some suspicion of commercial interest, which we should not care
to rest upon us.

F. R. V.— We regret to say that we can already answer your
question, for the Prime Minister announced last week in the
House of Commons that he has been advised by “ the authorities
best qualified to express an opinion ” not to appoint a Boyal
Commission on Cancer. He held out hopes, however, that one
might be appointed when the present research students have
elucidated a larger number of facts for consideration. See also
our editorial columns this week.

D. O. 8.—The name of the work vou want is probably
*' Anatomla Crime Galeno-8pagyrioa," by Henricus Martinius
Dantiscanus, D.M. It was published in Frankfort in 1658, but
we are not sure if that is the first edition. It is not very easily
picked up, but there are a fair number of copies about.

J&eetinjiB of the Societies, Hectares, &c.

Wednesday, July 3rd.

Obstetrical Society or London (20 Hanover Sauare, W._).—
8 p.m: Specimens will be shown by Dr. Eden, Miss Aldnch-
Blake, Dr. Lewers, Mrs. Boyd, M.D., Dr. Longridge and Dr.
R D. Maxwell, and Mr. Targett. Short Communication: Dr.
F. E. Taylor: Typhoid Infection of Ovarian Cysts.

Medical Graduates' Colleoz and Polyclinic (22 Chenies
Street, W.C.).—4 p.m.: Mr. J. Pardoe: Clinique. (Surgical.)
515 pm.: Lecture Dr. W. Langdon-Brown : 8ome Points
concerning Albuminuria, Phosphaturia, and Oxaluna.

North-East London Post-Graduate College (Prince of
Wales’s General Hospital, Tottenham, N.).—CTiniques :-^.30
p.m.: Skin (Dr. Meachen), Eye (Mr. Brooks), Medical Out¬
patient (Dr. Whipham).

Thubsdat, Jult 4th.

Medical Graduates' College and Polyclinic (22 Chenies
Street W.C.).—4 p.m.: Mr. Hutchinson : Clinique. (Surgical).
5.15 p.m.: Lecture Mr. E. M. Corner: Deformities of the
Foot associated with Adduction. , .

North-East London Post-Graduate College (Prince of

Wales's General Hospital, Tottenham, N.).— 2.30 p.m. . Gynieco-
logical Operations (Dr. Giles). Clinique* :—Medical Out-patmnt
(Dr Whiting), Surgical Out-patient (Mr. Carson). 3 p.m. .

Medioal In-patient (Dr. Cbappel). _ wn .

Hospital tor Sice Children (Great Ormond Street, WC.>—
4 p.m.: LectureDr. 8tlll: “ Bilious Attacks in Children.

Friday, July 5th.

Medical Graduates' College and Poltcltnic (22 Chenies
Street W 0 V—4 p.m.: Mr. A. Dawson : Clinique. (Eye).

North-East London Post-Gbaduatb College (Mnce of

Wales's General Hospital. Tottenham, N ).- 9 30 ».m Clinique .

(Dr. Auld), Eye (Mr. Brooks). 3 p.m.: Medical In patient (Dr.
Leslie).

July 3. 1907.

ftantnts.

LOn £°«~ Cou 2 t ? Cl*ybury —Junior Assistant Medical

°®“ r - , Swsry, £150 s year. Application* to H. F. Keene,
Clerk of the Asylums Committee. (See advt.)

■ of . Dublin Hospital.—Pathologist, Anaesthetist,
a-K ay 1st and Dental Surgeon. Applications to Mr. G.
Jameson Johnston, hon. sec. (8ee advt.)

Loughborough and District General Hoepital and Dispenaarr.—
Resident House Surgeon. 8alary, £100 per annum, with fur-
ni *— 1 “ room8 > attendance, board and washing. Applications
to Thomas J. Webb, Secretary, Loughborough.

Egypt.—Sub-Inspector of Ophthaimio Hospitals. Salary, £500
per annum, with two months' salary in lieu of travelling
expenses to and from England. Applications to A. F.
MacCallan, Esq., 32 Bedford Gardens, Kensington, W.

West Bromwich District Hospital.—Senior House Surgeon.
Salary, £110 per annum, with board, residence and laundry.
Applications to T. Foley Bache, Eeq., Churchill House, West
Bromwich.

8t. Mary's Hospital, Paddington, W.—Curator of the Museum
and Assistant Pathologist. 8alary, £100 per annum. Appli¬
cation* to Thomas Ryan. Secretary,

Warwick County Asylum—Assistant Medioal Officer. 8s 1 try,

£135 per annum, with board, apartments and laundry. Appli¬
cations to Dr. Miller, Hatton, Warwick.

Boyal 8urrey County Hospital, Guildford.—House Surgeon.
Salary £100 per annum, with board, residenoe and laundry.
Applications to the Hon. Secretary at the Hospital.

The Ingham Infirmary and South Shields and Westoe Dispen¬
sary.—Senior House 8urgeon. Salary, £100 per annum, with
residence, board and washing. Applications to James R.
Wheldon, Secretary, 74, King Street, South Shields.

West Suffolk General Hospital, Bury St. Edmunds.—House Sur¬
geon. Salary, £100 per annum, with board and lodging.
Applications to the Secretary.

^Ippomlntents.

St. Johnbtox, Thomas Reginald, M.R.C.8., L.R.C.P., M.8.A.
(Assistant. Medical Superintendent, Lewisham Infirmary,
London), to be Government Medical Officer. Fiji.

Cheatlb, G. Lenthal, O.B., F.R.C.S.Eng., Surgeon to the City
of London Hospital for Disease* of the Chest. E.

Cunning, Joseph, M.B., B.S.Melb.. F.R.C.S Eng., Surgeon to
In-patients at the Victoria Hospital for Children.

Dickinson, J. J., M.B.Cantab., Certifying Surgeon under the
Factory and Workshop Act for the Tenbury District of the
County of Worcester.

FleMmtno, Arthur Launcelot, L.R.C.F.Lond., M.R.C.8.,
Honorary Anaesthetist to the Cossham Memorial Hospital,
Kingswood, Bristol.

Gibbon. J. A., M.D.Edin., Medical Officer for the Rural District
of the Isle of Wight.

Hertz. A. F., M.B., B.Ch.Oxon., Physician to the Electrical
Department at Guy's Hospital. ,

Jordan. A. C., M.D., B.C.Lond., Medical Radiographer at Guy s
Hospital. . . _ .

Lewis, Thomas. MB.. B.S.Lond., M.R.C.P., Physician to Out¬
patients at the City of London Hospital for Diseases of the

Morton*. C. j., M.D., C.M.Edin., Surgical Radiographer at Guy's

Rubsfxl,' 1 Alfred Ernest, M.D.Lond., M.R.C.P., Physician to
Out-patients at St. Thomas's Hospital, London.

Smith. Robert Shinoleton, M.D., B Sc., F.R.C.P.Lond.,
M R C.8., Honorary Consulting Physician to the Lossbam
Memorial Hospital. Kingswood, Bristol

Thomas. Edmund J. Fairfield, L.R C.F. Lond.. m.k.l-.s.,
L.S A., House Physician at the Cardiff Infirmary.

jBirth:

Moore.— On .Tune 22nd. at Monage, Dartrey, co. Monaghan,
the wife of Dr. Arthur Moore, of a daughter.

JHarriaQfs.

Best—Crichton-Stuart.— On June 25th at the Church of King
Charles the Martyr, Tunbridge Wells, William Harm Beet.
L.R.C.F., to Audrey, younger daughter of the late Lieut.

St, Nichola*.

Sidney John Oldacres Dickins. M D -. of

Cicelv Margaret, elder daughter of William Whitchurch
Mawn tw-^ouvo!—On une 26° h .^t'^CheYd le H ulme. Cheshire,

““ “ffa Sf&’BaifSfeAi

to Janie Marian, elder daughter of the Rev. V llliam Young,

TRi£-6^N E -o“ h June 26th at St.

S h putnevf°elde EO son of Herbert H. Triet, of Brighton to
Louisa Harriet, elder daughter of E. Annesley Owen, Esq.,
Barristcr-at-law, of the Inner Temple.

Barths.

Br T^ n r^. 0 ;

of Major G. T. Rawnsley, R.A.M.L.

y Google

The Medical Press and Circular.

-SALUS POPUU SUPREMA LEX."

Vol. CXXXV. WEDNESDAY, JULY io, 1907. No - 2

Notes and Comments.

At the Annual Congress of the
Sir Jaaes Barr Royal Institute of Public Health,
at held at Douglas, Isle of Man, last

Doaglas. week, Sir James Barr, who was
President of the Section of Pre¬
ventive Medicine, was, evidently in gay humour
for he delivered a breezy address which has
received more extensive report and more editorial
comment than any address of the kind for a long
time. The audience seem from the reports to
have enjoyed the address immensely, for the
report is freely punctuated with “ laughter ” and
“ applause,” but the newspaper critics have for
the most part been puzzled whether to take it
seriously or not. The Liberal papers are indignant
with Sir James for dragging their bete-noir , con¬
scription, into a scientific address, and Conserv¬
ative ones hope that he did not really mean any¬
thing so socialistic as a special tax on the already
overburdened millionaire. One Yorkshire daily
finds in the address “ at least a suggestion of
Rabelais,” and a London evening paper thinks it
“ will not be far wrong,” if it attributes “ to pure
humour ” such suggestions as that physicians
should be called upon to pay the funeral expenses
of their patients, or that newspaper editors should
be placed in the forefront of the battle in order
that the nation may be rid of them. In fact to
the general mind Sir James Barr’s address has
been most disconcerting, and everybody is asking
his neighbour quite what he means. We should
be sorry to take upon ourselves the rdle of inter¬
preter, but it really seems as if Sir J ames regarded
the meeting of the Congress as a little holiday,
and wished to enjoy himself there. He therefore
talked on all the subjects on which he had formed
opinions, politics, sociology, medicine, and his
friends the surgeons who made so much money,
and incidentally a little public health was brought
in.

Drafooalflf Sir James Barr seems to have
versus a particular aversion for what
Pcscefal he calls the “ Exeter Hall type of
PersMsioa. Christian, imbued with a sickly
sentimentality,” and the usually
popular figure of John Bull. ‘‘This big, fat,
plethoric, pot-bellied man is never ready for a
fight of any kind,” whereas, according to Sir
James the ideal of manhood would seem to be a
muscular Christian—not a pigmy—who is always
ready to fight anyone in any place. But his
great admiration seems to be reserved for German
habits and the German Emperor, although, by way
of letting us share in Teutonic advantages, he

would have us shut out the alien. Everything
English seemed to be wrong, and everything Ger¬
man, except the foreign alien who comes over here,
about as good as possible. Well, it is a curious but
happy paradox that the Britisher, with his numer¬
ous faults and with his tantalising inconsistencies
and incongruities, is always a good bit ahead of the
German with his military habit of obedience and
his splendid organisation, so that it is possible that
the physique, the health, and the spirit of the race
are not so bad after all. And it would be a vast
pity if opposition to public health measures were
to arise by reason of English people imagining their
proper liberties were to be infringed. The difference
in mental habit between the Briton and the German
is sufficiently shown by the course of the vaccin¬
ation controversy, and public health reformers will
do well to take that sad but instructive lesson to
..heart. It has been proved a hundred times in
"the past that the free-bom Briton will be dictated
to by no prince, priest, or governor, and in the
twentieth century he is still stupid enough not to
let even a doctor do what is good for him.

There are many signs that the
Infant teachings of what may be called
Caltare. the “ new hygiene ” are beginning
to reach the lives and habits of
people. True, the progress is slow,
and knowledge filters rather than pours into the
domestic circle ; but in London already there are
two schemes on foot for the prevention of infant
mortality, which are both on sound lines. One of
these is a school for mothers, which Dr. Sykes,
Medical Officer of Health for St. Pancras, has
started, and which has already achieved a certain
success. No less than forty pupils are in attend¬
ance, and instruction in the proper management
of the infants is bound to have a profound effect
on the future health and physique of the little
ones. The other movement is the establishment
at St. Marylebone General Dispensary of “ infant
consultations ” on the lines of those founded in
Paris by the late Dr. Budin. Last week a meeting
was held, with Lord Robert Cecil in the chair, to
receive the annual report, which showed that 90
babies had been under treatment during the year,
and that the benefit had been great. When our
hospitals are put on right lines as consultative
institutions for cases in which the general
practitioner wants help, and the present over¬
crowded casualty departments are eased of their
trivial routine work, a far more useful and noble
function will lie before them, namely, that of aid¬
ing in the prevention of sickness and in the

Digitized by GoOgle

26 The Medical P«m

LEADING ARTICLES.

July io, 1907

education of the poorbysuch means as infant consul¬
tations and the giving of hygienic advice instead
of the present playful habit of doling out
bottles of medicine.

It is announced that an expedi-
A tion organised and equipped by

Mlislflf Link. the Royal Prussian Academy of
Science and the Dutch Govern¬
ment has arrived in Java to search
for the “ missing link,” which Professor Dubois
claimed to have found there some twenty years
ago. It is strange what a fascination phrases have
for people. The “ missing link ” to the popular
mind remains to be found before the Darwinian
theory can be authenticated, and it is probable that
it will cost as much trouble to teach them that
there is no “ link” missing between man and ape as
that there are no lost tribes to be found or no sea-
serpent to be harpooned. It is quite possible that
in J ava there may be some remains of pre-historic
man, indeed it is said that some skulls like the
Neanderthal one have been found there ; but Dr.
Moskowski, who leads the expedition, and his
followers have as much chance of finding the
“ missing link ” as of discovering the Golden
Fleece or the Holy Grail.

Mrtlcil Referees The new Workmen’s Compensa¬
te the tion Act which came into force
WerkaeE’s with the beginning of this month,
Ceapeasatiea it is generally acknowledged, is a
Act. legal patchwork which is likely to
give rise to as much difficulty in its interpretation
as its predecessor. It is certain that the Govern¬
ment missed a great chance of simplifying its
administration in not accepting the Labour
amendment to the effect that in any case of
dispute as to the medical aspect of the case the
question should be settled by a Government referee
without any legal proceedings being necessary.
It is hardly to be supposed that County Court
judges will take more kindly to the assistance of
medical assessors than they have done in the past,
and the same process in disputed claims is likely
to go on with the same result, namely, that the
working man whose case presents obscure medical
points and the malingerer who is shamming ‘‘in¬
ternal injury ” will both be in the same box, and
both will have an equal chance of a verdict.
Nearly the whole of the liability for payment now
consists in the nature and extent of the injury,
and not one case in a hundred need ever come into
court if a salaried Government referee were to
be able to give an authoritative and binding
decision on the facts, without the intervention
of any legal process.

LEADING ARTICLES.

KING EDWARDS HOSPITAL FUND FOR
LONDON.

The Bill for the incorporation of the King
Edward’s Hospital Fund for London having
passed its third reading, it may be well to
place on record a final protest against certain
principles which have now been formally approved
by Parliament. The modification of the clause
whereby absolute control over the revenues and
administration of the Fund were transferred
from the President to the Council was, in our

opinion, most desirable. So, also, was the change
of the conditions of the presidency, which it was
proposed to grant in perpetuity to the Prince of
Wales during the pleasure of the King, and
afterwards to succeeding presidents also ap¬
pointed to office by the Sovereign. These views
we have long held, and have urged, as loyal
subjects anxious to safeguard the best and truest
interests of the Royal Family in their public
relations. With profound regret we note the
failure of Dr. V. H. Rutherford, the Member for
the Brentford Division of Middlesex, to secure
the constitution of the Council of the Fund on
representative lines. The present Council is
small and autocratic, and is inevitably
exposed to the risk that its administration will
drift into the hands of one or two active members,
who will be absolutely independent of public
opinion and careless of criticism. Under these
circumstances there is an ever present danger
that injustice will be sooner or later done in the
dispensation of grants, and there will be
no appeal against a body which is absolutely
irresponsible. It seems almost inconceivable
that a Liberal Government, to whom repre¬
sentative control is as the breath of its nostrils,
could permit so retrograde a step to be taken
in the case of a great public trust dispensing
vast sums of money. As a matter of elementary
fairness and wisdom the representation, both of
the medical charities and of the medical pro¬
fession beyond one or two of its leading corpora¬
tions, would have gone far, toward securing the
permanent confidence of the community. Under
the present constitution there can be no guarantee
against the constant recurrence of troubles of a
more or less serious nature, and we regret that a
great opportunity has been lost of showing the
medical profession, by a graceful concession to
its wishes in the matter of representation on
the Fund, that the interests of the general
practitioners would not in future be overlooked
as in the past by the haphazard methods of
modem philanthropic enterprise.

THE HOUSING PROBLEM IN DUBLIN.

It is a commonplace among ranitarians and
social reformers that none of the many problems
with which they are faced can be completely
solved until the poor are supplied with suitable
houses at cheap rates. As Koch has pointed out,
the overcrowded, ill-ventilated houses of the
poor are the breeding-grounds of tuberculosis.
With airy, bright dwellings, and with due regard
to cleanliness such as comfortable housing
always fosters, there is little doubt that the
power of this plague would soon be undermined.
It is in the dirty, crowded tenements that the
filth diseases also persist, breaking bounds from
time to time and making their way into the
dwellings of the prosperous. Typhus, small-pox,
measles, scarlatina, and typhoid would, in these
countries at any rate, soon cease to be dreaded
if the poor were supplied with sanitary dwellings,
Intemperance, too, with its attendant vices, can

Digitized by GoOgle

July 10, 1007 .

CURRENT TOPICS.

Th« Midical hm 27

hardly be combatted as long as the working man
has no place other than the bar-parlour where he
can sit in comfort when his work is done. In
Dublin the problem is as pressing as in any city
in the kingdom. The tubercular rate is high, and
shows no signs of diminution, while the general
death-rate is one of the highest in Europe.
Typhus, a rare disease in English cities, persists
in Dublin slums, and the other zymotic diseases
contribute largely to the death-rate. Again, in
Dublin the dwellings of the poor are of a peculiar
nature. As the well-to-do population has first
migrated from the north side of the river to the
south, and again from the south to the suburbs,
the mansions and large houses it has deserted
have fallen into tenements for the poor. One,
two, three, or even four families, find a refuge in
the room which was formerly a drawing-room or
dining-room of fashion. Sanitary conveniences
are insufficient or absent, and there is no attempt
at cleanliness. The Dublin Corporation, which
has the duty of seeing that yards, halls, and
staircases are kept in proper condition, pays little
attention, and as the recent report of the Local
Government Board shows, the condition of the
-tenement houses is a disgrace to a civilised com¬
munity. Certain steps have been taken, how¬
ever, to substitute new dwellings of a proper nature
for the old rookeries. The Dublin Corporation
has spent, according to Sir Charles Cameron,
^345,000 in providing dwellings for the working
classes. Even at best this can hardly be
regarded as more than an experiment, and it
must be remembered that municipal enterprise
in Dublin often entails expense without pro¬
portionate returns. As Sir Lambert Ormsby
pointed out the other day, the Corporation paid
£ 33,000 for the Bride’s Alley area before a brick
-was laid, whereas an area similar in extent was
purchased by a private company for £2,000.
Much serious work has, also, been done in Dublin by
-various companies and trusts—the Dublin Arti¬
sans’ Dwelling Company, the Iveagh and Guinness
Trusts, and others—a total of 4,665 dwellings
having been erected by them. So far, however,
the blocks of buildings put up have been alto¬
gether in central areas, replacing the more in¬
sanitary of the older dwellings. This system
has many drawbacks. In the first place it is
•expensive, in that a highly valued property has
-to be bought, for many of the old rookeries are
extraordinarily remunerative to their owners.
Again, it dislodges a large population, which, at
any rate for the time, has to seek refuge in sur¬
rounding neighbourhoods already overcrowded,
and even when the building is complete it houses
a smaller number of persons than had previously
Inhabited the old area. It is a true charge,
therefore, that each block of new buildings, while
it provides excellent accommodation for a limited
number of persons, actually aggravates the con¬
dition in the other areas of the city. In future
■undertakings it will be well to attempt the
alternative of building in the country within
reach of the city. Sites will be cheaper and
surroundings more healthy; while the process

of building can take place without the dislodg-
ment of large numbers of people. Fortunately,
Dublin is well situated for such an enterprise. It
is compact, surrounded by open country, and
furnished with an excellent tram system. The
problem, as a whole, must be faced, and that
shortly. Only the fringe of the subject has yet
been touched, and the eulogiums showered on
the Dublin Corporation by certain of the Dublin
speakers at the recent meeting of the Royal
Sanitary Institute seem to us sadly premature.
With a death-rate the highest in the kingdom,
to boast of sanitary progress is either disin¬
genuous or ridiculous.

CURRENT TOPICS.

Motor Cars and Dust.

Motor dust has naturally come in for a good
deal of attention at the Isle of Man Public Health
Congress. Although of modem origin this
nuisance has pervaded the length and breadth
of the land with a thoroughness that cannot be
gainsaid. Motor dust is not always, as some
people seem to imagine, a distribution of deadly
disease. Good clean country dust may not cause
much damage to mankind beyond making his
eyes smart and his nostrils water for a time.
In a town, however, a cloud of dust may be
charged with harmful microbes of all sorts and
conditions of disease, which are not dissipated
harmlessly into surrounding fields and hedgrows,
as in the country, but find their way into our
living rooms, our kitchen, our larders, our dairies,
and, in a word, into every nook and comer of
every habitation made with hands. The ousting of
the horse by motors means the lessening of the
pollution of road dust with horse manure. That
is one compensation against the drawbacks of
motor traffic. Others come indirectly through
the necessity of bettering and perfecting our
methods of road paving, and above all, of
road cleansing. The President, Dr. Hele-
Shaw, foreshadowed the time when the
wheel of to-day would be superseded, and when
it would be possible to carry heavy loads at
fair speed without damage to the roadway. It
is quite time that the creative genius of the
nation rose to checkmate the long-standing
nuisance of the motor dust.

Annual Election to the Counoil of the
Royal College of Surgeons, England.

The annual election to the Council of the
Royal College of Surgeons, England, took place on
the 4th inst., and resulted in the return of Messrs.
Charters Symonds, Brace Clarke, Mansell Moullin,
and Eve. The poll was the heaviest on record,
upwards of 800 fellows voting out of 1166.
In the complete absence of any political questions
to disturb the feelings of the electorate, each
Fellow probably voted for the candidate for
whom he entertained some friendly feeling. Thus
on these grounds, no doubt, it has come about that
the representatives of the largest medical schools
have attained their ambition—namely Guy’s,
St. Bartholomew’s, and the London. In one

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CURRENT TOPICS.

July io. 1907.

respect the result of the election has been some¬
what remarkable, namely, in the non-success of
Mr. Herbert W. Page. Mr. Page was seeking
re-election, and the usual course of events, under
such circumstances, is for the retiring councillor
to be again returned. Such, however, was not
the case so far as Mr. Page was concerned,
although both his colleagues who were seeking
re-election, namely, Mr. Mansell-Moullin and Mr.
F. S. Eve, were successful. St. Mary’s Medical
School, to which Mr. Page belongs, cannot, of
course, compete in size with the other large
schools named, and this may have had something
to do with the failure of their representative to
secure re-election. The return at the head of
the poll of Mr. Charters Symonds, who was
competing for the first time, plainly shows the
weight and influence of the alumni of a large and
important school like that of Guy’s. So far as
Mr. Bruce-Clarke is concerned we desire to offer
our congratulations upon the success which has
attended his second effort to enter the Council.

“Siamese Twins."

In the “ Clinical Records ” in The Medical
Press and Circular this week, we record an
unusual case of conjoined twins which occurred
in the practice of Dr. Keane Healy. The monster,
which was born dead, possessed two heads, two
necks, four arms, a double pelvis, four legs, but
only one thorax and abdomen. This particular
variety is extremely rare. Conjoined twins were
divided by Dr. Playfair, who collected thirty-one
cases, into four classes, namely, those having
nearly separate bodies united in front to a varying
extent by thorax or abdomen ; those having two
nearly separate bodies united back to back by
the sacrum and lower part of the spinal column ;
dicephalous monsters, the bodies being single
below, but the heads separate ; and, finally, those
with bodies separate below, but whose heads were
fused, or partly united. Dr. Keane Healy’s case,
therefore, does not fall under any of these divisions
for it had a complete double set of limbs, two heads
and necks, but only one thorax and abdomen. To
meet with such a creature is hardly, perhaps, a
matter of congratulation, but it is certainly an
event in a medical man’s routine of existence.

Lists of Consultants and Specialists.

Some few years ago an enterprising firm of
London chemists published a list of consultants
and specialists. Their publication was speedily
scotched by the British Medical Association,
who wrote individually to every medical man
whose name was included therein. The official
letter thus issued fell with the suddenness of a
thunderbolt upon the gentlemen in question,
whose names had been thus pilloried without
their authorisation. We presume the British
Medical Association will take similar notice of
a publication of a similar nature recently issued
by the Scientific Press, wherein a so-called classi¬
fied directory of medical consultants and special¬
ists is appended to a list of “ Medical Homes for
Private Patients.” The proceeding is certainly

not in accordance with the ordinary code of
professional ethics, and the men whose names
are thus paraded in the public gaze deserve our
sympathy. The book is sold at sixpence. It is
edited by a layman, a fact which perhaps ac¬
counts for some extraordinary omissions from the
list. This light-hearted compiler, for instance,
selects seven names from Scotland and five from
Ireland. The most distinguished men in both
countries are conspicuous by their absence. We
trust that the gentlemen whose names appear
and the association committee will enter their
protest against this unwarrantable trespass upon
the decencies of private and professional life.

An Echo of the Alcohol Manifesto.

The echoes of the alcohol manifesto published'
some months ago by a contemporary in the shape
of a letter signed by a number of leading -
medical men have already resounded far and near,
and seem likely to be continued into a distant
future with recurrent multiplication. The medicat
profession has been extensively billed with reprints,
by a trade journal. Some time ago a number of
persons interested in temperance matters signed a
memorial to the British Medical Association urging
them to make a counter declaration at their Exeter
meeting against the use of alcohol as a food and
a beverage. The petition was duly presented by
a medical man who is one of the honorary secre¬
taries of the Exeter Total Abstinence Society. The
Council of the Association have declined to accede
to the demonstration. Nor is it easy to under¬
stand why the most ardent temperance reformers
should not be satisfied with the counter declara¬
tion to the manifesto published some weeks ago in
the columns of the Medical Press and Circular.
We have reason to believe that our own document
received less publicity from the temperance journals
than the original somewhat revolutionary mani¬
festo.

Premature Burial.

A meeting was held in the City recently to-
forward the aims of the Association for the Preven¬
tion of Premature Burial, and from the accounts
of its proceedings that have appeared we should
judge that the blood of the audience must have run
cold. One of the speakers, Mr. George G. Green¬
wood, M.P., related that two members of the Asso¬
ciation had gathered together 149 cases in which-
people had been buried alive, 219 in which they had
narrow escapes from the same fate, and 10 in
which they had actually been dissected alive 1 We
should doubtless be accused of prejudice if we threw
any suspicion of doubt on the authenticity of these
records, but we cannot help wondering from what
source they were compiled. Were the cases culled
from ancient or modern literature? And were any
historians more trustworthy than the modern re¬
porter relied upon? The person who just escapes
being buried alive is a chronic newspaper canard,
or rather, we should say, a recurrent one. It is due
about once every three months, and it is seldom
that it fails to turn up to time. No doubt lay
persons who have never seen a dead body may
make mistakes about the fact of death, but we
would back the ordinary undertaker, and a fortiori
any medical man, to know the difference between
any trance yet invented and horrida mors. But we

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Diqitiz.

PERSONAL.

Tot Medical Press. 29

July 10 , 1907 -

should certainly support the contention of the Asso¬
ciation that death certification should be more care¬
fully carried out, and that only a certificate signed
hy a medical man should be acceptable as evidence
of death. As we have said over and over again,
the present method by which a registrar may, and
does, accept the word of any midwife or similarly
uninstructed party as to the death of a human
being, is a scandal in a civilised country. Hap¬
pily, the Lord Chancellor is himself engaged in
an investigation into the matter at the moment.

A Substitute for Radium.

An unconfirmed rumour comes from Paris of
the discovery of a substance possessing qualities
similar to those of radium bromide. The latter-
day rival of Professor and Madame Curie is a
medical student of Rochefort, who has only
recently attained the mature age of twenty-one
years. The new substance is said to cost six¬
teen shillings a gram, as against £120 a gram,
-which is the price of the radium compounds.
Should this be the case a great impetus is likely
to be given to radio-active therapeutics. The
•costliness of radium effectually prevents any
extended researches into its curative and other
reactions, so far as the human body is concerned.
Should this rumoured discovery be confirmed,
the young Rochefort student is likely to leap into
-fame at, medically speaking, an extremely tender
age. He has bestowed upon his product the some¬
what weird and mysterious name of “ Molybdopp ”
A detail of that kind, however, is not likely to
repel workers who have been unfortunate enough
to break a tube of radium at a value ranging
from ten to forty pounds sterling.

A Scotch Judge on the Liabilities of
Chemists.

An important judgment has been made in
-the Outer House by a Scotch J udge, Lord Johnson
The pursuer in an action sued for ^500 damages
in respect of injuries sustained by his daughter,
five years of age. The defender, a pharmaceutical
•chemist, of Dundee, was alleged to have said
that butter of antimony should be rubbed on
the head of the child, who was suffering from
ringworm. He supplied a bottle of that substance
with the result that the girl lost all her hair,
while her general health was also injured. Lord
Johnson concluded his judgment by saying that
•circumstances might impose a duty on the chemist,
to give warning of any possible danger from the
use of the article sold of which he, as a chemist, was
•or ought to be aware, but of which his customer
was or might reasonably supposed to be ignorant.
But assuming his duty as a ground of liability
against the defender, his Lordship was satisfied
that the drug might be used if properly applied,
or at least that the defender took pains to ascer¬
tain whether it could be so used, and was reason¬
ably justified in believing that it could be so
used. His Lordship was further satisfied that,
in the first place, the defender warned the pursuer
that he had no personal knowledge of its being
used for the purpose in question, and, in the

second place, that he warned him that if used it
must be applied carefully and sparingly and only
with a camel’s hair brush. On that evidence,
his Lordship could not hold that the defender
had been guilty of such neglect of the duty in
question as should render him liable. His Lord-
ship was, therefore, of opinion that no case was
made against the defender of actionable negligence.
This judgment serves to show the difficulty of
ensuring any efficient dealing with unqualified
medical practice in the present state of the law.

PERSONAL.

At the recent International Nursing Conference
held at Paris, presided over by M. J. Mesurier, the
English representatives included Mrs. Bedford Fenwick
and Miss Isla Stewart.

Principal Donald MacAlister has been ap¬
pointed a member of the Governing Body of the
Imperial College of Science and Technology.

Dr. G. D. Pidcock took the chair at a special
meeting of the medical profession of Hampstead, on
July 3rd, to consider the constitution of the Hamp¬
stead General Hospital.

Dr. W. R. Jack has been appointed Assistant
Physician to the Western Infirmary. Glasgow.

Dr. John M. Cowan has been appointed Professor
of Medicine at Anderson's Medical College. Glasgow,
and Dr. Ivy Mackenzie Lecturer on Medicine at the
Western Medical School.

Surgeon-General G. J. H. Evatt, C.B., President
of the Poor Law Medical Officers’ Association of
England and Wales, took the chair at the annual
meeting of that body at the Trocadero on June 27th.

The name of Dr. Charles Creighton has b^en
plated on the C.v.l Lst for the pension of £75, in
consideration of his medical and baologicaf researcnes,
and of his inadequate means of support.

Lord Ludlow, who was accompanied by Lady
Ludlow, received the guests at the Conversazione
in the grounds of the Cancer Hospital on July 2nd.

Mr. Mayo Robson presided at a conference on
Milk Contamination and Distribution at the In¬
corporated Institute of Hygiene on July 1st.

Dr. Lehmann has been appointed by the Chinese
Government, for two years, Chief Medical Sanitary
Officer of Mukden.

The Council of the University of Sheffield have
appointed Mr. Percival E. Barber, B.A.Cantab.,
M.R.C.S., L.R.C.P., Surgeon to the Jessop Hospita 1
for Women, to the post of Lecturer in Midwifery
and Diseases of Women, in succession to Dr. J. W.

Martin. -

Professor Alexander Macphail, of St. Mungo’s
College, Glasgow, has been appointed Lecturer on
Anatomy in the Charing Cross Hospital Medical
School of the University of London.

The Liverpool Chamber of Commerce, in connection
with the meeting of the’ Associated Chambers of
Commerce in that city in September, has agreed
to contribute £250 to the Liverpool School of
Tropical Medicine to establish in Liverpool an
exhibition of colonial products under the direction
of Lord Mountmorres. The Cotton Exchange has
placed at the disposal of the chamber the old Cotton
Exchange for the purpose.

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30 The Medical Pszss.

CLINICAL LECTURE.

July io, 1907.

A Clinical Lecture

ON

SOME OBSERVATIONS ON INTRA-ABDOMINAL ADHESIONS, WITH

ILLUSTRATIVE CASES.

By E. PERCY PATON, M&, FAC.S„

Surgeon In charge of Out-Patients to Westminster Hospital.

The abdomen is now so often opened for various
reasons that the condition of the peritoneum
during life can be much more frequently noted than
used to be the case, hence the known common
occurrence of intra-abdominal adhesions in cases
in which they were not previously expected,
but in which they have proved to be the only,
or at any rate, the main lesion, has led to their
being looked upon, and with good reason, as the
real cause of certain abdominal troubles. No
doubt in many cases adhesions are of no import¬
ance, and do not in any way affect the health
or comfort of their possessor; but in other
persons, and under other cicumstances, this is
not so, and they may cause symptoms which
are merely of the nature of some occasional dis¬
comfort, or are much more severe, even amounting,
as is well known, to the most acute intestinal
obstruction.

How frequently adhesions may be expected
to be found in the abdomen I know of no statistics
to show, nor do I think that it is likely that any
such exist ; but that they must be very common
is clear from the frequency with which they
are seen post-mortem, and the way in which one
comes across them when there is no reason to
expect them in the course of operations.

Any form of irritation of the peritoneal surfaces
may cause adhesion between one surface of
peritoneum and another. This irritation may be
mechanical, chemical, or due to a micro-organic
infection. The first two causes mentioned will
only occur as the result of injury or operation
or in consequence of the rupture of some hollow
viscus, while in other cases infection must be
the reason for their formation. The nature
of the infection may be acute or chronic ; but
in the acutest forms adhesions are sometimes
conspicuous by their absence, as, for instance, in
the following case :—•

Case 1.—A girl set. about 20,was attacked, almost
suddenly, with acute pain in the abdomen,
sickness and diarrhoea ; she had been practically
well to the day before this illness, when she had
felt a little seedy, she had not been ill in any way
previous to this ; she became very rapidly col¬
lapsed, and I saw her about twelve hours after
the onset ; she was then suffering from acute
general peritonitis, the cause from which was
obscure. I opened her abdomen in several places
in order to examine the condition of the stomach,
appendix, and pelvic organs ; there were universal
signs of peritonitis, but no fluid and no adhesions,
the surface of the membrane having a generally
greasy feel ; no cause could be found at the opera
tion for the trouble; this had to be terminated
in consequence of her collapsed condition, but
after death it was discovered that she had a new
growth in the sigmoid which had not previously
given her any trouble, and no doubt the infection
of the peritoneum had occurred here, though

there was no perforation. The peculiar greasy
feeling of peritoneum above described is commonly
found, I think, in those cases of very virulent
peritonitis, such as are seen not very uncommonly
in connection with appendicitis, and as a rule
adhesions are absent in such a condition. On
the other hand, in some acute cases adhesions
may be formed with very great rapidity, as I shall
mention later. That micro-organisms will pass
through the, to the naked eye, uninjured intestinal
wall, the case just related shows well, for a culture
obtained from the surface of the inflamed intes¬
tines gave a pure growth of colon bacillus.

The chief causes for the formation of intra¬
abdominal adhesions may be enumerated as
follows :—In the upper half of the cavity gall¬
stones and other affections of the gall bladder,
and ulcers of the stomach and duodenum, while
in the lower half the appendix and in women
the pelvic organs are much more frequently to
blame. In addition to these causes may be men¬
tioned any inflammatory trouble of the intestines.

That external injury may be sometimes respon¬
sible for the formation of adhesions, even when no
gross lesion has occurred to the intestines, was very
clearly shown by a case that had been under my care
recently.

Case 2.—The patient was a man, aet. about 40, who
was admitted into hospital with acute intestinal
obstruction ; no history of injury could be ob¬
tained from him before the operation, at which
it was found that a large packet of small intestines
were so adherent to one another that the kinking
so caused had obstructed the gut. With a good
deal of difficulty these adhesions were separated
and the raw surfaces of the peritoneum carefully
stitched over with normal membrane. The
man made a good recovery from the obstruction,
though he was attacked with bronchitis a week
after and was ill for a long time with this. A
subsequent further investigation of his history
revealed the fact that six months before his present
illness he had received a blow on the abdomen
from the pole of a van, which was severe enough
to lay him up for about three weeks, and this, I
think, was undoubtedly the cause of the adhesions.
Not improbably even in such a case the injury
permits some passage of the micro-organisms
through the gut wall, and it is at any rate in
part to the irritation to which these give rise that
the adhesions are really due.

The form which adhesions take varies very
much in different cases; sometimes they are
broad, extensive and firm, at others they are
long, thin and cord- or even thread-like ; it is
the former kind that interfere most with the
motility of the abdominal organs, while the latter
are not infrequently responsible for the kinking
and snaring of the gut which leads to obstruction,
and may also, especially about the stomach,
cause a good deal of pain.

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CLINICAL LECTURE.

The Medical Press 31

The rapidity with which adhesions form is of
considerable importance to the surgeon, as it is
not infrequently the case that upon this he has
to rely for the success of various abdominal
operations, and for the prevention of the fouling
of the general peritoneal cavity in sudden in¬
flammatory attacks of the organs contained within
it.

The following case will give some idea of how
rapid the formations of adhesions may be :—

Case 3 -—A year or two back I was asked to see
a lady who was suffering from perforation of a
gastric ulcer. She was aet. about 50, and when
I saw her was clearly desperately ill, but in
view of the fact that operation was her only
chance, it was therefore done. She died two or
three hours after it was finished. At the opera¬
tion practically no adhesions were encountered,
but at the autopsy there were many adhesions
matting the various viscera together and some of
these were of considerable firmness and required
some force to separate them.

A very important question may be asked
here, namely, do adhesions when once fairly
formed ever disappear ? The answer to this
query is undoubtedly Yes, as the following cases,
among many others that could be cited, clearly
show :—

Case 4 .—A salvation army officer, an intelli¬
gent man, came to see me a little time back with
a view to having a radical cure of hernia done,
and at the same time having his appendix re¬
moved and a ventral hernia, which had followed
on the opening of an abscess which he had had in
connection with his appendix some little time
before in India cured. The history that he gave
was as follows : He had had an ordinary attack
of appendicitis, this had resulted in an abscess,
which was opened and drained by a tube which
at first was about six inches long and which was
kept in for at least six weeks. It was clear,
therefore, that at this time the appendicular re¬
gion must have been quite cut off from the general
peritoneum by adhesions. When I operated
for the removal of the appendix there were no
adhesions about the organ whatever, and only
one or two very fine omental ones in the vicinity.
The appendix was removed and the ventral and
inguinal hernias were all dealt with at the one
operation.

Case 5.—Another case, that of a lad, aet. 18,
is almost exactly similar, but in his case the
wound had been packed with gauze at the opera¬
tion, the appendix not being removed at the
same time on account of the extensive nature
of the adhesions, but when I removed the organ
about a year later for recurrent pain in this
region there was scarcely a vestige of an adhesion
to be found.

A third example will suffice to demonstrate
this point, which must be a matter of common
knowledge to all who have frequent opportunity
of watching surgical abdominal cases.

Case 6.—I was asked to see a child, aet. n,
who had been ill some weeks with an obscure
abdominal illness which was uow thought to be ap¬
pendicitis. In this view I concurred and advised
an operation. This was done, and very extensive
adhesions were found about the appendicular
region and some pus, and also an opening into
the caecum. It appeared that an abscess had
formed and was discharging itself into the gut.
The immediate result was, of course, a faecal

fistula, but the child’s general condition was much
relieved,. About six months later, as the fistula
continued to discharge, I operated again and
successfully closed the fistula by a plastic operation,
but the point that I wish to note here is that as
the general abdominal cavity had to be opened
in the course of the operation, it was found that
the adhesions noted as very extensive at the
previous operation had now almost entirely
disappeared.

There can be little doubt, I think, that the
disappearance of adhesions is mainly brought
about by the movement of the intestines upon
one another due to their peristaltic action and, as
I hope to show, the promotion of such movement
is the best means of preventing their formation.
This movement of the intestines upon one another
sometimes leads to the strangest complexities
when the bands of adhesion are long and cord¬
like, of which several examples are given in
Treves’s book on Intestinal Obstruction. In
these cases the cord has been knotted or even
double knotted round a coil of gut in a knot
which might have been tied with the hands.
This process seems to be aided when there is a long
band formed which becomes free at one end and
at this end there is a small thickened mass or
knob which can slip through a loop previously
made by the sliding movements of the gut.

The useful purpose peritoneal adhesions serve
in innumerable cases is so well known that it
is hardly necessary to do more than refer to
the frequency with which they prevent the most
serious and even fatal damage from occurring.
For example, a patient is attacked with acute
inflammation of the appendix which is speedily
followed by gangrene, perforation and suppura¬
tion ; if the onset of the trouble be not absolutely
sudden the intestines around adhere to one
another, the omentum almost seems to crawl to
the spot and speedily becomes matted to the
guts and anterior abdominal wall, the result being
that the seat of mischief is soon shut off from the
general peritoneal cavity.

A very similar process goes on in association
with trouble in Fallopian tubes, as in the following
case which was under my care recently.

Case 7.—A woman, aet. about 25, gradually
developed a mass in the pelvis of irregular out¬
line, fixed, and with some inflammatory symptoms.
Without going fully into the details, which are
not important for our purpose at present, the
diagnosis was provisionally made of tubal sup¬
puration. At the laparotomy which I subse¬
quently did this diagnosis was found to be the
correct one, both tubes were found to be full of
pus, and to be widely adherent to the intestines
and the wall of the pelvis, these adhesions having
successfully prevented the generalisation of an
abscess which was found containing about four
ounces of pus at the bottom of Douglas’s pouch.
The tubes were removed and the abscess emptied,
the cavity being packed with gauze, the patient
making an excellent recovery.

It would be easy to multiply examples of this
sort showing the way in which adhesions limit
inflammatory troubles or how they prevent extra¬
vasation of the contents of the hollow viscera.
In very many abdominal operations it is merely
a commonplace to say, that were it not for the
rapidity with which we know that adhesions
will form, many procedures would be impossible, as,
for example, in the drainage of many cases of

32 The Medical Pee<«.

CLINICAL LECTURE.

July io, 1907.

appendicular abscess. This often has to be carried
out across the cavity of the abdomen, but can
be done with almost perfect safety by packing
the cavity with a little gauze, adhesions soon
making a definite barrier. Again, in excisions
of parts of the gut the union of the divided ends
depends on the same adhesions of the peritoneal
surfaces, but it is not necessary for me to multiply
instances of a similar kind.

But it is true here, as in many other things,
that “ There is no rose without a thorn,” and
adhesions may be a source of very great trouble
by tethering the viscera to one another in such a
way as to interfere with their movements, thus
causing pain and discomfort, interference with the
passage of food in the proper direction, and
therefore dilatation of the portion of the alimentary
tract above the fixed spot. While in some
cases the touble may be still more acute, urgent
intestinal obstruction being the result. I may
mention here a few examples of this sort.

Case 8.—A gentleman, aet. 40, had several
attacks of appendicitis,. It was before the era
of removal of that organ for such recurrent trouble,
and the attacks at last ceased to recur after a
long period of rest and invalidism ; but though
the inflammatory attacks did not come back
he was still subject, over a long course of years,
to occasional dragging and aching in the region
of the caecum which, however, was not sufficient
to lay him up, this was particularly the case if
the bowels were allowed to get loaded. There
can be no doubt, I think, that these residual
troubles, so to term them, were due to the adhe¬
sions around the old inflamed organ. The trouble,
however, was never deemed sufficiently great
to demand operation.

Case 9.—A few years ago a woman came under
my care with the signs of a ruptured tubal preg¬
nancy, in which there appeared to be no very
acute bleeding but a gradual oozing into the
peritoneal cavity. The abdomen was opened
and the condition found as described above, the
left tube, which was the one affected, was removed,
and the pedicle tied in the usual way. The patient
did well for the first two or three days, except
ior a little sickness which was thought to be due
to the chloroform, as her general condition was
excellent; but on the fourth day the vomiting
became more serious and it was found impossible
to get the bowels moved, though she passed some
flatus. As this condition still continued the next
day the abdomen was re-opened, when it was at
once found that a coil of small intestine had
become adherent to the pedicle of the tube which
had been removed, resulting in a kinking which
in the distended condition of the intestines caused
an obstruction, the adhesion was easily separated,
but unfortunately the condition had been recognised
too late, and the woman did not recover. This
case shows very plainly how a raw area of peri¬
toneum may be the seat of the formation of a firm
adhesion and points to the importance of, as far
as may be, avoiding leaving such raw areas in
the peritoneal cavity.

Another case of obstruction following adhesion
which was the result of a blow upon the abdomen
has recently been related in the earlier part of
these remarks.

Apart from new growth narrowing of the
pylorus most frequently occurs as the result of
ulceration of the stomach with subsequent con-
t faction of the scar; but it may also be due to

the tying of the viscus to the under aspect of the
liver and to other structures by adhesions. Of
this trouble the following cases are examples:—
Case 10.—A man, aet about 50, was recently
under my care in Westminster Hospital. He had
suffered a good deal from pain in the epigastrium,
which did not seem to bear any very marked rela¬
tion to food on examination a mass could be felt
in the region of the pylorus, the outline of which
could not be very clearly made out. On filling
the stomach with gas the viscus was found to be
clearly dilated, its outline terminating at the
mass above described, which was therefore
plainly shown to be, as had been previously
thought, at the pylorus. As the man was over
fifty and had lost a good deal of flesh, the probable
diagnosis was made of carcinoma; it was, how¬
ever, thought wise to make an exploration in
order to determine if anything could be done
surgically. At the operation I found that the
mass which had been felt consisted of a com¬
plicated collection of adhesions around the
pylorus and pyloric end of the stomach, which was
otherwise normal. These adhesions were separated,
but no cause for their formation could be found
and the wound was closed. The man did well,
was relieved of his pain and began, while in hospital,
to regain some of the weight that he had pre¬
viously lost.

Case 11.—A similar case is that of a woman,
aet. about forty, who had for several years been
a sufferer from dyspepsia and vomiting. I was
asked to see her with a view to operation by
my friend and colleague Dr. Gossage. She had
been in hospital some weeks, and dui mg that
time had vomited once or twice almost every day ;
she also had a good deal of pain at times of the
character of heart-burn. There was nothing
certainly abnormal to be felt in the abdomen
until the stomach was distended with gas, when
it was found to be very considerably dilated;
it was therefore decided to do an exploratory
laparotomy and, if necessary, a gastro-jej unostomy.
At the operation the stomach was found to reach
well below the umbilicus and there were a good
many adhesions in various parts of the abdomen ;
the most important of these, however, were some
very firm ones tying up the pylorus and the
lesser curve of the stomach to the under aspect
of the liver, the connection with the lesser curve
being especially firm and broad. It was clear
that these attachments interfered seriously with
the power of the stomach to empty itself, and as
it seemed doubtful whether they could be separated
with success, and if they were separated whether
they would not speedily reform; a posterior
gastro-jej unostomy was done. For the first
few days after the operation the patient was in a
very critical condition, owing to the constant
vomiting, a good deal of which seemed to be due
to regurgitation of intestinal contents into the
stomach. It was found, however, that by sitting
her up in bed that efficient drainage out of the
stomach was obtained, and, except for a slight
attack of phlebitis in her left leg, she steadily
improved having, as she said, not been so well
for many years.

The adhesions in this case were almost certainly
due to old gastric ulceration, though no definite
evidence of this was found at the operation.

Case 12 .—A third case of this sort was that of
a man of about the same age or a little older.
His symptoms were of a very' similar nature

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July i o, 1907.

CLINICAL LECTURE.

The Medical Press. 33

and need not be detailed. At the operation his
pylorus was found surrounded with adhesions
which were clearly the cause of the reduction
in the size of its lumen, as separation of the
adhesions did not seem likely to give a satisfactory
result, a pyloroplasty was done, which greatly
relieved his troubles, but in a month or two these
returned, apDarently due to the recontraction of the
pylorus. It was therefore thought wise to do
a posterior gastro-jejunostomy, after which,
though he for some time was subject to occasional
attacks of vomiting of a somewhat severe nature
he gradually improved, and when I last heard of
him he was free from his troubles.

But adhesions may not only interfere with the
lumen of the alimentary tract but also interfere
with the bile passages and that of other ducts
as the following case shows very well :—

Case 13.—Between eight and nine years ago a
medical colleague asked me to see with him
a case of jaundice. The patient was a woman
between forty and fifty, and her jaundice had
begun with some pain which was not, however,
now at all severe, but she remained a deep yellow
colour and had been so for about a year. There
was nothing beyond a little tenderness to be
felt in the region of the gall bladder, and as the
case had gone on so long it was not thought likely
that it was one of malignant disease, and the
probable diagnosis was made of impacted gall
stone in the common duct. At the operation
a complicated series of adhesions was found tying
up the pyloric end of the stomach to the duodenum,
colon, gall bladder and small omentum. These
adhesions were separated with difficulty and the
gall ducts carefully examined but with negative
result, so the abdominal wound was closed. The
patient did well and gradually lost her jaundice,
and when I saw her again, more than eight years
after the operation, she was quite well, having
never had any return of her trouble. In this
case it seems that the adhesions caused a kinking
of, or pressure on, the bile ducts, which was the
cause of the obstruction to the passage of bile.

With regard to the diagnosis of adhesions, in
most cases the only thing that can be done is
to keep in mind the fact that this is one of the
causes of the various troubles already referred to,
and it is only at the operation that the matter
can be cleared up, but a history of injury, or of
old abdominal inflammation, or other cause for
their formation make the presence of adhesions
the more probable, more particularly when
more gross diseases can with apparent safety
be excluded.

The treatment may be discussed under two heads,
namely, as preventive and curative.

By the preventive treatment I refer to the
means which should be commonly used in the
course of abdominal operations to prevent the
viscera adhering to one another when this is not
essential to the success of the operation. Refer¬
ence may here be made to the experiments of
Karl Vogel in connection with this matter. These
observations were made upon guinea pigs. After
opening the abdomen and somewhat irritating
the surface of the peritoneum in such a way that
in the ordinary course adhesions would have
formed, various substances were used to try and
prevent their formation, such as a solution of gum
arabic, olive oil, paraffin, saline solution or the
interposition of oil silk which was removed in
the course of a day or two. None of these means.

however, were found to be very successful in
procuring the end in view. Experiments were
made to determine if by promoting peristalsis
during the after-treatment better results would
be obtained ; the animals were therefore fed
on such food as beetroot, which- was known
to cause frequent movement of the bowels,
and also were treated with atropine or physos-
tigmine with the same end in view. This treatment
not only promotes movement of the intestines
on one another but also prevents distention,
and so pressure of the intestines against one
another. It was found that by this line of pro¬
cedure adhesions were much less frequently and
extensively produced.

From these experiments, and also from clinical
experience, it may therefore be said that to
prevent the formation of adhesions after abdominal
operations every care should be taken at the
operation to avoid anything that is likely to
irritate the surface of the peritoneum, and to this
end asepsis, rather than antisepsis, should be
aimed at; sterile swabs or sponges and sterile
saline solution being used rather than antiseptic
swabs and antiseptic lotions ; at the same time
pains should be taken as far as may be not to rub
or irritate or break the surface of the peritoneum
more than is absolutely necessary, and when
it is feasible to cover in raw surfaces uncovered
with peritoneum by carefully suturing a layer
of that membrane over such areas.

The preventive after-treatment is no less important
than the method of doing the operation, and
should be along the lines indicated by the experi¬
ments detailed above, that is to say, the bowels
should not be kept confined, but should be moved
at an early date unless this is especially contra¬
indicated by the nature of the operation. As
mentioned above, this serves two purposes as
far as adhesions are concerned, namely, it causes
movement of the intestines and so prevents two
coils from lying constantly in contact with one
another, and also at the same time prevents
distention, and therefore pressure of the intes¬
tines and other organs against each other. Quite
apart from the prevention of adhesions this line
of after-treatment, which is exactly the reverse
of that adopted in the early days in the manage¬
ment of abdominal sections, has other advantages,
and it is familiar to all who have much experience
of such cases how very different is the condition
of a laparotomy patient before and after the first
free evacuation of the bowels subsequent to the
operation.

I do not think that the particular means to be
used for opening the bowels is of very much
moment. Personally, I generally give five grains
of calomel the day after the operation and follow
this with a turpentine enema containing half an
ounce of the oil about five or six hours after the
calomel has been given. If the enema does not
have a satisfactory result it can be repeated in the
course of an hour or two and a further dose of
calomel given later if necessary. The adminis¬
tration of the calomel in one grain doses every
hour till the bowels are moved has been strongly
recommended by some, but I have not adopted
it as it has seemed to me to cause more griping
than the method described. Some prefer to
give magnesium sulphate, but I have found
that it is usually rather more difficult to prevent
the patient bringing this up than the calomel
when it is given before the anaesthetic sickness

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34 Th* Medical Pus*.

ORIGINAL PAPERS.

July io, 1907.

has entirely passed off or when it has only just
stopped ; it may, however, be given with advan¬
tage, I think, if the first dose of calomel does not
act satisfactorily. I have not tried atropine or
physostigmine as recommended by Vogel on the
ground of bis experiments.

The curative treatment of adhesions that have
already formed is carried out on just the same
lines as indicated above, after the attachments
of the organs to one another have been separated ;
this has been exemplified by one or two of the
cases recounted. Unfortunately, however, in
some cases the adhesions reform in spite of every
care at the operation and in the after-treatment;
also in some cases the connections of the viscera
to one another are so dense, and so extensive,
that to divide them would be too hazardous
a procedure while at the same time the likelihood
of preventing their reformation, if so extensive,
would be very small ; under such circumstances
a gastro-jejunostomy or a pyloroplasty, as was
done in two of the cases that I have described,
or some similar operation in different circum¬
stances, may be found to give satisfactory results.

Note. —A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture
for next week will be by Seton Pringle, M.B., B.Ch.
{Univ. Dub.), F.R.C.S.I., Surgeon to Mercer's Hospital,
Dublin. Subject 1 “ The Treatment of Carcinoma of
the Great Intestine."

ORIGINAL PAPERS.

THE GENERAL PRACTITIONER.

I. —His Outlook.

By J. LIONEL TAYLER, M.R.C.S., L.R.C.P.

Lond.

The position of the general practitioner needs
re-defining. He has gained in knowledge ; to some
extent in social recognition, and his responsibilities
have greatly increased. Yet his status in the
medical profession has hardly changed from that
which it was nearly a century ago.

He has gained in Knowledge. —Writing in 1803,
Thomas Percival, in the then standard work on
“ Medical Ethics,” quotes with approval Adam
Smith (a) to the effect that the apothecary “ is
the physician of the poor in all cases and of the
rich when the distress or danger is not very great.”
This same apothecary, who had a very imperfect
medical training, dispensed his own medicines, and
Percival condemns the practice of a physician
sending prescriptions to the druggist rather than
allow the apothecary who is consulting with him
to do it himself, and charge the patient for his
trouble. He adds, however, that the physician
should occasionally inspect the drugs that the
apothecary uses, so as to see that they are satis¬
factory. In the whole work it is made clear that
the apothecary is inferior in all respects to the
physician, as at that time in the large majority of
cases he undoubtedly was.

In 1849 a third edition of this work was re-issued
and as it still seems to have been regarded as
authoritative, and as no comment on the old pas¬
sages dealing with the status of the apothecary were
inserted, it may be taken that the view presented
was still more or less representative of the times.

(a) "Wealthof Nations." First published In 1775 .

Kerrison, (b) however writing in 1814, after quoting
the same passage from Adam Smith, asserts that
the surgeons now constitute “ the most numerous
class of general practitioners in England and
Wales,” while Mackenzie (c) writing on " Specialism
in Medicine,” seems to place the beginning of the
tendency of consulting physicians and surgeons to
specialise somewhere about i860. Therefore, the
low standard of medical efficiency exhibited by the
general practitioner began to be modified some¬
where about the second decade of last century, if
we are to trust Kerrison. It was still a low
one in 1849, but from this time a gradual improve¬
ment took place, so that the consulting medical
practitioner commenced to specialise in particular
branches of medicine, because presumably more
specialised knowledge came to be better appre¬
ciated.

There can be little doubt that the better qualifi¬
cation and culture of the general medical man has
caused him to rely more upon himself in all dis¬
eases that he is familiar with, but probably also to
seek more freely advice for disorders that are un¬
familiar. This change, be it noticed, alters the
relation that has hitherto existed, for the position
is no longer that of inferior and superior, but of
generally experienced and specially experienced
workers. His status being no longer a subordinate
one, his authority in medical matters should be
more recognised.

The Gain in Social Status. —It is indisputable
that the medical practitioner’s social position has
improved. One has only to glance at the earlier
and later literary writers of last century to realise
this fact. Dickens, and earlier men make this
evident. The Bob Sawyer type of student and
practitioner ; the surgeon swearing at his patients,
though these are varieties that may still exist, are
yet now in such marked minority as to be no
longer representative of any section of the pro¬
fession to which they belong. And the general
public, whatever view it may take as to capacity,
has recognised the greater refinement that has
become evident as a result of better education
in our profession.

His Responsibilities have Increased. —This point
like the last is a commonly acknowledged fact.
Since 1870, when the education of the poorer
classes of the community became recognised as
a public necessity, the medical practitioner has had
more and more responsibilities in reference to
school questions thrust upon him. And, before
this, factory legislation has given him both an
interest and an incentive to study employment
liability risks, and assurance societies have accentu¬
ated the tendency.

The fact that patients are now far more ready
than formerly to detect failure of skill in their
medical attendants has raised the general standard
of efficiency, but it has also added much to the
anxiety of medical practice.

Yet his Status in the Medical Profession has not
Improved. —It is a curious fact that, in spite of
this obvious upward change, both in his own
capacity and in the class of practice which he has
had to undertake, the general practitioner is still
regarded as being largely the inferior of the special¬
ist, precisely as the old apothecary really was to
the more skilfully trained physician. His represen¬
tative rights are very little improved. His voice

(h) “Ad Inquiry Into the Preaeot State of the Medical Profeealon In
England."

(e) “ Essay a.”

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July io. 1907.

ORIGINAL PAPERS.

Thk Medical Pers< 35

is seldom heard in the medical journals, and he i s
never invited to contribute to the larger medical
text books or to deliver lectures at medical train¬
ing institutions. In every respect he is treated,
though courteously, as a subordinate whom the
principal has nothing to learn from. This attitude
cannot fail in the end to lower the general practi¬
tioner in his own estimation and cause him to take
less interest in his work, and it must be finally
<lisastrous to the whole medical profession.

It is claimed by the writer of these articles that
the general practitioner has a distinctive position
of his own, which the specialist is quite unable to
represent; that his position should therefore no
longer be a subordinate one as heretofore. The
simple difference between him and the consultant
being wholly and solely one of aspect of approach
to common studies. Hence, if these contentions are
sound, it will be evident that a change in his pro¬
fessional status is advisable, corresponding with the
change in the character of his work.

I hope to take up “ The General Practitioner’s
Claim to Recognition,” in my next essay.

FRACTURES OF THE SHAFT OF THE
FEMUR—A DISCUSSION ON THEIR
TREATMENT AND DIAGNOSIS. 0)

By SIR THOMAS MYLES, M.D. Univ. Dubl.,
F.R.C.S.I.

Surgeon to the Richmond Hospital.

For a long time past it has seemed to me that
surgery, while advancing by leaps and bounds in
other domains, has been singularly unprogressive
in the matter of fractures, especially of fractures of the
thigh. One reads every day in the journals, records
of daring and brilliant operations in the abdomen
thorax or cranium. Suggestions full of careful thought
are made by many workers in these fields, but, so far,
little progress has been made and, with a few excep¬
tions. but little surgical thought has been bestowed
on the subject I have chosen for my communication.
In this particular branch of surgery the surgical mind
seems to have fallen into what Swinburne calls “ the
slothful hebetude of the grave.” We are still not
merely in the early Victorian age—that era of ugliness
—but it is hardly an exaggeration to say, in the days
of Galen and Hippocrates. The full tide of human
thought has swept past us, engulfing old landmarks
in almost every direction, but here a rigid conservatism
apparently offers an insurmountable obstacle to pro¬
gress, and one still sees in a most up-to-date hospital,
fully equipped with the costly appliances demanded
by modem surgical technique, patients with broken
thighs treated by practically the same methods as
their predecessors have been treated for the last
hundred years, or even more.

Very few appear to consider the subject worth
giving more than a passing thought to, and the result
is that progress has been practically nil. And yet
the subject is worthy of the most careful consideration,
as I hope to show very soon. One reason why it had
so little consideration bestowed on it, perhaps, is that
medical men themselves rarely suffer from fractures
of the femur, in this respect contrasting markedly with
appendicitis, enlarged prostate, and other more
widely diffused ailments, the prospect of being a
possible subject to each or any or all of these maladies
being constantly before our mental vision, thus
stimulating that imaginative faculty which is essential
for novel suggestions. If medical men themselves
were more frequent sufferers from these injuries they
would long since have rebelled against the traditional
methods of treatment, and more modern methods
would soon have displaced the older ones.

Fracture of the femur is not a common a cci dent ;

la) Bead before Mae Royal Academy of Medlolne In Ireland (Section
of Sorcery) May IOth, 1907.

practically it presents itself amongst two classes of the
community only—the workingmen and the sports¬
men. Of course, it may happen to anyone in a railway
or other accident, but, speaking broadly, it is met with
most frequently amongst the classes I have mentioned.
Now it may not be of any great consequence to a
millionaire or a salaried official to be lame and weak in
one leg, but it means a great deal to a hunting man,
and still more to a workingman, whose bread depends
on his muscular efficiency. The first question I have
set myself to consider, therefore, is that of the prognosis
in such an injury in a workingman or a hunting squire.
Is a workingman as efficient after this accident as
before, and can a sporting man ride, shoot, play cricket,
tennis, etc., as well as he used to before he broke his
femur ? The answer to these questions can be sup¬
plied in part by one’s individual experience, and in
part by a study of museum specimens and X-ray
photographs. My own experience of the result of
routine treatment in these cases is not very encourag¬
ing. I have found that in nearly all cases occurring
in adults there has been considerable shortening
and consequent lameness, some stiffness in the knee-
joint, some limitation of the movements of rotation
at the hip-joint, a varying degree of muscular atrophy,
pain with changes in the weather, and almost always
an ugly nob of callus to be felt or seen at the seat of the
united fracture. Some of these patients amongst
the well-to-do found that riding became painful after¬
wards. probably from the pressure of a bony projection
on some of the nerve trunks ; none of them could run
or jump as they used to do, and they all suffered
for some years after from coldness and oedema of the
foot on the injured side. At first I felt inclined
to blame myself for these results, but further study
of the subject soon taught me that they are the
invariable and inevitable results of the methods of
treatment usually adopted—methods sanctioned by
tradition and the teaching of the schools.

A study of the museum specimens of this injury is
very instructive, and calculated to modify one’s
previous conception of what actually takes place
in these cases. We are not all pathologists, nor have
we all access to museum specimens, by the study of
which we may hope to educate ourselves; conse¬
quently we are not much to blame if our imaginary
conception of what takes place in these injuries is
found to differ very materially from the actualities
presented by museum specimens. I remember
once, some years ago, asking a well-known surgeon of
great intelligence—now, alas ! no more—if he found as
great difficulties as I had in effecting even decent
approximation of the broken ends in fractured femur.
To my astonishment he told me that under an anaes¬
thetic he had never any difficulty in effecting perfect
end-to-end apposition in transverse fractures, and that
he always got good results in such cases ! I could
only congratulate him on his good fortune, and envy
him the mental condition which enabled him to hold
such a belief. Now such a belief—absolutely founda¬
tionless—is fairly widespread. The general idea
amongst such believers is that it is not difficult under
complete anaesthesia to get end-to-end apposition
of the fragments, that they can be held in this position
by splints, weight and pulley arrangements, etc., and
that a nice spindle-shaped lump of callus surrounds
and holds the ends together, and that the patient’s
leg is just as well as ever after the fracture, if not a
little better !

It is a very curious fact that amongst the many
museum specimens of this injury I have examined I
have never yet had the good fortune to meet one
illustrating this method of union. One is either forced
to believe that the museum contributors fgr several
generations have wickedly combined to exclude such
specimens from their collections or, horribile dictu,
that such specimens do not exist. That the latter is
the more probable explanation is supported by a study
of X-ray photos of these injuries. Of these there are
a great many now inexistence, and men who have made
a special study of X-ray work—such as Dr. R. Lane-
Joynt and Dr. W. Haughton—tell me that they have

36 The Medical Press.

ORIGINAL PAPERS.

July to. 1007.

no specimens in their collections illustrating this
traditionally-accepted method of union.

As a matter of fact a study of museum specimens
and of X-ray photos show certain constant factors
in these cases :—

1. There is always shortening due to overlapping of
the fragments.

2. The lower fragment may be in front or behind,
inside or outside the upper fragment; it is never
exactly where it ought to be.

3. The lower fragment is rotated either inwards
or outwards ; it is never in perfect alignment with the
upper. It may be in approximate alignment, but it
is never in the perfect alignment, and it cannot be.

4. It is absolutely impossible to decide by the
unaided eye, touch, or measurements what the actual
displacement of the fragment is. The mass of muscle
surrounding the bone, the extravasated blood, the
enveloping skin and fasciae all combine to soften
the asperities of the actual outline in the same way
as a fresh fall of snow smooths out and diminishes the
irregularities of contour in a landscape. It is the
tell-tale X-ray which shatters one’s hopes and shows
us that the limb, after all our effort, is little better
than a whitened sepulchre ; that we are still far indeed
from the rea’isa’ion of our ideal. The amount of actual
bony displacement that may exist, completely masked
by the soft parts, is incredible to all save those who
have studied this question with the aid of X-ray
photos. Let anyone glance for a moment at the
specimens illustrated here and he will, I think, have no
difficulty in understanding why such patients com-

f darned of pain and weakness in the limb, of marked
ameness, of coldness and cedema of the foot below
nor is it more difficult to understand that men so
afflicted can no longer ride, run, swim, or tramp across
a moor, gun in hand, as they did before their accident.
It is, I think, fairly obvious, therefore, that fracture
of the shaft of the femur is a very grave accident
indeed, and one well worthy of the most careful
consideration.

Hitherto surgeons have quietly accepted the teach¬
ings of the great men of the past, that shortening of
an inch or more is the inevitable outcome of such
injuries, and that nothing can be done to prevent it.
But surely this is an unworthy position to take up
at this period of the world’s history. Are we not
bound to make use of all the advantages that progress
in other directions has made available for us ? Is the
technique which has made safe the great operations
in other branches of surgery not to be utilised in this
particular branch of our work ? Are we bound to
doom a young man to lameness and inactivity for the
rest of his life through lack of courage to face a com¬
paratively novel problem ? My plea is for greater
boldness in dealing with these cases ; that in suitable
circumstances we should not deny them the advantages,
added risks notwithstanding, which the improvements
in modern technique have placed within our reach.
Let the facts be stated frankly and plainly to our
patients; let them understand clearly the risks and
advantages on the one hand, the freedom from risk and
disadvantages on the other, and I am convinced that
the average young man will not hesitate to face the
risks inevitably incidental to all operative methods.

There is one other point to which I should like to refer
before leaving this part of the subject. Hitherto the
loss of muscular efficiency in these cases has been
attributed to the shortening due to the overlapping
of the segments and possibly to some angularity at
the seat of union. While not denying that these factors
play a prominent part in producing the ultimate
result, I'am convinced that too little importance has
been attached to the want of perfect alignment in
the united fragments. Somehow most of us in making
a mental picture of the femur consider it as roughly
a straight bone, slightly convex forwards. Take a
normal femur and study it carefully ; it is by no means
a straight bone, but a series of curves and angles.
I need not attempt here to give a verbal picture
' the anatomy of the femur. It is to be found with

more or less accuracy in every text-book of anatomy.
But if we look carefully first at a normal femur and
then at any of the specimens of united fracture in the
museums, we cannot fail to see how large a part
the inevitable lack of perfect alignment must play in
producing the diminution of muscular efficiency
which is so painfully apparent in these cases.

No method of treatment other than exposure by-
dissection holds out any hope of a perfect restoration
of alignment. It is only by actually seeing the parts-
dove-tailed back into their original positions that we
can ensure perfect alignment. Apart from this
operative exposure, the most careful measurement,
palpation and manipulation are in vain—even the
X-ray itself fails us here. True we can rotate the
lower fragments inwards or outwards, but practi¬
cally we can neither precisely determine the actual
position qua rotation of the upper fragment, nor can
we adequately correct it if we wish to do so by any
appliance at present at our disposal, I am quite aware
that in urging the more frequent use of operative
methods I am assuming a grave responsibility, and this
responsibility I propose to diminish by certain limita¬
tions. In the first place, operations of the kind to be
described hereafter should not be undertaken by
men other than those engaged in daily operative
work at the hospitals. They should not, save in
very rare cases, be undertaken in private houses.
They should never be performed save in healthy youths
or adults.

A very perfect technique must be at the operator’s
disposal, and plenty of skilled assistants. The operator
must have an adequate armamentarium, and his
requirements in this direction should be determined
by previous experiment on the cadaver. Given
all these preliminary requirements, operations on
fractured thighs should not be mere hazardous than any
of the countless operations performed in the hospitals
of a great city throughout the year. It is fairly
well known now, thanks to X-ray photography, that
the broken ends of the fragments present great diver¬
sity in the minute details of their appearance. Some¬
times the bone is broken nearly square across, with,
or without partial or complete detachment of angular
fragments. In others the line of fracture is of varying
degrees of obliquity, ranging from one to as many as.
five inches in length. In cases of extreme obliquity,
the long axis of the bone seems to be almost bisected,
so that each segment offers but little holding ground,
for any mechanical appliance to be embedded in.
In others, again, the line of fracture is an irregular
spiral; while in some the bone may be extensively
comminuted. It is obvious, therefore, that it will
be very difficult to make any one method of treatment
equally efficient for the treatment of these divers
conditions, and the surgeon who proposes to sub¬
stitute operative for non-operative methods of treat¬
ment must be prepared to modify his plans as the
actual conditions to be dealt with are revealed by
X-ray examination, and by the preliminary exposure:
of the seat of fracture.

The methods I now propose to discuss are of three:
kinds :—

1. Simple wiring of the fragments together after
exposure and drilling.

2. A modification of the ingenious apparatus,
suggested by Mr. Park Hill, of Denver.

3. The use of short steel screws as recommended
by Mr. Arbuthnot Lane.

SUTURING WITH WIRE.

Even with the most perfect equipment the securing,
of a plain transverse fracture by drilling and wiring
is a task of great difficulty. To get the parts rigidly
into position at least four separate wire sutures must
be passed, each suture entering the periphery of one
segment, then emerging through the medullary-
canal at the seat of fracture, re-entering the medul¬
lary canal of the other segment and emerging at its
periphery. If four such sutures can be passed and
secured with a uniform degree of tension, an excellent
result will be achieved. But practically this is im¬
possible to accomplish. One suture must be at the

zed by Google

July io. 1907.

ORIGINAL PAPERS.

The Medical PEE«8. 37

side of the bone remote from the surgeon, and this
suture it is practically impossible to make secure.
Assuming that the ends of the fragment have been
projected through' the wound and duly drilled, the
sutures can now be passed, with some difficult manipu¬
lation no doubt, but still the four sutures can be passed
and got into position for tightening. Now comes the
crux. The segments when reduced are overlapping.
This overlapping has to be overcome by traction on
the lower segment, but thi 9 very traction now makes
the aponeuroses and muscles so tense that there is
no room for one’s hands to grasp and make traction
on the suture most remote from the operator, and if
this deepest suture is not made taut a hinge move¬
ment will be permitted by the other three—not only
will a hinge movement be possible, but even a worse
result may happen, namely, that the lower fragment
may slide so far outwards as to be ultimately in lateral,
not end-to-end, apposition. This result is due to
the fact that so-called flexible wire, iron or silver, is
never so flexible as silk or other common suture
material. It is mechanically impossible to make wire
sutures as tight as silk could be made around
the four angles which each suture must traverse.
Further, any slight initial relaxation that may have
occurred at the operation tends to increase from day to
day, partly by actual stretching of the wire itself,
partly by the absorption of the bone from pressure
at the drill holes. If the broken faces can be kept
squarely in position these changes do not occur, but
if the least lateral movement is allowed by the presence
of the fourth suture the factors described at once
become operative. I do not mean to say that this
is a fatal objection to the method, as the defects may
be neutralised by splints, but then one great advantage
of the operation is lost—viz., the ability to dispense
with the splints altogether and to procure immediate
fixation of the fragments in their original relative
positions. A consideration of these factors and
practical experience have led me to abandon the simple
wiring method in clean cut transverse fractures.

In oblique fractures the problem is totally different,
and here the wire may be used most effectively. The
method I have adopted in such cases is as follows :—
An incision is made on the outside or in front, and the
segments examined by both sight and touch. In
these oblique fractures it is usually fairly easy to
determine the previous relations of the spikes and
recesses on the two fragments to each other. Once
this is done it is easy to drill at least one hole in each
segment in such a position as will give satisfaction
afterwards. It is not advisable to drill the bone
directly at right angles to its long axis. It is better
to drill it obliquely, that is to say, to drill the lower
fragment at a slightly higher level than the upper.
This makes the wires more tense when the muscles
tend to draw the lower segment upwards. This
difference in level must not be too great, as then there
will be a thread of wire intervening between the frag¬
ments, preventing perfect apposition. It may be
advisable to drill a second, or even third, hole, but in
the long oblique type one drill hole is sufficient—the
upper and lower ends being simply secured by a circular
lashing of wire or chromic catgut.

THE PARK HILL METHOD.

The method that I think, on the whole, promises to
give the best results is that associated with the name
of Mr. Park Hill. The principle underlying this
method seems to me to be very sound, though in the
original appliance certain mechanical deficiencies
became apparent on use. These deficiencies have
been largely corrected by adopting the suggestions
of my friend, Dr. R. Lane-Joynt, whose mechanical
aptitudes are so well known, and arc placed so freely
at the disposal of his professional brethren.

The apparatus which he has devised and perfected
and which I am now using fairly extensively, may be
described as follows :—First let me understand the
fundamental principle on which the instrument
is based. Everyone is familiar with the fact that a
fractured tibia undergoes but slight displacement
if the fibula remains unbroken. To Mr. Park Hill

belongs the credit of proposing to supply to a broken
femur or humerus an artificial equivalent of the
fibula in the lower limb. To do this several holes are
drilled in the upper and lower segments of the broken
femur, at right angles to the long axis of the bone
In these holes long, strong, steel screws are firmly
embedded, their free ends projecting six or seven
inches, or more, beyond the muscles and skin of the
limb. If these free ends are now caught in a long
clamp, so strong and so tightly clamped that the screw
cannot move, it is obvious that the clamp becomes
practically an artificial fibula to the femur, and it is
equally obvious that if the fragments have first been
absolutely restored to their original position, and when
so restored that the clamp has then been tightened
on the screws, nothing short of a great violence can
disturb the bony segments. When first using this
apparatus we met with certain mechanical difficulties,
and all the modifications suggested and executed by
Dr. Joynt have been designed to overcome these
difficulties.

First you have the difficulty arising from the fact
that the femur is curved slightly, and the clamp sides
are striaght. In other words, assuming that four or
six long screws are put from outside into the shaft
of the femur, say one inch apart, and exactly equi¬
distant from the anterior and posterior surfaces of the
bone, a line connecting the external ends of these four
or six screws will be a curved line, while the sides of
the clamp that hold them are in a straight line. The
result of tightening the clamp, therefore, will be to
tend to diminish the normal forward convexity of the
femur. On the other hand, if the sides of the clamp
be curved, it will be necessary to equip oneself with a
number of clamps to suit the varying degrees of
femoral convexity and the exact seat of the injury.
Again, if six screw holes have to be drilled in the
shaft of the bone, to ensure that they are exactly
in the proper line, each equi-distant between the ante¬
rior and posterior surfaces, it will be necessary to make
an enormous incision, and to expose the bone over a
very large area. These difficulties have been overcome
in Dr. Joynt’s modification of the apparatus by
interpolating a universal joint, capable of being
rigidly locked in the middle of the clamp. This device
makes the instrument easier of application, and
increases its efficiency enormously. Thus it is no
longer necessary to make a huge incision, exposing the
bone over a large area. It is now sufficient to make
one incision, say two inches in length, at the seat
of fracture, to enable the operator to see and feel
that perfect adjustment has been accomplished. The
screws, four or six in number, are inserted through
small puncture wounds at some distance from the
site of fracture. So long as those in each segment
of bone are fairly well in line it is immaterial if those
in the upper segment are not at first completely in
line with those of the lower, as to be rotated in any
desired direction until perfect alignment of the segments
is obtained, when the clamp can be easily locked
securely.

Parenthetically I may say here that the farther
from the seat of fracture that the top and bottom
screws are inserted the greater will be the mechanical
advantages of the method in securing absolute rigidity
in the fracture.

The method is not suitable for children, as the
femur is too small in calibre to carry the screws well,
and force applied through the screws, using them as
levers, may cause longitudinal fractures of the bone ;
but for uncomplicated cases in adults it promises
to be the easiest and safest method yet devised.
Moreover, in fractures near the trochanters above, or
the condyles below, it is incomparably superior to any
method of wiring or the use of screws. It is in fractures
near the trochanters that the most hideous results
are met with from the ordinary treatment by splints,
flexion of the thigh, bandages, etc. The upper seg¬
ment in these cases is seriously displaced ; being
usually flexed, abducted and everted, the lower frag¬
ment is drawn up inside and behind it, so that when
union takes place the result is something which

38 The Medical P»esi.

CLINICAL RECORDS.

July 10, 1907.

resembles the striking end of a polo mallet. The shorten¬
ing and irregularity are not the worst features, how¬
ever. Owing to the abduction of the upper segment
the top of the great trochanter is approximated to the
pelvis, so that when union has taken place actual
abduction becomes impossible owing to the top of the
trochanter striking against the pelvis. Further,
it is practically impossible to maintain any real exten¬
sion by strapping plaster fixed above the knee only,
a limitation necessitated by the flexion of the thigh
required to bring about even approximate parallelism
of the two segments.

Another point not to be forgotten is that in the frac¬
tures close to the trochanter minor splints applied in
front exert little or no pressure on the upper segment,
owing to the fact that a bandage around the thigh
at the level of the perineum is really below the end of the
upper fragment. Similarly the fractures near the
condyles, where great distortion occurs through the
rotating influence of the calf muscles, the Park Hill
apparatus promises to be of great service. In this
situation wiring is, from anatomical and mechanical
reasons, very difficult, involving great labour and
prolongled exposure of the parts, whereas even a
very small lower fragment will permit of the application
of two screws, one of which may be inserted into the
condyle itself if necessary. The clamp and screws
are left in situ for about four weeks, when, in a healthy
patient it will be found that fairly firm union has
taken place. One very striking clinical fact about the
use of this method is the immediate relief from pain
that the patients obtain. All muscular spasm seems
to cease, good sleep is obtained, and the discharge of
the natural functions is no longer an ever-recurring
painful ordeal. If the technique has been perfect
one dressing suffices for the entire case. When this
dressing is removed a number of small crusts are found
around the apertures in the skin through which the
screws emerge. These latter are gently withdrawn
by unscrewing. They should not, even if loose,
be pulled out. In a few days’ time the minute channels
have healed and the patient is practically well, with a
limb, save for the muscular atrophy due to inaction,
as efficient and useful as before his injury. In all these
operations it will be advisable to have X-ray photos
taken at intervals from points 90° apart, to ensure
that perfect apposition is being maintained throughout.

THE USE OF SCREWS.

This method, which owes its origin to the suggestion
of our brilliant countryman. Mr. Arbuthnot Lane,
is well worthy of a more extended trial than it has
hitherto received. It is especially applicable to
cases of oblique fractures; the greater the obliquity
the better, provided that the ends of the bone are not
comminuted. The method of employing screws
has been given with such amplitude of detail by
Mr. Arbuthnot Lane that it is not necessary for me
to refer to it here. A word of warning, however,
is necessary for those who are yet practically un¬
acquainted with the method, but may wish to make a
trial of it. It must not be forgotten that to ensure
getting the screws exactly into correct position;
the fragments must first be accurately reduced, and
then firmly held in position by the special forceps
designed for the purpose. This necessitates rather a
free exposure of the bone and detachment of the
muscles from the areas grasped by the forceps blades.
If this is not done necrosis of the crushed muscle
fibres may ensue and afford a nidus for infective
organisms to develop in.

Again, in the small bones of women and boys the
screws hardly get enough grip to make secure union.
In the'adult this objection does not hold, and excellent
results indeed can be obtained. In fact, in a satis¬
factory case, the after result of the use of two well-
placed screws is, to my mind, better than that obtained
by any other method, but it must be acknowledged
that it requires a higher degree of mechanical aptitude
to use the screws properly than to employ the wire
or the Park Hill apparatus. One has also to keep
clearly before one’s mental vision the position of the
femoral vessels, that they may not be injured by the

ends of the screws coming through the bone, and the
length of the screws to be used must be very precisely
determined before insertion. All the precautions as
to riming the proximal compact layer of bone so as
to allow of depression of the head of the screw, insisted
on by Mr. Lane, must be carefully adopted if success
is to be achieved. It will, of course, be understood,
that in this method the incision to expose the fracture
may be in front, or outside, as may seem most con¬
venient, but the presence of the femoral vessels pro¬
hibits incision on the inner side of the thigh.

Recently an ingenious suggestion has been made
to use an aluminium plate as an imbedded splint by
fixing it with screws to the two fragments and closing
the wound over the lot. I have no practical experience
of the method, and therefore do not venture to offer
an opinion on its merits. Further experience by its
originator will doubtless in time enable us to contrast
its comparative efficiency with the methods described
above.

In concluding this communication I may be per¬
mitted to offer a word of advice to those who may
desire to practise one or all of these methods, but as yet
are without practical experience on the subject.

1. Find out as much as you possibly can as to the
exact condition of the broken bone at the seat of
fracture by a series of X-ray photos.

2. Think out very carefully beforehand which
method is likely to give the best result.

3. Drill the bone with a Morse drill set in a brace.

4. If using the Park Hill screws see that the tap
for cutting the screw thread in the bone is of exactly
the same size as the screw to be inserted later, and is but
little larger than the Morse drill.

5. Never try to hurry the tap, let it cut its own way
in the bone.

6. When the ends of the fragments are exposed,
measure their diameters and mark the screws at a
point from their buried ends, exactly equal to
this depth, so that they may not project through the
bone, and perhaps injure the vessels.

7. If using the Park Hill method remember that the
wooded faces of the clamps taken from the boiler wet
will shrink as they dry, and the screws holding them
in position must be tightened in an hour or so.

8. Take an X-ray photo the next day from two
points 90° apart to insure that position is maintained.

9. Remember that to pass a ligature around the
bones a very large and powerful needle must be used
as the tough tissues about the linea aspera offer a
considerable obstacle to the passage of a needle.

Lastly, practise the operation on a cadaver before
trying it on the living.

CLINICAL RECORDS.

AN INTERESTING CASE OF BIRTH OF
" SIAMESE TWINS.”

Under the Care of J. Keane Healy, L.R.C.P.I., L.R*.,

Mil town Malbay.

The following case, in general practice, will, I
think, interest many of your readers :—On June 15th
1 was called to attend Mrs. M., who, I was informed,
was sick in her third confinement for twenty-four
hours, and attended by the district nurse.

On arriving, after a drive of ten miles, I examined
her, and found a foot presenting through the mem¬
branes. The os was fully dilated, and on rupturing
the membranes, a great quantity of water came away
(at least five or six quarts). On again examining I
found a second foot; but on making traction I could
not bring down the birth. On making very careful
examination I found two other feet protruding and,
of course, came to the conclusion that it was a case
of twins. I attempted to get back one of the twins,
as I thought, but failed. I then got down the four
legs and found I had to deal with a case of Siamese
twins. I gave the patient a few whii.s of chloroform
and made traction on the whole thing which (to my
agreeable surprise) came away in a slop, without

ized by G00gk

July io. 1907.

OPERATING THEATRES.

Th« Medical Pkkss. 39

the ^slightest injury to the maternal parts. The
mother has made a rapid recovery.

On examining the birth I found it had two heads,
two necks, four arms, one thorax, one abdomen,
one lunis, four legs, double pelvis, with anus and
vagina in each, all fully developed. Mrs. M. did
not expect her confinement for three weeks after
this occurred. Of course they were bom dead. I
■did what I could to get hold of the birth, but failed,
as the father would not consent to give it. They were
united from top of sternum to the double pelvis.

OPERATING THEATRES.

ROYAL FREE HOSPITAL.

Thoracotomy. —Mr. Willmott Evans operated on
a case of empyema. The patient was a woman,
aet. 23. married, who had been admitted into the
hospital three days before the operation. A month
previously she had had an attack of acute pneumonia,
and two days later she was confined of a living child
at full term. A day or so after this, the doctor who
was attending her diagnosed a pleural effusion on the
right side of the chest, and three ounces of serous
fluid were withdrawn by an aspirator. Since then
she had suffered much from pain in the chest and
■cough, and her temperature, instead of subsiding
after the pneumonia, varied between 102° and 103°.
.r*.n empyema was diagnosed, and she was advised to
■enter the hospital for operation. In the past
history of the patient the only facts of importance
were that she had had pneumonia when set. 14, and
several attacks of influenza. On admission, her
temperature was ioo°, and her pu'se 108 ; she was
very thin and looked ill. Slight dyspnoea was present,
but no cyanosis. She had slight cough with a little
yellowish sputum. On measurement, the right side
of the chest was found to be three quarters of an inch
larger in circumference than the left. The right side
moved very slightly on respiration, and on percussion
there was dulness as high as the fourth rib behind in
he axilla and in front; from the fourth rib to the
apex the note was impaired anteriorly. Over the
dull are avocal fremitus was absent. On auscultation,
over the greater part of the right side the breath
sounds were almost wanting. In the first and second
spaces anteriorly pectoriloquy was heard and there
were a few moist sounds. On the left side a few
rhonchi were heard, but breath sounds and vocal
fremitus were normal. The heart apex beat was in
the fifth space one inch external to the nipple line.
The evening temperature varied from 103° to 102°,
but it fell to normal each morning. The patient
having been anaesthetised, was placed on her right
side—that is, the affected side—and brought near the
edge of the table ; an exploratory syringe needle was
introduced just above the eighth rib, and a small
amount of pus withdrawn. An incision about an inch
and a half long was made over the eighth rib in the
posterior axillary line ; the tissues were divided down
to the bone and the periosteum stripped off the rib
by means of a periosteal elevator; the bone was
divided by cutting forceps, and about an inch was
removed; the pleura was then incised, but many
adhesions were present and it was not until some of
these had been broken down by means of the finger
passed upwards that the empyema was opened. About
a pint of pus was evacuated. A large empyema tube
was inserted, and a pad of gauze and wool applied.
Mr. Evans said that in all probability this would prove
to be a case of pneumococcal empyema, for the patient
had had a very definite attack of pneumonia about a
month previously, and, moreover, no tubercle bacilli

i had been found in the sputum. If this were so the
prognosis would naturally be much better than if the
empyema had resulted from pulmonary tuberculosis,
as was so often the case. The bacteriological examina¬
tion of the pus would probably clear up this point.
The question of the best treatment of empyema was
not so simple, he considered, as it was often thought
to be. It seemed fairly certain that simple aspiration
was practically never sufficient in itself. Some cases
had been described in which aspiration apparently
sufficed, but certainly in the great majority of cases
it needed to be followed by other operative measures.
Occasionally simple incision of the thoracic wall be¬
tween two ribs was sufficient, but this chiefly happened
in those cases where the quantity at first was not
great, or where the empyema was of ve r y recent origin,
so that the lung was in no way fixed by adhesions and
was able at once to resume its former size and position
when the pus was withdrawn. If however, the puru¬
lent effusion was of longer duration, so that the lung
bad become thoroughly collapsed and contracted
close to the spine, the cure of the empyema could only
be effected by the falling in of the chest wall. As the
chest wall falls in the ribs approximate to one another
with the result that the opening made between two
ribs becomes greatly narrowed, and any drainage tube
placed therein is blocked. Therefore, in cases such as
these, it was essential that a piece of rib should be
removed. If this is done, most empyemas will get
well; the chest wall falling in and the lung expanding
to a certain extent. It was only in very exceptional
cases that any more elaborate operation, such as
Estlander’s, was required, as when the lung was
unable to expand in the slightest degree. With regard
to the question of drainage, there was no need, in his
opinion, for any great length of tube to be employed.
It was sufficient if the tube reached just into the pus
cavity. The approximation of the pleural surface
always occurred first at the most distant part, and
there was practically no tendency to pocketing of pus.
One other point, he considered, deserved attention :
Was it necessary or advisable to wash out the pleural
cavity in cases of empyema ? It was certainly not
necessary, for, if the drainage was satisfactory the
patient did quite well without it. Further, it was not
advisable, for a certain number of instances had been
recorded in which washing out the pleural cavity
had been followed by immediate death. It was true
that this had occurred in only a small percentage of
the cases in which it had been done, but, as there was
no real advantage in it, it was not worth while to run
the risk. The cause of this sudden death, he thought,
was probably attributable to reflex vagal inhibition
of the heart, and it was not unlikely that the use of a
lotion below the temperature of the body had been
the real cause, for he could not see that the introduction
of a non-irritating lotion at the same temperature as
the pus that had been evacuated could produce any
harmful results. The clinical pathologist’s report on
the pus in this case was as follows :—“ Films show
many pneumococci; cultures did not grow ; probably
a pure pneumococcal infection.” A large amount of
pus was daily poured out. but as the quantity di¬
minished a smaller tube was employed and by the end
of a week the discharge of pus had almost ceased. The
temperature fell to normal on the evening of the
operation day and did not again rise above ioo°.
The dulness rapidly diminished, and the breath sounds
improved. The patient was discharged to a con¬
valescent home twenty-five days after the operation.
The wound had completely healed. The percussion
note was slightly impaired at the right base behind,
but elsewhere it was resonant. Vesicular breathing
was heard all over both sides, though the sounds were
rather weak at the right base and in the lower part of
the right axilla. No adventitious sounds were present.
The patient’s general condition had much improved ;
she was gaining flesh. She was seen a month later,
and was then perfectly well.

40 The Medical Press.

TRANSACTIONS OF SOCIETIES.

July io, 1907.

TRANSACTIONS OP SOCIETIES.

EDINBURGH MEDICO-CHIRURGICAL SOCIETY-

Meeting held July 3rd, 1907.

Dr J. O. Affleck, President, in the Chair.

Drs. Ford Robertson and Douglas McRae
showed (1) Rats showing paresis resulting from the
action of Bacillus paralyticans brevis. (2) Micro¬
scopical preparations from cases of general paralysis,
illustrating bacillary injection.

Dr. Dawson Turner showed (1) A case of rodent
ulcer refractory to X-rays, but amenable to radium.
(2) A case of rodent ulcer treated by zinc electrolysis.

Dr. Logan Turner showed a patient successfully
treated by X-rays for lupus of the larynx.

Mr. J. W. Struthers showed a case of trigeminal
naevus with epilepsy and paresis of the arm and leg
on the opposite side to the naevus, such a grouping* of
symptoms had been described in other cases, and in
some of these a naevoid condition of the dura had been
present. In this case, however, the dura mater was
shown at the time of operation to be healthy, the only
abnormality present being some flattening of the con¬
volutions. In cases of congenital trigeminal na?vus
it was important to give a guarded prognosis, bearing
in mind the possibility of the subsequent occurrence
of epilepsy or pareses.

Dr. Cranston Low showed (1) A case of mixed in¬
fection—syphilitic and trilocular. The patient had
various patches of lupus, and also evidences of con¬
genital syphilis. (2) A case of erythema iris. (3) A
case of bromide rash, peculiar on account of the
amount of scurvy present. The patient was an epi¬
leptic and had taken bromide for many years. (4) A
case of acnekeloid.

Mr. Alexis Thomson read a paper on
the making of a shelf below the unduly mobile
kidney.

The principle of the operation had been introduced
in America some years ago, but it had apparently not
yet been adopted in Europe. He did not propose to
enter into a discussion of the cause of movable kidney.
If one said that it was due to pregnancy one was met
by the answer that well-marked instances occurred
both in multiparous women and in men. Tight-lacing,
again, had been accused of its production ; probably a
good deal depended on the level of the constriction ;
if it was at the natural waist the constriction was below
the kidney and would tend to keep it steady ; whereas
if it was higher up, at the level of the tenth rib, it might
tend to displace the organ downwards. He thought
that mobility of the kidney was favoured by anything,
such as a tight corset, which tended daily to alter the
position of the organ. Muscular strains might perhaps
act in a similar way through fixation of the diaphragm
during the exertion, and a consequent pushing down
of the kidney. One thing which was noticeable was
that the middle zone of the abdomen—from the lower
end of the sternum to the tenth rib—was diminished
in size in cases of dropped kidney. The arrangement
of the fascia of the kidney was important in connection
with displacement of the organ. The transversaJis
fascia split into two layers, one anterior and the other
posterior, and between these the kidney lay. The two
layers of fascia were firmly united in the external aspect
and at the upper pole of the kidney, but on the internal
aspect, and below the lower end of the organ, they
were not fused, but were lost on the outer surface of the
eritoneum. As a result of this arrangement the
idney lay in a sac of fascia which was closed outside
and above, open internally and below. Consequently,
displacement readily took place in a directionjdown-
wards and inwards. The space below the kidney,
between the two layers of the transversalis fascia, was
known as Gerota’s space, and into this the kidney
slipped, as the bowel does into a hernial sac. The new
operation, which he had performed on five patients,
was analogous to that for the cure of hernia. The

abdomen was opened by the gridiron method ; the
kidney was replaced, and the two layers of the fascia
below its lower pole were united by a row of sutures
so as to prevent the kidney from slipping down between
them. The operation had the immediate advantage
over nephropexy of not being followed by the nausea,
vomiting, and discomfort which stitching the kidney
often produced, while the ultimate result, as regards
immobility, had been very satisfactory. When there
was much displacement it was best to open Gerota’s
space from outside the ascending colon, so as to get
better access for stitching. He did not think that
sudden violence could produce prolapse of the kidney
into Gerota’s space. As to the reason for the right
kidney being so much more frequently affected than
the left, the liver, of course, had been blamed for it.
But in prolapse of the liver the organ rotated forward,
so that it was difficult to see how it could displace the
kidney downward, seeing that it only came into relation
with the latter organ by its posterior part. It seemed
more likely that abnormalities in the mesenteric attach¬
ments of the ascending colon played a part in the
mechanism of movable kidney.

Mr. Cotterell said that one reason why cases so
often relapsed after nephropexy was that patients were
allowed to get up too soon, before the recent adhesions
had time to become firm. He thought that the main
thing was to get the kidney into its proper position,
and to keep it there for six weeks. He did not think
stitching had much value; his method of operating
was to plug the space between the fascia below the
kidney with a large quantity of gauze, and to keep the
patient in bed for a much longer time than usual after
operation.

Dr. Waterson discussed the anatomical relations of
the kidney, and suggested as a possible explanation
of the persistence of Gerota’s space the large size of
the foetal kidney.

Mr. Stiles thought the new operation promised well ;
he suggested combining the method of making a shelf
with nephropexy.

Drs. Ford Robertson and Douglas MacRae read
a paper on the

treatment of cases of general paralysis and
tabes dorsalis with vaccines and antisera.

They first referred to their previous observations on
the organisms of general paralysis and tabes, and to
the conclusion they had arrived at that two varieties
of diphtheroid bacillus, named B. paralyticans longus
and brevis, were the specific cause of the disease. This
conclusion was based on the constancy with which
these organisms were found in cases of general para¬
lysis, and on the fact that animal experiment gave
both symptoms and pathological appearances as charac¬
teristic of general paralysis. In preparing a vaccine
sterilised cultures were used and these had been tested in
eight cases of general paralysis and one of tabes dor¬
salis. There was usually some local reaction, and
general symptoms—rise of temperature, leucocytosis,
and an exacerbation of the physical and mental
symptoms—which was followed by a period of more
or less prolonged remission. Notes of the cases so
treated were read. In the single case of tabes healed,
the vaccination caused some local irritation, which,
was followed by lightning pains. Repetition of the
vaccination, however, had resulted m considerable
improvement, and had abolished the attacks of light¬
ning pain for the time. After attaining this success-
with vaccines, they had tried to produce an anti¬
serum, using sheep for the purpose. They tested the
effect on the sheep by noting the bacteriolytic power
of the corpuscles. At first this power was possessed
by the corpuscles only to a very slight degree—o to
4 or 6, but after repeated inoculation it rose to 70 or 8o_
The serum was then withdrawn from the jugular vein,
with antiseptic precautions, and could be kept for a.
considerable time. They had administered it to gene¬
ral paralytics by the nose, mouth, and hypodermically.
Given by the mouth it was liable to produce nausea,
and vomiting. Hypodermically, it caused a variable
amount of irritation. The general symptoms were a.
rise of temperature (in 17 out of 24 cases) with increase

Digitized by GoOgle

July io. 1907.

of incoordination, tremor, and mental confusion.
Thereafter there was great amelioration of the symp¬
toms. The antiserum had been tried in 24 general
paralytics in all ; in 10 out of 12 under their personal
observation there had been very marked benefit, and
in 3 ont of 5 partially under their own care. In other
cases of insanity of various types no reaction, and no
change in the symptoms were produced, while in general
paralysis other antisera (diphtheria antitoxin and anti-
streptococcus serum) had produced no reaction. Apart
from its curative or beneficial effect, therefore, they
ascribed considerable diagnostic value to the serum,
the febrile reaction which followed its injection being
strongly in favour of the existence of general paralysis.
Their conclusions were (1) that their antiserum was
really diagnostic of general paralysis ; (2) that in most
cases it caused an improvement of the symptoms ;
(3) that a polyvalent serum, made from several strains
of the diphtheroid organism would probably be more
efficacious. (4) That the bacilli were very apt to lose
their virulence, and hence it was difficult to obtain a
really active serum ; (5) that having prepared this
anti-bacterial serum they were in hopes of obtaining
an antitoxin.

Dr . George M. Robertson read a paper on

THE PRESENCE OF A BACILLUS (mUIRHBAD’S BACILLUS)
IN THE BLOOD OF PERSONS SUFFERING FROM
GENERAL PARALYSIS, AND OBSERVATIONS ON THE
BACILLUS PARALYTICANS.

Dr. Robertson first criticised Ford Robertson’s
conclusions concerning the bacillus paralyticans, on
the ground that the identity of this organism was not
established, and that the information given concerning
it was too vague to allow of its recognition ; he also
alluded to the possibility of terminal infection as in¬
validating the significance of its discovery post¬
mortem, and the complexity of the flora of mucous
membranes in general as a reason for being very cau¬
tious in drawing conclusions from organisms found
on such sites. The observation made at Larbert had
been begun with the view of confirming Robertson’s
researches, and the observers had confined themselves
to trying to find an organism in the blood and cerebro¬
spinal fluid of cases of general paralysis. They had
found in the blood a bacillus of the Xerosis group of
diphtheroids on 15 separate occasions in 7 out of 13
cases of general paralysis. From the precautions taken
he was satisfied that it was not due to any contamina¬
tion. The organisms grew on agar plates, but inocu¬
lation experiments had not been successful. In order
to distinguish it from the Bacillus paralyticans, and
to avoid the assumption of any theory as to the part
it played in the aetiology of general paralysis, they had
named the organism “ Muirhead’s diphtheroid,” after
the asylum bacteriologist. They had thus failed to
confirm Ford Robertson’s work, never having found the
bacillus paralyticans longus, and the bacillus paralyti¬
cans brevis only once, post-mortem, in association with
a leptothux, circumstances which supported the idea
that it was due to a terminal invasion.

Dr. Clouston spoke of the very remarkable improve¬
ment he had noticed in the cases of general paralysis
treated by the antiserum. They were all well-marked,
definite examples of the disease.

Dr. Bruce confirmed Dr. McRae's statement that
the reaction was of diagnostic value ; he doubted the
pathogenic nature of Dr. George Robertson’s organism,
and stated that he had made many attempts to grow
bacilli from the blood of general paralytics, which always
failed. Dr. Robertson’s success in half his cases made
him (Dr. Bruce) suspect there must be some contami¬
nation.

Dr. Lawson said that one difficulty in accepting the
reaction as pathognomic was the absence of control
experiments on normal persons ; he also hoped the
investigators would try to standardise their anti¬
serum.

In his reply. Dr. Ford Robertson said that the
organism he had received from Dr. George Robertson
did not give the same cultural reactions as the latter
had found, and he did not think it was specific.

The Medical Pres s. 41

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Paria. July 7 th 1907,

The Treatment of Metritis.

The treatment of the different forms of metritis is a
complex problem, and frequently the practitioner
hesitates, says Professor Soubeyran, by reason of
the multitude of the means employed and their
imperfect indications.

On the one hand the treatment should be directed
against lesions of the inflamed mucous membrane
(acute and chronic metritis) whose glands are hyper¬
trophied and secrete abundantly lesions which can
invade the interstitial tissues which are accompanied
frequently with vascular dilatations, bleeding with
the greatest facility (haemorrhagic form).

On the other, all kinds of lesions of the os. ulcera-
tifins, polipy, rents, frequently complicated with a
bad constitutional condition of the patient.

The treatment showed at first prophylatic, con¬
sisting mainly in avoiding the two great causes of
genital infection : gonorrhoea and puerperal in¬
flammation. Consequently all cases of vulvo-vaginitis
and haemorrhagic bartholinitis should be treated with
care, and the husband still suffering from chronic
gonorrhoea should be warned of the danger his
wife is exposed to.

Puerperal infection should be treated by the ordinary
means of asepsy and antisepsy at the moment of
delivery or of miscarriage, and if there is retention of
the debris of the placenta prompt action should be
taken before the haemorrhage has shown that the
infection has already spread to the mucous membrane.

As soon as the temperature has reached 100 F.,
according to the principles of Pinard, an intra-uterine
injection should be made.

Permanganate of potash, gr. 15,

Water one quart.

After this injection, if the temperature has fallen
below 100 F., another should be given.

If the temperature exceeds 100 F. with a pulse of
120, large irrigations should be made with 10 or 12
quarts of liquid, and repeated three times daily:
water, one quart; permanganate of potash, seven
grains.

If, in spite of all this, the fever persisted, a curettage
will be necessary, preceded by digital curage or the
use of the brush.

These different means, however, should not be
used until after the third day of delivery.

All the varieties of metritis require general treat¬
ment, hydrotherapy, dry rubbing, cod liver oil,
arsenical or ferruginous preparations.

Constipation should be attended to as it produces
congestion of the pelvis.

The patients should keep the horizontal position
during the acute periods, and wear an abdominal
belt, avoid fatigue, all effort and coiters.

The vaginal injections should be given very warm
(F. 104 or 112), and taken in the recumbent position.

Acute Metritis .—Here all attempts at exposing the
uterus should be avoided. Ice will be placed on the
abdomen, or cold compresses; or, on the contrary,
poulticesonwhich are scattered a few drops of laudanum;
suppositories of belladonna and opium will be pre¬
scribed, with hot vaginal injections and warm drinks.
When the acute period has passed intra-uterine
injections will be necessary at F. 104° every day, with
a solution of permanganate of potash (seven grains to
the quart). The speculum is introduced gently, the
current dilator of Reverdin placed in the os. After
the injection a plug of iodoform gauze is left in the
vagina.

Once the gonoccocus has disappeared, injections
of corrosive sublimate (five grains for a quart) should
be made, and the interior of the uterus cauterized
with a solution of nitrate of silver (1-50).

Digitized by GoOgle

CORRESPONDENCE.

4 2 The M edical Press._ CORRESPONDENCE. _ July io . 1007

Chronic Metritis. —(LeucoiThTa, pain, inflammation
of the cervix, &c.). In the ordinary catarrhal form,
accompanied with hypersecretion of the glands
extending sometimes to the cavity of the uterus, the
general treatment should not be neglected, but
vaginal antisepsy should be insisted upon. The
essential point in the treatment is to arrive at modi¬
fying the mucous membrane by intra-uterine thera¬
peutics.

The intra-uterine treatment is effected by three
modes of procedure : intra-uterine dressings, cauteriza¬
tions, curettage.

Naturally, dilatation of the cervix should precede
the manoeuvres when it is narrow. In the case of a
woman who has had several children it is generally
not necessary. The dilatation can be made by either
the slow or rapid process. The former has the disad¬
vantage of producing great pain and sometimes
inflammation. For the latter the bougies of H6gar or
the dilators of Sims, Clin or Reverdin, preferably the
latter, for it allows dilatation of the orifice under a
stream of warm water.

Irrigation of the uterns follows, after which a
solution of corrosive sublimate or of nitrate of silver
(1-100) is injected.

GERMANY.

Berlin. July 7 th. 1907.

At the Medizinische Gesellschaft, Hr. Marmorck.
a.G., introduced the subject of

The New Tuberculosis Investigation.

He had studied the early stages of the tubercle bacilli,
and had made this the starting-point for his inquiries.
The bacillus, in the course of two or three days, formed
an exceedingly fine pedicle on the agar and also showed
different tinctorial properties from the adult.

These early forms were injected into the abdominal
cavities of mice after they had been washed with a
solution of hydrochlorate of quinine, which served to
paralyse phagocytosis and to make the animals ex¬
perimented on more receptive. Treated in this manner
the bacilli showed that their virulence was very slight.

In experiments on guinea-pigs, it was shown that
animals springing from tuberculous mothers were
more receptive to tuberculosis than those from healthy
ones. In older animals the receptivity diminished.

It was by inoculation with these slightly virulent
bacilli that the speaker obtained his serum.

If this attenuated virus was given to animals and
tuberculin injected at the same time, in the first in¬
stance the upper part of the lungs became diseased.
The administration of tuberculin also excited the
toxine action, and favoured the development of
cavities in the lungs. It was therefore in a position
to activate weakened bacilli, which, without the
simultaneous action of the tuberculin would not have
been strong enough to set up tuberculosis. If the
weakened bacilli were injected arterially, they did not
set up tuberculosis, and when injected into the veins,
at the most a slight attack of the disease.

On the other hand, tuberculosis serum injected into
the veins acted much more energetically than when
injected subcutaneously or intraperitoneally, and it '
should perhaps be injected into the vein in cases of ,
tuberculous meningitis.

He then went on to speak of the employment of
tuberculosis serum in the human subject, and formu¬
lated the requirements that were demanded in such
a serum, and claimed that they were all fulfilled in
his own serum. An important advantage in the em¬
ployment of the serum was the fact that it could
with propriety be administered by the rectum.

Hr. v. Pinquet, Vienna, had made vaccination his
starting-point. After the first inoculation, immunity
was induced, but it was not quite absolute. After \
every re-vaccination, also, a reaction arose, which,
however, ran a different course as to time and was 1
milder than the first vaccination.

If children were inoculated in the skin with tuber- ,
culin, with a vaccination lancet, there arose a small j
papule at the inoculation spot so soon as the children I

became tuberculous ; this remained for about eight
days and developed in twenty-four hours.

In a large number of children with tuberculosis
clinically determined, this reaction took place. It
only remained absent in children with miliary tuber¬
culosis and tuberculous meningitis, and in very cachec¬
tic children.

Adults almost all reacted to this inoculation, which
corresponded to the fact that the majority of hospital
patients of large towns were infected with tuberculosis.

Hr. A. Neumann had treated sixteen children with
surgical tuberculosis, and two adults with Marmorck’s
serum, and mos ly by the rectum. Children received
1 to 5 ccm. daily for three weeks, adults 5 to 15 ccm.
They were all severe cases. Not one showed any im¬
provement that could not be attributed to other
therapeutic measures. No injury certainly was done
by the serum ; when injected into the veins also it
set up no infiltration, nor did it act visibly on the
general condition. He must believe, however, that it
was not without effect, for the reason that during the
treatment patients lost 2 lbs. to 3 lbs. in weight,
which, however, they quickly recovered. Only one
child increased in weight during the treatment. On
the whole it appeared so harmless that patients could
go about whilst it was being carried on.

Hr. Van Diiren reported that no accidental com¬
plications, infiltrations, urticaria, &c., appeared when
the serum was given by the rectum. The patients,
improved in their appetites and gained in weight.
Pains ceased and secretions from fistulae became less,
and they slowly closed.

Hr. Landau and Hoffa also spoke favourably of the
treatment by Marmorck’s serum.

AUSTRIA.

Vienna, July 7th, 1907.

Spondylitis Infectiosa.

Schlesinger exhibited a patient to the members-
of the Gesellschaft with spondylitis, the result of
Dengue fever, which the patient contracted in Egypt
last year, but left that country about the month of
October and came to Europe in the hope of
recovering from the devastations of the sequela?.

This fever commences innocently with yawning,
and lassitude, followed by severe pains in the joints,
gradually increasing till the patient is laid prostrate
in febrile agony. In a short time a remission ensues,
with an exanthematous and desquamation lysis.
The prognosis in most cases is good, but in the patient
before the members, after many remissions, a compli¬
cated central nerve disease appeared, which from all
appearance was an encephalo-myelomeningitis. After
lying three weeks unconscious the patient gradually
improved, though the recovery was slow, before being
able to walk, when he resolved on coming to Europe
seven weeks ago, so runs Becker’s report who at¬
tended the patient in Cairo.

When he was received by Schlesinger in Vienna he
was suffering from a painful form of kyphosis in the
lumbar region, evidently developed on the journey
thither. There was patella and right foot clonus on
examination, but no trace of tubercle could be detected
anywhere, neither could any hereditary blemish or
other congenital weakness be detected. This new
development seems to have been the result of the
febrile poison, and therefore of an infectious character,
as shown by Quinke in his case of spondylitis. This
opinion has been confirmed by tne improvement
that had taken place since his residence in hospital.
One milligramme of a tuberculin solution was injected
on admission, but no reaction took place, neither
locally nor constitutionally, eliminating tubercle in the
diagnosis. This poisoning of the nerve system is not
an isolated condition, as we meet with it in typhoid,
influenza, &c., and it is reasonable in Dengue.

Atoxyl and Syphilis.

Zeissl next presented a patient that he had treated
with atoxyl for syphilis as an example of others who
had benefited by its administration. He would not
dogmatise on the efficacy of the drug in this particular
disease, but from the results he had obtained he was.

Digitized by GoOgle

July io. T907.

CORRESPONDENCE.

The Medical Press. 43

of opinion that the drug had some special virtue in
this disease. It certainly retained the strength of a
■weak luetic patient where mercury and iodates would
be injurious.

Diagnosis of Tubercle.

Pirquet presented a six months' child on whom he
had performed the “ Allergie ” test for tubercle with
a positive result. The child was received into hospital
on the 12th of June suffering from an eruption on
the right cheek of a doubtful character. The scab
covering the sore was about five centimetres across,
with a red swollen margin—the scab being yellow and
black. Scattered around in the neighbourhood were
a number of white tubercles, several of which were as
large as beans with enlarged glands below the angles
of the jaw. These tubercles also became purulent and
formed scabs which, when removed, left depressions
in the tissue with red efflorescent edges. Lungs,
heart, and all the internal organs were healthy—no
other pathological change could be discovered, unless
this tubercular ulcer on the cheek, which seems to
have been the primary sore causing the swelling in
the regionary glands.

Now came the crucial point of determining whether
this is tubercle or not. At this age tuberculin rarely
acts positively, and thus tuberculoids are resorted to.
Both of the arms were inoculated below the elbow,
while the control was watched by a simple scratch,
Around the surface (twelve millimetres), where the
tuberculin was inoculated, papules presented them¬
selves, while the simple scratch remained free.

Hirschsprung’s Disease.

Schnitzler presented a child, ait. 3 years, on whom
he had performed resection of the sigmoid flexure.
He recommends Hirschsprung’s bilateral operation for
the disease as the most satisfactory.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

THE ASSAULT ON DR. CARSEWELL, GLASGOW.

—THE QUESTION OF INSANITY.

Dr. Carsewell’s assailant was tried before the
High Court of Justiciary in Glasgow on July 2nd.
Evidence was given as to the purchase of a revolver
and cartridges by the prisoner a week before the
assault was committed. When mak ; ng the purchase
the accused asked if the weapon would kill a man,
and tested it by firing into some empty boxes. Eye¬
witnesses then told the story of the assault. After
the accused was arrested he said he did not mean to
kill the doctor, adding : “ Do I look like a murderer ? ”
He continued that he was justified in his act, and had
committed it to protect himself and the public. His
object was to get Dr. Carsewell brought before the
public in a witness-box. Medical evidence was given
concerning the extent of Dr. Carsewell’s injuries, and
then to the effect that the prisoner was of unsound
mind His Lordship (Lord Maclaren) at this stage
remarked on the exceptional course being taken by
the defence. It was not attempted to prove that the
prisoner did not commit the act charged, and instead
of taking the usual course of trying to show that the
accused is insane, the attempt was to prove that he
was perfectly sane, while the prosecution was seeking
to prove the opposite. The prisoner’s counsel said
his plea was that the accused deliberately shot at Dr.
Carsewell with the purpose of bringing his case, having
failed by other means, before the public. He was,
however, careful not to do him serious harm, and he
had pleaded not guilty under the notice that the real
question at issue was as to his sanity, and his object
was to prove before all else that the prisoner was
perfectly sane. The view the Crown took was that
the man was dangerous as a subject, and that the
proper method was to treat him as a criminal lunatic.
Medical testimony having been given as to the pri¬
soner's sanity, he was then examined on his own
behalf. He described how proceedings were taken

without his being aware of their object, by Dr. Carse¬
well and Dr. Gilchrist, which resulted in his being
certified as insane, and placed for some months in an
asylum. He knew that while in that institution, if
his wife had consented to his being liberated, he could
have got out. After he did come out he raised an
action against his medical attendants for wrongous
certification. Failing by that means to attain his
object, he tried every other legitimate means he could
think of, and having failed in all these and lost all
his money in the endeavour, he had taken this last
course as the only one left of having this case brought
before aj ury of his fellow countrymen. He considered
his grievance a violation of public liberty. After an
absence of ten minutes the jury returned a unanimous
verdict of guilty, but without intent to do serious
bodily harm.

His Lordship then passed sentence of seven years
penal servitude. He considered it a very serious
offence. He quite believed the prisoner did not mean
to kill the doctor, but he could take it from no man
that he fired shots into the body of a fellow-creature
not meaning to do him serious harm. He had made
the sentence as light as he could.

Apart from the interest which the circumstances
leading up to the assault lend t to this case, the itrial is
remarkable as another instance of the peculiar rela¬
tionship of insanity and criminal responsibility to
the law. As in the New Cumnock poisoning case,
the Crown tried to prove the prisoner insane, a plea
which, if successful, would have barred a verdict on
the facts. The evidence was to the effect that the
accused suffered from delusional insanity arising from
a mental deterioration quite consistent with general
intelligence, and also (in the opinion of defender’s
witnesses) consistent with an appreciation of right
and wrong, and the legal consequences of his actions.
The question of insanity barring a verdict on the facts
was duly laid before the jury, and it is interesting that
the commonsense of the jurors very quickly arrived
at the conclusion that, despite his delusions, the pri¬
soner was responsible—in a word, the layman’s posi¬
tion was, as we think, behind that which medicine has
for long, and the law for a shorter time, tended to take
up. Possibly the jury shrank from admitting the
principle of an extension of mental irresponsibility,
when they knew that the view of the Crown was that
this would carry with it permanent incarceration in
an asylum. The public mind is evidently not pre¬
pared to have everyone whom an expert declares
irresponsible placed under control. From a medical
point of view, however, there seems strong reason to
believe that the contention of the Crown was right.
The prisoner was certified as insane (and corre-tly
certified as insane, for he failed absolutely, despite
the best efforts of leading counsel, in obtaining a verdict
of damages for wrongous certification), and subse¬
quently committed a premeditated, serious crime,
“ to bring his case before the public.” It is admitted
that he suffers from mental deterioration with de¬
lusions. Who can doubt that he is a fit subject for
asylum treatment ? Yet by the action of the jury
he is sent to penal servitude.

BELFAST.

The Corporation and the Local Government
Board. —At a recent meeting of the Public Health
Committee of the Corporation it was reported that a
small deputation from the Committee had waited on
the Local Government Board with reference to several
matters recently under consideration. The deputa¬
tion brought before the Board the necessity that
exists for the committee obtaining fuller details of the
deaths in the city, with the name and residence of the
deceased, and the cause of death, so that more efficient
action might be taken in the case of death from
infectious disease. This information in the case of
Dublin is supplied by the Registrar-General, and there
seemed no reason why Belfast should not be given
similar aid. The Board replied that they considered
it the duty of the Registrar-General to demand from

Digitized by GoOgle

44 The Medical Press.

CORRESPONDENCE.

July io. 1907.

the local registrars a copy of all deaths registered by
them, and the proper course was to approach the
Registrar-General and obtain this information, which
it was most important to have.

LETTERS TO THE EDITOR.

PROPOSED ROYAL COMMISSION ON CANCER.
To the Editor of The Medical Press and Circular.

Sir, —The excuse given by the Prime Minister for
refusing to appoint a Royal Commission to enquire
into the subject of cancer, was, to say the least, a very
lame one—“ he was advised that much remained to
be done before any facts could be brought before a
Royal Commission with any likelihood of their making
such an enquiry fruitful for the public a-i vantage.”
At any rate, this objection could not possibly apply
should a Royal Commission be asked for with regard
to quackery, now more rampant than ever, and pro¬
ducing quite as much harm as the spread of cancer
itself. I trust this agitation in favour of a Royal Com¬
mission to enquire into the evils of quackery, patent
medicines, &c., will not be allowed to fizzle out, but
that before long public opinion will insist on such
enquiry quite as necessary as that with regard to
cancer.

I am, Sir, yours truly,

Alexander Duke.

London, W.

QUACKERY AND PRACTICE BY COMPANIES.
To the Editor of The Medical Press and Circular. ;

Sir, —Lord Hylton’s Bill was read a third time and
assed in the House of Lords on Wednesday last,
t will now be sent down to the Commons ; and those
who care may believe that it will be accepted by the
Lower House, and in due course find a place in the
Statute Book. Since I last wrote on this subject, I
have had the opportunity of seeing the full notes of
the evidence given before the Lords’ Committee, and
I am not at all surprised to find that Dr. Heron,
Chairman of the London and Counties Medical Pro¬
tection Society, and Dr. Bateman, Secretary of the
Medical Defence Union, express precisely the same
opinion that I have twice put forward in your pages,
namely, that the Bill is useless as a blow against quac¬
kery, and that at the best it could only put to tem¬
porary inconvenience the very small percentage of
impostors who make use of the Companies Acts as a
cloak for their nefarious games. It is amusing to
note that the promotors of the Bill had to stand on
the defensive, and to show that the legitimate (?)
interests of unqualified quacks would not be inter¬
fered with by the proposed legislation. If, on the
other hand, a Royal Commission such as I advocate,
had been sitting, the case against the quacks of every
denomination would have been stated, and these gentry
had they dared to put in an appearance, would have
been obliged to undergo cross-examination by counsel.
In my letters so far I have not referred separately to
the case of the dentists. It would be easy to prove
before a Commission the injury to the public from
quack dentistry. The quack’s bait—artificial teeth
at prices which would not pay for the work if the
operations could be reduced to a mere mechanical
routine, which is, of course, impossible—at tracts mostly
simple and foolish women. Virtually, they never get
teeth at the prices promised. They are supplied with
teeth of the most inferior make, and the remaining
diseased teeth and roots are invariably left without
the necessary treatment. As a result, in a vast pro-
ortion of cases, a septic condition of the mouth is
ept up which is often enough seriously to affect the
general health, and even to form a contributory
cause towards a fatal termination of an existing
malady. The quack dentist is only less harmful than
the quack doctor because his scope for mischief is more
limited.

I am, Sir, yours truly,

Henry Sewill.

Cavendish Square, July 4th, 1907.

IS ENGLISH LOCAL GOVERNMENT A FAILURE ?
To the Editor of The Medical Press and Circular.

Sir. —In spite of the recent scandal of criminal
convictions, we find that at last week’s election of a
new Board of Guardians for West Ham, only 15 per
cent, of the burgesses recorded their votes. On pre¬
vious occasions you have allowed me to point out that
similar apathy prevails as a rule throughout the land,
in urban and rural districts alike. Local governing
bodies have practically complete control of the sani¬
tation of their districts, and are, besides, now the
directors of education. All our State institutions are.
in fact, democratised, and it is certain that unless the
great bulk of respectable and responsible citizens will
take due interest in their working—unless they will
accept office themselves or take at least an active part
in getting proper representatives to serve—mal¬
administration and corruption will appear. These
local bodies have in their hands the appointments of
medical officers under the Poor Law, and Public Health
Acts, and it is impossible to expect any real improve¬
ment in the present deplorable status of these officers
so long as local bodies continue to be largely made up
of ignorant and vulgar men, whose object very often
is to obstruct the administration of laws which conflict
with their own sordid interests. The extreme develop¬
ments consequent upon the lack of true patriotism in
the citizens of a democratic society are now being
sufficiently illustrated in the United States. It seems
that the same dangers exist at home, and if the spirit
of our people cannot be roused we must be prepared
in the end for national disaster. This pessimistic
forecast will not be deemed exaggerated by serious
students of the sociological phenomena of the present
day. I am, Sir, yours truly,

July 1st, 1907. M. O. H.

(VOYAGE D’ETUDES MEDICALES.

To the Editor of The Medical Press and Circular.

Sir,—M ay I call the attention of your readers to
the facilities for seeing certain of the French health
resorts which are annually offered by the organisation
which bears the above title ? For the purposes of these
visits, France is divided into five districts, each 01
which contains a large number of spas and mineral-
water stations. Every year one of these districts is
made the object of a carefully arranged inspection.
The time chosen is the first fortnight in September.
The party, which is strictly limited to 100 persons,
travels under the most favourable conditions. A first'
class special train conveys the members from plac e
to place. The hotel accommodation and the food is
provided for in advance. The care and transport ot
the luggage is undertaken by the organisers in such a
way that a member’s valise left at the proper hour
outside his bedroom at the place of departure, is found
inside his bedroom at the next halting-place. The
advantages of the particular stations visited are ex¬
plained at each place by Professor Landouzy, who
acts as the president of the company. This year the
health resorts to be visited are those in the district
of the Vosges, which include such well-known p' aC ® s
as Contrex6ville, Vittel, Martigny, Plombiires, Luxueu.
and many others. The rendezvous is at Reims on
August 31st, and the company parts at Divonne, <> n
the Lake of Geneva, on September 13th. Having now
taken part in five of these trips, I can assure y® u
readers that there is no more agreeable or instructiv
manner of spending a part of one’s summer holiday-
The price (300 francs, or £12) is astonishingly lo *’
especially when it is realised that this includes every-
thing from the rendezvous to the dislocation. Ther
are no tips or extras of any kind. Medical men an
their wives, and medical students, are allowed to jo* •
Those coming from this country are always sure 01
particularly warm welcome. .

I shall be happy to supplement this inform 41 '®
if any of your readers should desire further particulars
on the subject.

I am, Sir, yours truly,

Leonard Williams-

8 York Street, Portman Square, \V.

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SPECIAL ARTICLE.

The Medical Puss. 45

OBITUARY.

WILLIAM SCOTT. M.D.Edin., L.R.C.P.Edin.

We regret to record the death on July 2nd, at the age
of 78 years, of Dr. William Scott, of Huddersfield. From
September last the deceased gentleman had been in
indifferent health, and he died from heart failure
following passive congestion of the lungs.

Dr. Scott was born at Hexham, and was educated
at Newcastle and Edinburgh University. He took
the degrees of M.D. and L.R.C.P. in i860. He after¬
wards became assistant to Dr. Ramsbotham, at
Huddersfield, whose practice he took over at the death
of that gentleman. Many years ago he took into
partnership Dr. Thornton, of York Place, Huddersfield,
and the practice became a very extensive one. Forty
years ago he was well known in cricket circles as a
good batsman, and played many times against touring
All-England elevens. He was one of the founders of
the Huddersfield Gentlemen’s Club. In politics Dr.
Scott was an ardent Liberal, and he was a vice-presi¬
dent of the Huddersfield Liberal Club, but he took
no active part in public life. He was a Congrega-
tionalist and attended Highfield Chapel, Hudders¬
field. He leaves two sons and two daughters.

ROBERT SETTLE, M.D.Glasg.,L.R.C.S.Ed., L.S.A.,
V.D.

We regret to announce the death of Dr. Robert
Settle, of Bolton, who passed away last week at the
ripe age of 82. He studied medicine at Dublin and
at Glasgow, and graduated M.D Glasg. in 1849. Sub¬
sequently, he took the L.R.C.S. of Edinburgh, and the
L.S.A. of London. He was a native of Bolton, and
he practised in that town for sixty years, and held
many public appointments. He was an ardent
volunteer, and till lately held a commission as Surgeon-
Major in the 2nd V.B. Loyal Notth Lancashire
Regiment. He was awarded the volunteer decoration
for his long and faithful service. Shortly before his
death he resigned the post of Medical Officer and Public
Vaccinator to the Bolton Union. He was also Honorary
Consulting Surgeon to the Bolton Infirmary and
Certifying Factory' Surgeon for his district.

CHARLES LATHAM, M.R.C.S., L.S.A.

We regret to record the death at Sandbach, of Dr.
Charles Latham, in his 91st year. Dr. Latham had
held many public appointments in the district, and was
once a famous cricketer. Last year, on the attain¬
ment of his 90th birthday, he was presented with a
wedding cake with a representation on the top of a bat.
wicket and ball, and the inscription, “ 90 and not out.”
He qualified M.R.C.S. and L.S.A. as long ago as 1839.

THE LATE DR. E. H. BENNETT.

Referring to our obituary notice of Dr. E. H.
Bennett “ a colleague and friend ” sends us the
following note, which we have pleasure in publishing :
—By the lamented death of Dr. Edward H. Bennett,
Irish Surgery has lost one of its most accomplished
representatives, and a link between the present and
the past generation has been severed. He was a man
of sterling qualities, and had a wide reputation for
his intimate knowledge of surgical literature, which
freely permeated all his teaching. Although he did
not attain to a very extensive practice, nor was he a
brilliant operator, he was an acknowledged expert
in several branches of surgery, notably in the domain
of fractures and dislocations, and his opinion as a
consultant in this department was often sought by
his professional brethren, and always carried weight.
In manner sometimes a little brusque, he was one of
the most kind-hearted of men, and few teachers have
enjoyed greater popularity with medical students,
a class quick to recognise genuine merits. Socially
he was a genial host, and excellent companion, and
his unfailing good temper carried him serenely through
life, and enabled him to meet a trying and prolonged
illness with fortitude.

His knowledge of anatomy was sound and accurate.

and for many years he filled the post of University
Anatomist in the School of Physic, T.C.D., where he
conscientiously trained a large number of students.

The writer of this note well remembers the first
" demonstration ” he received from Dr. Bennett,
who unfolded to him the mysteries of the inguinal
region, and the perplexing layers of fascia which adorn
that region. He was devoted to his work in Sir
Peter Dun's Hospital, and it is largely due to his
unsparing attention and zeal that the surgical reputa¬
tion of the Hospital was securely established at the
critical time—now many years ago—when it was
transformed from a purely medical hospital to a fully
equipped Medico-Chirurgical Hospital.

SPECIAL ARTICLE.

IMPERIAL CANCER RESEARCH FUND.

The annual meeting of the general committee of the
Imperial Cancer Research Fund was held at Marlbor-
borough House, on Monday, July 1st, H.R.H. the Prince
of Wales in the chair. Among those present were Sir
William Church, Sir Richard Douglas Powell, Mr.
Henry Morris, Sir Henry R. Swanzy, Sir Henry Howse,
Sir John McFadyean, Dr. John Tatbam, Dr. Rose
Bradford, Mr. H. T. Butlin.

The annual report of the Executive Committee de¬
scribed the proceedings of the fifth meeting of the
General Committee, held on July 25th, 1906, under the
presidency of Lord Strathcona. The General Superin¬
tendent took part in a discussion on cancer at the
annual meeting of the British Medical Association, held
in Toronto, last August. He subsequently proceeded
to the United States, and visited many of the important
laboratories, including the Rockefeller Institute, in
which cancer investigation is being carried out.

In September Dr. Bashford also attended, as the
representative of the Imperial Cancer Research, the
German International Cancer Congress, held in Heidel¬
berg and Frankfort, of which he was elected one of the
Honorary Presidents. Whilst in Germany he was able
to obtain a valuable interchange of views with Professor
Ehrlich and others engaged in the investigations on
cancer.

Since that meeting a communication had been re¬
ceived from some of the German representatives pro¬
posing the establishment of a permanent international
conference on cancer, and forwarding an outline scheme
of organisation, with its headquarters in Berlin. The
General Superintendent was asked to organise a British
branch and to become one of the representatives, but
he was of opinion that at present little advantage was
to be gained by such a conference.

The General Superintendent and staff had been con¬
tinuously engaged in investigation, and a considerable
number of new facts had been ascertained. They were
not, however, yet ready for publication in the form of a
third scientific report. The progress of the investiga¬
tions was recorded in the papers from the laboratory'.

A grant had been made to Mr. W. Sampson Handley
towards the expenses of an investigation into the mode
of growth and dissemination of cancer of the stomach.
The Government of Cape Colony had forwarded an
important report of a Committee of the House of
Assembly appointed to investigate certain reputed
cancer cures, principally consisting of herbal remedies.
Dr.’Sidney Martin, F.R’.S., had been re-elected a mem¬
ber of the Executive Committee by the Royal College
of Physicians. Sir John Tweedy and Mr. Edmund
Owen had been elected by the Council of the Royal
College of Surgeons to fill the vacancies on the Com¬
mittee occasioned by the expiration of Mr. John Lang-
don’s period of office on the council, and by Mr. Henry
Morris becoming ex-officio a member of the Committee,
in virtue of his appointment as President of the Royal
College of Surgeons, whilst Mr. Henry T. Butlin was
also re-elected a member of the Committee by that
College. Dr. Rose Bradford was again nominated by
the Royal Society as their representative on the Com¬
mittee, The Committee once more expressed its appre¬
ciation of valuable services rendered by the Foreign,

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46 Thi Medical Press.

MEDICAL NEWS IN BRIEF.

July io, 1907

Colonial, and India Offices in obtaining and forwarding
information relating to cancer throughout the Empire.

In December the Committee received from one of
the vice-presidents, Mr. H. L. BischofFsheim, an inti¬
mation that he intended to give a donation of £40/000
in commemoration of his golden wedding. This muni¬
ficent gift, which was warmly acknowledged by the
Committee, was particularly gratifying as evidence of
the confidence felt by the donor in the efforts being
made by systematic scientific investigation to arrive
at a more exact knowledge of the nature, causes and
treatment of cancer.

The General Superintendent’s Report was then read.

Honorary Treasurer’s Report.

The report of the Honorary Treasurer for the year
ending June 24th, 1907, stated that in August, 1906,
the Fund was increased by a donation of £1,000 re¬
ceived through His Royal Highness the President from
an anonymous donor. This was followed in December
last by the munificent donation of £40,000 from Mr.
and Mrs. Bischoffsheim on the occasion of their golden
wedding.

The amount in donations and subscriptions received
during the year, apart from the Bischoffsheim Fund,
was £3,515 ns. This compared favourably with the
amount (£2,315 2s.) received during the year 1905-6.
Special reference was made to the gift of £600 received
through Sir Samuel Wilks, Bart., F.R.S., to the gift,
of £500 from Miss Black, to the sum of £120 from
the Government of Hong Kong, which represents the
subscription of £30 per annum for the years 1904-7
inclusive which was obtained through the good offices
of the Governor, Sir Henry A. Blake, G.C.M.G. In,
addition to several fresh donors of varying sums, eight
new annual subscribers had been added to the list this
year, one of whom was the Worshipful Company of
Carpenters. This was the first City company to become
an annual subscriber. The Worshipful Company of
Pewterers had, however, given a third donation. At
the present time there w;re eighteen annual sub¬
scribers. The Fund was still deficient to the extent of
nearly £13,000 on the estimated amount required -to
provide a sufficient and permanent income from in¬
vested capital.

Sir William Church moved the adoption of the
report.

Sir Henry R. Swanzy, in seconding the motion, said
the thanks of all were due to Dr. Bashford and his
assistants for the sustained, well-directed and skilful
efforts made by them to solve the many problems sur¬
rounding the subject of cancer. Substantial progress
was being made, and they believed that nothing which
scientific skill could devise was being omitted to solve
this problem.

The resolution was carried unanimously.

Sir Julius Wernher proposed a vote of thanks to the
Chairman and members of the Executive Committee,
the Sub-committees, the Honorary Treasurer, the
Secretary, Auditor, and others who had assisted in
the work of the Fund during the past year. It was
sometimes said that the work of the Fund was, perhaps,
slow ; but very few people recognised the nature of this
scientific difficulties which had to be surmounted.

Mr. H. L. Florence seconded the motion, which was
unanimously agreed to.

The Bischoffsheim Donation.

Mr. Henry Morris next moved :—“ That the General
Committee desire to place on record their deep sense oi
gratitude to Mr. and Mrs. Bischoffsheim for their
recent munificent gift of £40,000, which, together with
Mr. Bischoffsheim's original donation of £5,000, will
do so much towards placing the Imperial Cancer
Research Fund on a secure financial basis.”

Sir Charles Morrison Bell seconded the motion, which
was passed unanimously.

On the motion of Dr. Rose Bradford, seconded by
Mr. Ludwig Neumann, Mr. Watson Cheyne was re¬
elected a representative of the General Committee
on the Executive Committee; and on the motion of
Mr. Butlin. seconded by Sir John McFadyean, Sir
John Tweedy was elected a member of the General
Committee.

Sir R. Douglas Powell proposed a vote of thanks to
the Prince of Wales for presiding.

Mr. Edmund Owen seconded the motion. |

The motion was passed with applause.

The Prince of Wales, in reply, said it was a great
pleasure to him to have been able to preside at the
meeting. They had every reason to be satisfied with
the growing confidence of the public in the work of
the Fund. The broad lines of inquiry undertaken by
the Imperial Cancer Research Fund, had, they felt
certain, influenced the whole nature of investigation at
home and abroad. It was recognised that the work
was conceived and carried out in a liberal spirit; that
whatever facts were ascertained were immediately
made known to every one; that the material was
freely placed at the disposal of all qualified to use it to
good advantage ; that their staff was not working for
its own ends, but with a whole-hearted desire to help
on a solution of the problem. Another tribute to the
success of the efforts of the Fund was the number of
applications from skilled investigators to take part in
the work. Thanks to the liberality of the Royal
Colleges, further accommodation had been placed at
the disposal of the General Superintendent, and he had.
therefore, been enabled to add materially to the staff.

His Royal Highness concluded by expressing his
thanks to the chairman and members of the various
committees, Dr. Bashford, and the officers of the Fund,
for the valuable and untiring services which they had
given during the past year to the work of the Fund.

Medical News in Brief.

Rsjral College of Sargeoae. England.—Ann oel Election to

the Connell: a Record Poll.

The annual meeting of Fellows of the Royal College
of Surgeons of England took place last Thursday for
the purpose of electing four Fellows into the Council
of the College. The President, Mr. Henry Morris,
occupied the chair, and appointed Mr. Willmott Evans
and Mr. T. Crisp English, who kindly offered their
services, to act as scrutineers for the occasion. After
the secretary had read the list of candidates, the Pre¬
sident declared the poll open for two hours, for the
convenience of those Fellows desiring to vote in person.
Only fourteen Fellows, however, voted in this manner,
no fewer than 878 Fellows recording their votes by
post. The poll proved to be a record one. At the
conclusion of the counting the President declared the
result of the poll to be as follows :—Mr. C. J. Symonds,
Guy’s Hospital, 452 (26 plumpers) ; Mr. Wm. Bruce
Clarke, St. Bartholomew’s Hospital, 413 (52 plumpers) ;
Mr. C. Mansell Moullin, London Hospital, 403 (6
plumpers); Mr. Frederic Eve, London Hospital, 388
(3 plumpers); Mr. H. W - Page, St. Mary's Hospital.
349 (11 plumpers); Mr. W. D. Spanton, Hanley.
Staffs, 348 (34 plumpers) ; and Mr. Charles

Higgens, Guy’s Hospital, 234 (10 plumpers). The
President then declared Messrs. Symonds, Clarke.
Moullin, and Eve duly elected members of the Council.
The scrutineers found three balloting-papers to be
invalid, and three arrived too late.

Society el Physicians and Sargeotu el the Society e«

Apothecaries. London.

The first dinner of this newly-formed society was
held in London last week at the Restaurant Frascati,
to celebrate the obtaining of the Act of Parliament
which received the sanction of his Majesty the King
on July 4, 1907, the day of the banquet. This act
confers the title of “ Licentiate in Medicine and.
Surgery” on its members, since June, 1887. There
were present the President, Dr. Rivers Willson and
Lady Willson, the Ex-president, Dr. Percy Lodge,
the Vice-president, Dr. McComer, J.P.

Dr. Parker Young, the Master of the Society of
Apothecaries, the Senior Warden, Dr. G. Willes, and
the Junior Warden, Dr. F. G. Brown, were the guests
of the evening. The representatives of the Society of
Apothecaries present were Sir Hugh Beevor, Bart., Dr.

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July io. 1907.

MEDICAL NEWS IN BRIEF.

Thi Medical Pusn. 47

Gerald Dalton (the Hon. Treasurer). and Dr. S. H. Green,
Dr. Marsh, Mr. L. Darlington, Dr. Horace Saunders
and Mrs. Saunders, Dr. George Brown (late of the
General Medical Council), and Mr. M. Upton (Clerk to
the Society), and many others.

After the Royal toasts had been duly honoured,
the President gave the toast, “The Association of
Physicians and Surgeons,” introducing in his remarks
a resume of the work done in the obtaining of this Act
of Parliament. The next toast was “ The Master
Wardens and Court of Assistants of the Apothecaries
Society,” who had influentially furthered the move¬
ment. which was duly honoured and responded to
by Dr. Parker Young (the Master). Dr. Geo. Brown
gave the toast of “The General Medical Council, and
its Reform.” Sir Hugh Beevor responding. Then
followed “ The President and Officers,” proposed by
Dr. G. W. B. Marsh, who alluded to the founding of the
Society some years ago by Dr. Percy Lodge. Dr.
Rivers Willson responded, and also made allusion to
the good work done by Dr. Lodge, and said that that
gentleman had according to the rule vacated the
Presidentship on his becoming a Fellow of the Royal
College of Surgeons. Dr. Lodge also responded, and
said that some six years ago he had the honour of being
received by the then Master and Wardens of that
Society on these matters, and received much support
from Dr. Parker Young and the Court of Assistants.
He congratulated Dr. R. Willson, the President, on
the good work he had done in his years of office, and
that the Society of Physicians and Surgeons had
been able to attain so much of the object they had in
view. M. and Madame Cokhinis and their son gave
a very excellent musical programme during the evening,
which was much appreciated.

Rayal Army Medical Carps.

At a recent inspection by Col. A. T. Sloggett,
C.M.G.. Principal Medical Officer of the London
District, of the Companies as well as the bearer com¬
panies of the 1st, 2nd, and 3rd London Infantry
Brigades, numbering about 400, the column was ac¬
companied by an ambulance and transport train of
eight wagons, a cyclist section, and a couple of
ambulance dogs trained by Major Richardson, who
was present with the corps, to which he has been
attached. A field ambulance was pitched, and a
demonstration was given of carrying patients in
cacolets and on horse-back. The inspection was
attended by the War Minister, Mr; Haldane, who
showed great interest in the programme of work
carried out by the troops. Among the other officers
present was Col. J. Cantlie, F.R.C.S., the honorary
colonel and organiser of the corps.

gtjral Colter* at Surgeon*, England.—Vacant BxamlneraMp,

The period of office of Mr. C. H. Golding-Bird on
the Court of Examiners of the Royal College having
expired, the Council will proceed to elect a successor
on tie 25th instant, Mr. Golding-Bird having notified
his intention not to seek re-election. A vacancy
on the Board of Examiners in Dental Surgery is also
announced ; Mr. B. Pateman, the present examiner,
whose period expires, is eligible for re-election, and
will offer himself for the post. Applications for either
appointment must be sent in to the Secretary, S. Forrest
Cowell, Esq., on or before the 17th instant.

St. Saha's Hospital for DUoasoa of tbs Akta, Leicester
Square.

The annual competition for the Chesterfield Silver
Medal (which was instituted in 1895, by the Earl of
Chesterfield. President of the Hospital) took place on
May 24th, and the Medal has been awarded to
E. J. D. Mitchell, M.A., M.B., B.C., for proficiency in
Dermatology.

Epson College.

The annual general meeting of the governors of
Epsom College took place last week at 97 Soho Square,
London, W., under the chairmanship of Mr. Henry
Morris (President of the Royal College of Surgeons).
Among those present were Sir R. Douglas Powell,
Sir William S. Church, and Sir C. Holman. The chair¬

man announced the foundation of the Robert Arm¬
strong scholarship of £60 a year for classics, and of the
R. R. Cheyne annuity for the daughters of medical
men who are Protestants. Three pensioners and seven
foundation scholars were elected, and at a meeting of
the council, held immediately after, two pensioners in
addition to the foregoing were admitted, vacancies
having arisen.

PASS LIST.

Ualvwvlty of London.

The following candidates have passed the M.B.,
B.S. Examination :—

With Honours .—Harold Garfield Bennett, St.
Thomas’s Hosp. (a) ; Gerald Tyler Burke, St. Barth.
Hosp. (c); Bertram Walter Cherrett, St. Barth.
Hosp. (e) ; John Henry Farbstein, University Coll. ( d );
John Athelstan Braxton Hicks, Westminster Hosp. ( h) ;
William Henry Miller, Guy’s Hosp. (d); Henry John
Nightingale, St. Thomas’s Hosp. (a, b, c, d, University
Medal) ; Alfred Chas. Foster Turner, St. Thomas’s
Hosp. (6.); Charles Wilfred Vining, St. Mary's Hosp. («).
(a) Distinguished in Medicine, (b) Distinguished in
Pathology, (c) Distinguished in Forensic Medicine
and Hygiene. ( d) Distinguished in Surgery. ( e) Dis¬
tinguished in Midwifery and Diseases of Women.

Ordinary Pass. —Godfrey F. E. Allison, Charles J.
Armstrong-Dash, John S. Avery, Alfred Ball, Alec
Barber, Tom Bates, Ella Beales, Sylvia R. M. Black-
stone, Mary A. Blair, John F. Broughton, Stanley W. F.
Colyer, Eustace J. C. Dicks, Kenelm H. Digby, Allan B.
Feamley, John Ferguion, Kenneth M. Gibbins, Elliott
T. Glenny, Samuel 1 * Graham, Arthur D. Griffith,
Leopoldine W. D. Griffiths, Sidney W. Grimwade,
George Hamilton, Hoi ice B. Hill, Frank N. S. Hitch¬
cock, Frank P. Hugh's, Gwilym G. James, Sidney
H. J. Kilroe, Herbert S. Knight, Janet Lane-Cla vpon,
D.Sc., Alexander Manuel, Marian Mayfield, Emily H.
Morris, Frederic M. Neild, Geoffrey E. Oates, Catherine
Payne, August F. Perl, Arthur J. S. Pinchin, John M.
Plews, David Ranken, Frank D. Roberts, Cecil F.
Robertson, Francis W. Schofield, Henry J. Smith,
Ronald E. Todd, James A. Torrens, Stuart W. J.
Twigg, Joseph Unsworth, Thomas W. Wade, Norman
H. Walker, Thomas E. Walker, Robert J. Waugh,
David Wilson, Alfred W. G. Woodforde, Carl E. Zundel.

B.S. Examination (for students who graduated in
Medicine in or before May, 1904).—John Acomb,
Dora E. L. Bunting, Edward C. B. Ibotson, Rees
Phillips, Frank Tratman, M.D., Hilda K. Whitting-
ham.

Trinity Colter*, Dublin.

The following candidates passed the Final Medical
Examination (Trinity Term), Part II., Surgery
William Pearson, Robert E. Wright, Richard G. S.
Gregg, Allman J. Powell (passed on High Marks) ;
William E. M. Armstrong, Frederick Stevenson, Henry
de C. Dillon, Oliver St. J. Gogarty, Thomas B. W.
MacQuaide, Reginald Holmes, Wallace D. Mitchell,
James C. C. Hogan, Madeleine S. Baker, Charles H.
O’Rorke, James E. M’Farlane, Joseph C. Ridgway,
William A. R. Spong.

Final Examination. — Part III. — Midwifery. —Frank
R. Seymour, Henry de C. Dillon and William A. R.
Spong (equal), William E. M. Armstrong, Robert de
C. Wheeler, Arthur E. Knapp, Thomas P. Dowley
John H. Waterhouse, Alfred H. Smith.

University of Birminfftuun.

The following is a list of the successful candidates in
the Faculty of Medicine at the examinations held
June, 1907 :—

Degree of Doctor of Medicine. —Leonard George
Joseph Mackey.

Degrees of Bachelor of Medicine and Bachelor of
Surgery for Past Students of Birmingham Medical
School .—William Frederick Ewart Ashton. Under
Ordinary Regulations .—Herbert Charles Horace Bracey,
*f James Fenton, Philip James Mason, Nevill Coghill
Penrose, Arthur Addison Sanders, Arthur John
Smith, Rupert Wesley Thompson, Herbert Henry
Warren. (*Queen’s Scholarship. J Ingleby Scholar¬
ship.)

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48 The Medical Press.

WEEKLY SUMMARY.

July jo, 1907

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT PATHOLOGICAL LITERATURE.

Mode of Spread of the Meningococcal. —Fraser and
Comrie ( Scottish Medical and Surgical Journal, July,
1907) report the result of their inquiry into the mode
of spread of infection during the recent outbreak of
cerebro-spinal meningitis at Leith. They are led to
agree with the conclusion of Ludwig Jehle that
although children most commonly suffer, they are
not to any extent carriers of the disease. Jehle. from
his investigations during the epidemics in Silesia and
in the Rhine coal-fields, suggested that the real
carriers of infection in those provinces were millers
who, bringing the organisms from an infected pit,

1 >assed it on to their children. Substituting dock-
abourers for miners, and ship-holds for coal-mines,
Fraser and Comrie hold similar views in regard to the
recent epidemics at Leith and other sea-port towns
in the kingdom. The question has to be decided,
however, of the manner in which the meningococcus
can be carried without infecting the carrier. Fraser
and Comrie examined the naso-pharynx in 13 cases
of the disease, and in 69 cases of intimate contact.
The meningococcus was present in 2 of the 13 cases
(15 per cent.), and in 10 of the 69 cases (14 per cent.).
Of the 69 cases, 15 were fathers of affected patient*,
the remaining 54 being mothers, brothers, sisters, and
other intimate associates. Of the 10 contacts in
whom the meningococcus was found, 5 were fathers of
patients. Thus, while the organism was found in
33 per cent, of the fathers, among others contacts in
as close intercourse it was found in only 9 per cent.
The fathers appeared, therefore, to be especially
prone to have the meningococcus in the naso-pharynx,
although they did not themselves contract the disease.
Of the 15 fathers examined, 5 were employed in over¬
hauling the same ship; the meningococcus was
recovered from the air in the engine-room. In several
other fathers the naso-pharynx was found to contain
gram-negative diplococci, but owing to the excess of
saprophytic organisms isolation was impossible. In
the case of 23 controls, who had no connection with the
disease, the naso-pharynx was examined for the
meningococcus with negative results. Fraser and
Co.nrie summarise their conclusions:—(1) That
dusty, ill-ventilated atmospheres, which provide
conditions favourable to the growth of the meningo¬
coccus and to the occurrence of naso-pharyngeal
catarrh, are often associated with the dissemination
of epidemic cerebro-spinal meningitis. (2) The high
comparative proportion of fathers, whose naso¬
pharynx was found to contain the meningococcus,
suggests that they are the carriers of disease to their
children. (3) The chief incidence of the disease in
the Leith epidemic was among children of the lower
classes, a point in favour of naso-pharyngeal in¬
fection. (4) Infection of the naso-pharynx is an
important factor in spreading the disease. (5) It is
advisable to isolate all contacts, and to carry out a
bacterioscopic examination of the nose and naso¬
pharynx. It should be added that Fraser and Comrie
relied for the bacteriological diagnosis of the organism
on the characteristics described by Gordon in his
recent report to the Local Government Board. R.

Muscular Tuberculosis. —Kirmisson ( Bulletin de
l’Acadtmie de Mtdecinc, No. 6, 1907) and Cornil (id.,
No. 8, 1907) report cases of this rare condition. In
Kirmisson’s case, a child, set. 10, presented numerous
fusiform nodules scattered through the muscles of
both lower limbs. The glandular system was also
widely affected. The nodules were found on micro¬
scopic examination to consist of masses of epithelioid
and giant cells, embedded in fibrous capsules. Bac¬
teriological examination by smear, by culture, and by

inoculation, was entirely negative. In Cornil’s first
case, a nodule, of the sire of a hazel-nut appeared
in the masseter muscle; microscopically, it was a.
conglomerate tubercle, showing typical structure,
with commencing caseation. His other case was of
more usual type—cold abscess in the muscles of the
thigh, unconnected with any disease of bone. R.

The Bacteriology of Cerebro-Splnal Meningitis.

—In view of the very varied descriptions of the
meningococcus which still find place in the text-books,
it is important that the careful observations of recent
investigators should be on record. We, therefore,
call attention to a paper by Symmers and Wilson on
the cultivation of the meningococcus in the Belfast
epidemic ( British Medical Journal, June 22, 1907).
They examined 7 5 cases, either postmortem, or by
lumbar puncture during life. In 52 of these, the
meningococcus was separated from the spinal fluid.
They examined the blood of 15 patients during life,
and found the organism in 3 cases. They identify
the organism by the following characteristics : (1) The
colonies on suitable agar (agar with ascitic fluid and
peptone) are smooth, circular discs, grey in colour,
translucent, closely resembling colonies of B. coli
communis. The colonies are, when first discovered,
always discrete. (2) The colonies consist of cocci in¬
distinguishable in size and shape from gonococci. In
the older cultures many organisms, spherical in shape,
and closely resembling staphylococci, are found.
(3) The organism is negative to Gram’s stain, although,
in every culture a few cocci are found which retain the
stain with considerable persistence. (4) The organism
does not grow at 20° to 22 0 C. (5) Media containing
dextrose and maltose are fermented by the growth,
acid being produced, whereas galactose and saccharose
remain unchanged. The authors find that the meningo¬
coccus grows readily, but during the earlier generations
in vitro sub-cultures should be made every day.

R.

Some New Facts abont Agglutination. —Miss
Fisher (Journal of Medical Research, May, 1907) pub¬
lishes the results of a careful study of agglutination
with special reference to the agglutinins of the various
types of dysentery organisms. Some of her conclu¬
sions have a general bearing. (1) The use of more
than one organism in animal immunisation tends to
reduce the agglutinins produced for each of the in¬
oculating organisms. Miss Fisher suggests that this
is due either to over-stimulation of the cell due to the
action of so many organisms, or to the likelihood that
a cell is capable of producing only a certain number
of agglutinins. When two or more organisms are
used, the number of agglutinins being limited must
be divided between these organisms, resulting in a.
decrease in the agglutination of each. (2) The simul¬
taneous inoculation of various types of organism pro¬
duces specific agglutinins for each organism, but not
in as great quantity as when each organism is injected
separately. (3) The agglutination reaction has a very
limited value in the differentiation of types of intes¬
tinal organism, and has none in distinguishing the
various dysentery bacilli. R.

Haemolytic Properties of Organ and Tnmonr Ex¬
tracts. —Weil (Journal of Medical Research, May,
1907) attempts to discover the factors giving rise to
the anemia occurring in cases of malignant disease.
He first examined the haemolytic properties of extracts
of organs. In this respect he concludes : (1) Extracts
of normal organs (liver and kidney) cause haemolysis
of the red cells of the same species of animal, or even

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WEEKLY SUMMARY.

The Medical Pekss. 49

of the same animal, but the haemolytic power varies
considerably, or may be altogether absent. (2) If
the organ be thoroughly freed from blood, the hemo¬
lytic power is greatly diminished, or altogether lost.

(3) Addition of entire blood, or, separately, of leu¬

cocytes and serum, to the bloodless organ extracts,
diminishes their hemolytic activity, but addition of
red blood cell extract increases the activity of blood¬
less organ extracts. (4) It is the red blood cell extract
plus the hemolytic principle of the organ extract which
causes hemolysis. With regard to tumours, Weil
concludes: (1) Tumours differ greatly in their

hemolytic activity, according as they are necrotic
or non-necrotic. (2) Non-necrotic tumours are much
less auto-hemolytic than are necrotic tumours. (3)
The hemolytic activity of non-necrotic tumours can
be increased by addition of red blood cell extract.

(4) The hemolytic activity of necrotic tumours is not

increased by the addition of red blood cell extract.
<5) The anemias of malignant tumours are probably
due in part to the hemolytic and toxic action of the
products of necrosis. R.

A Theory of Colour Vision. —Pretorius ( Dublin
Journal of Medical Science, April, 1907) puts forward
a theory of colour vision which deserves considera¬
tion. He regards the cones of the retina as made up
of a series of segments, each of which has the property
of perceiving its particular colour, the visual sensation
being set up by molecular vibration. When all the
segments are equally stimulated, white light is per¬
ceived. In support of this, Pretorius points out that
man y of the white rays falling on the lens are dispersed,
and that, therefore, the different spectral rays must
strike the cone at different segments of its length.
We see the light as white, however, in spite of its dis¬
persion, and this synthesis is best explained by his
hypothesis. Pretorius adduces many facts which are
consistent with his theory but he admits the absence
of the possibility of experimental proof. R.

Atypical Leukaemia. — Rychlik ( Zenhalblatt fur
Inn. Med. No. 22, 1907., p. 562) writes on this
subject, and describes the case of a youth, set. 18,
who for two months had suffered from a splenic
tumour, and who, during nine months was jaundiced,
and had pain in the region of the gall bladder, though
with normally coloured stools. Haemic cardiac mur¬
murs were present, but there was no glandular enlarge¬
ment and no pain over the long bones. The blood
examination gave 3,624,000 red corpuscles; 15,600
white cells ; and 50 per cent, haemoglobin. The
plasma was coloured yellow with bilirubin, and some
normoblasts and myelocytes were detected. The
diagnosis made was that of Banti’s disease in the
second stage, and a splenectomy was performed.
Six hours after operation the red cells numbered
6,050,000 per ccm. ; the leucocytes 31,280 per ccm. ;
and the haemoglobin was 65 per cent. Twenty-four
hours after the operation the numbers were Red
cells 6,104,000; white cells 25,600; haemoglobin
65 per cent. The patient died shortly afterwards,
and the autcmsy showed general hypertrophy of the
mesenteric glands, and of the intestinal lymphatic
tissues ; a lymphoid state of the bone-marrow;
partial myeloid alteration of the spleen, and islets
of myeloid cells in the kidneys. The writer criticises
the latest views of Banti’s disease, and identifies the
condition with Maixners’ haemorrhagic cirrhosis of the
liver. He regards the leukaemias as quite distinct
from infectious granulomata, and more inthe nature
of specific re-actions to definite irritants.

M.

Contraction of the Stomach in Polyserositis.—

Scery ( Archiv . fur Verdaungskranhh, Bd. xivi. heft 1),
as the result of a microscopical and macroscopical
examination of a case of the above, comes to the
following conclusions :—Simple inflammatory con¬
traction of the stomach is a disease sui generis. The
cause in most observed cases has been chronic hyper¬
emia in diseases of the heart. It consists essentially

of a chronic inflammatory hypertrophy of the con¬
nective tissue in the serous and submucous coats. In
the sclerosed tissue the blood vessels and lymphatics
become narrowed, and further one often finds a
chronic inflammation of the gastric glands, with
increase of the connective tissue between them. A
similar fibrous hyperplasia may occur in cases of
chronic inflammation, such as is set up by alcohol
or syphilis. M.

Diabetic Llpcmia. —Klemperer and Umber (Zeitsche.
f. Klin. Med., Bd. 61, L. 145) state that lipaemia is
not characteristic of severe diabetes or of diabetic
coma alone, but is to be found in about one half of
all cases. It depends in part upon a real increase of
the cholesterin and lecithin, and only in some cases
to an actual increase in the fat of the blood. In two
cases examined, for example, the amount of fat
present was from .4 to .6 per cent., which is hardly
up to the normal; whilst the cholesterin percentage
was 3 to 4 times normal, and in one case more than
10 times normal. Owing to the fact that the sub¬
cutaneous and mesenteric fat is not rich in cholesterin,
this condition cannot be explained as being due to a
simple fat transport from one part to another. The
authors think that it must be due to the excessive
destruction of fatty substances in nerve tissue, or to
the breaking down of proteid-containing tissues.

M.

The Influence of Coloured Lights upon Blood-
pressure. —Spiston has carried out a series of experi¬
ments on the above subject. They were made for
the most part upon young men of from 23 to 25 years
of age and the exposures took place either after the
individual had been for some time in diffuse daylight
or in complete darkness. The following were the
more important results :—(1 / The blood pressure
sinks progressively under the influence of red and
green light. This fall takes place rapidly, and soon
reaches a minimum at which it remains almost
stationary. (2) The blood pressure under the in¬
fluence of blue light at first rises, but only slightly,
and'-then falls, but not to so low a level as with green
or red light. (3) On returning to daylight after
exposure to coloured lights, the blood pressure rises
and reaches the normal level in about ten minutes.

(4) On going into the dark after exposure to daylight
the pressure sinks slightly, but not to so low a level
as with any of the coloured lights mentioned above.

(5) Red and green light following blue light produces

a fall in pressure, while blue light after red or green
causes a rise in blood pressure. jyj.

King Edward's Hospital Fond.

Amongst the latest contributions received at the
Bank of England for King Edward’s Hospital Fund
for London arc the following :—Annual subscriptions :
Messrs. Coutts and Co., ^250; Messrs. Glvn, Mills,
Currie, and Co., £250 ; Mr. Cecil H. Olivorson, ^250 ;
the Duke of Westminster, /100; Sir H. Seymour
King, M.P., Is o. Annual subscription to additional
permanent income fund : Viscount Iveagh, K.P., -5500.
North-East London Clinical Society.

The annual meeting of this popular society was
held on July 4th. the President, Dr. Arthur E. Giles,
being in the Chair. The following officers were
elected for the year 1907-8 :—President, Dr. M. C.
Comer. Hon. Treasurer, Mr. Herbert W. Carson.
Hon. Librarian, Dr. A. J. Whiting. Hon. Secretaries,
Drs. G. P. Chappel and G. R. Plaister. After the
report of the Council and the balance-sheet for the
past session had been adopted, the meeting resolved
itself into a social gathering, which was well attended
by the members, including ladies.

The new City of Lpndon Lying-in Hospital, City
Road, was opened on'july 1 st by Princess Christian.
Her Royal Highness was .received by the consulting
physician (Dr. C. Godson), the consulting surgeon
(Mr. J. Langton), and other members of the reception
committee, by whom she was escorted over part of
\ the new buildings.

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50 Tins Medical Press. NOTICES TO CORRES PONDENTS.

July iq, 1907

NOTICES TO
CORRESPONDENTS, ffc.

|0*OouurOiiDiiiTf requiring t reply In this ootaunn ere particu¬
larly requested to make me of e Dittinetivt Signature or Initial, mod
to avoid the praetioe ol signing themselves “ Boeder," “ Subscriber,"
“Old Subscriber," So. Mach confusion will be spared by attention to
this rule.

BsrKlMTS.—Hep tints of artloles appearing In this Journal can be had
at a reduoed rate, providing authors give notice to the Publisher or
Printer before the type has been distributed. This should be dons when
returning proofs.

Original Articles or Lbttim Intended for publication should
be written on one side of the paper only and must be authenticated
with the name and address of the writer, not necessary for publica¬
tion but as evidence of Identity.

A. M. 8 .—The quotation you ask for eomes from the preface
of Stevenson's poems. It runs as follows" There are men, and
classes of men, who stand above the common herd; the soldier,
the sailor, and the shepherd not (infrequently; the artist rarely,
rarer still the clergyman; the physician almost as a rule. He
is the flower (such as it is) of our civilisation, and when that
stage of man is done with, and only remembered to be marvelled
at In history, he will be thought to have shared as little as any
in the defects of the period, and most notably exhibited the
virtues of the race. Generosity he has, such as it is possible to
those who practise an art, never to those who drive a trade;
discretion tested by a hundred secrets; tact tried in a thousand
embarrassments; and what are more important, Heraolean cheer¬
fulness and courage. 80 it is that be brings air and cheer into
the sickroom, and often enough, though not so often as he
wishes, brings healing.”

Mr. Thorne Baker's paper is unavoidably held over until
our next.

ACCIDENT INSURANCE TO MEDICAL MEN.

A corresponent asks If subscribers to this journal are Insured
against accident and death. Our reply is that it Is not necessary
for a journal of the standing of The Medical Press arc
Circular to attract subscribers by these methods, os
every medical man who uses an ordinary sixpenny or
shilling diary, is Insured against accident and death
without ooat to himself If he will only take the trouble
to read and carry out the instructions of the coupon whioh is to
be found in almost every diary published. Thus, if the coupon
be filled in, and the possessor be killed in a railway acident,
his representatives can claim £1,000. If killed by tramway,
omnibus, or cab accident, £500, while, in the case of non-fatal
accidents, smaller sums are paid, according to injuries, and
weekly allowances in other cases.

Compensation. —Our correspondent can insure bis oosobman.
as well as his horse and carriage, in "The Imperial Accident
and Live Stock Insurance Company,” 17, Pall Mall, London

O. F. n. (Glasgow) —The new work on anatomy by Prof. \ M.
Buchanan would beBt answer your purpose, as it embraces both
systematic and practical teaching, and is particularly well
illustrated.

CjHgOH.—The question is really one for a lawyer, but we
may refer you to the Habitual Drunkards Act, 1879. which allows
a separation to be applied for by a woman whose husband i 9 an
habitual drunkard. In oase of a husband, a separation oouid be
obtained by the Licensing Act, 1902, which included drunkenness
as one of the causes for separation under the Summary Juris¬
diction (Married Women's) Act, 1895.

JReetinaB of th t gtorieiits, %tctox to, &c.

Wednesday, July 10th.

Dermatological Society or London (11, Chandos Street,
Cavendish Square, W.).—5.15 p.m.: Meeting.

Medical Graduates' College and Polyclinic (22. Chenics
Street, W.C.).—t p.m.: Mr. H. L. Bernard: Clinique. (Surgioal.)
5.15 p.m.: Lecture:—Dr. W. Langdon Brown: Sudden Death.

North-East London Post-Graduate College (Prince of

Wales’s General Hospital, Tottenham, N.).—Cliniquea2.30
p.m. : Skin (Dr. Meacnen), Eye (Mr. Brooks), Medical Out¬
patient (Dr. Whipham).

Thursday, July 11th.

British Gyn.kcolooical 8ociett (20, Hanover Square, W.).—
8 p.m.: Exhibition of Specimens.

Medical Graduates' College and Polyclinic (22. Chenies
Street, W.C.).—4 p.m.: Mr. Hutchinson: Clinique. (Surgical).

Nobth-East London Post-Graduate Colleoe (Prince of

Wales'! General Hospital, Tottenham, N.) — 2.30 p.m.: Gynaeco¬
logical Operations (l)r. Giles). Cliniques :—Medical Out-patient
(Dr. Whiting), Surgical Out-patient (Mr. Carson). 3 p.m.:
Medioal In-patient (Dr. Chappel).

Hospital for 8icx Children (Great Ormond Street, W.C.)—
4 p.m.: Lecture:—Dr. Thurufleld: The Diagnosis, Prognosis, and
Treatment of Pleural Effusions in Children.

Saturday, July 13th.

Incorporated Sociktt oe Medical Opticf-RS or Health (Town
Hall, Colchester).—11.15 am.: Paper:—Dr. W. G. Savage (Pre¬
sident of the Eastern Counties Branch): Recent Work upon the
Bacteriology of Typhoid Fever in its Relationship to Preventive
Measures.

Medical Graduates’ Colleoe. and Polyclinic (22, Chenica
Street, W.C.).—4 p.m.: Mr. W. Dodd: Clinique. (Eye.)

North-East London Post-Graduate Colleoe (Prince of
Wales's General Hospital, Tottenham, N.V—9 30 a.m.: Clinique :
—Surgical Out-patient (Mr. H. Evans). 2.30 p.m. : Surgical
Operations (Mr. Edmunds). CliniquesMedical Out-patient
(Dr. Auld), Eye (Mr. Brooks). 3 p.m.: Medical In-patient (Dr.
Leslie).

UaamatB.

Ayr District Asylum.—Junior Assistant Physician. 8 *Ury.
£120 per annum, with board, apartments and laundry.
Applications to the Medical Superintendent.

West Suffolk General Hospital, Bury St. Edmunds.—House Sur¬
geon. Salary. £100 per annum, with board and lodging.
Application! to the Secretary.

Egypt.—Sub-Inspector of Ophthalmic Hospitals. Salary, £500
per annum, with two months’ salary in lieu of travelling
expense# to and from England. Applications to A . r.
MacCallan, Esq., 32 Bedford Gardens, Kensington, W.

Stockton and Thornaby Hospital, Stockton-on-Tees.—House Sur¬
geon. Salary, £180 per annum, with residenoe, board and
washing. Applications to H. 0. Sanderson, Secretary, Ex¬
change Office*, Stockton-on-Tees.

Monmouthshire Asylum, Abergavenny.—Senior Assistant Medical
Officer. Salary, £250 per annum, with board, furnished
apartments, washing and attendance. Applications to the
Medical Superintendent.

Middlesex Hospital, W. (Cancer Department).—Medical Oflloer
and Registrar. Salary, £100 per annum, with board and
residence. Applications to F. Clare Melhado, Secretary-
Superintendent.

Rotherham Hospital and Dispensary—Senior House Surgeon.
Salary £100 per annum, with rooms, commons, and washing.
Applications to the Secretary, H. Kelson, Masonic Buildings,
High Street, Rotherham.

£ppohttmtni 0 .

David, John, M.B., C.M.Glasg., a District Medical Officer by
the Neath (Glamorganshire) Board of Guardians

Ewino, J. Millar G., L.R.C.P. and 8 Edin., House 8 urgeon to
the Wallasey Dispensary and Victoria Central Hospital,
Lisciird.

GuN.Ni.vt-, Charles John Hope. M.R.C.S., L R.C.P.Lond.,
Anesthetist to the Victoria Hospital for Children, Tit©
Street, Chelsea. S.W.

Loo an, Frederick Thomas Bishop, L.R.C.P , L.M.Edin.,
M.R.C. 8 ., Medical Officer for the Bishopsworth District of
the Long Ashton (Somerset) Union.

Macphail, Alexander, M B., M.S.Olasg., Lecturer on Anatomy
at the Charing Crosi Hospital Medical School.

Robbs, C. H. D., M.B.Lond., Certifying Surgeon under th©
Factory and Workshop Act for the Grantham District of th©
Countv of Lincoln

Rywk, M. A., M.D.Dub., Certifying Surgeon under the Factory
and Workshop Act for the Cheltenham District of the
County of Gloucester. _ . , „

Syhes. J. Odf.p.y, M D.Lond., Physician to the Bristol General

Chilm^vaVs, David Brynmoh, L.R.C.P.Lond., M.R.C.S.,
Assistant Medical Officer at the Swansea Workhouse.

0OLYF.R, Stanley, M B., B.S.Lond., D.P.H., House Physician at
the General Lying-in Hospital, York Road, Lambeth. •

Coombs, Carey, M. D.Lond., Assistant Physician to the Bristol
General Hospital.

#irth0.

Dodgson.— On July 2nd. at Sherburn House, Durham, the wife
of G. 8 . Dodgson, M.B., of a daughter.

Hayxb.—O n June 27, at Dunvegan, Longton Grove, 8 ydenham, the

wifeofj. Hayes, L R.C.P.L, of a daughter.

Ow*N-TAYLOR.-On July 6 th, at Cherwell House, Nottingham, the
wife of Herbert Owen-Taylor, M.D.,of a daughter.

iHarriages.

Dicxins—Taunton —On June 86 th, at St. Nicholas Worcester,
Sidney John Oldacre. Dickin., M.D., of Cowfold, Sussex, to
Cicely Margaret, elder daughter of W. W. Taunton, B.So.,
M.R.C.P., of Worcester. . „..._.

3ILE8—Cooper.— On July 4th, at St. James s Church, Kidbrook,
Blackheath, Hubert Mathieson, elder son of Captain H.
Giles R.N., of Little Heath, Alverstoke, Hants, to Florence
Muriel, only daughter of Peter Cooper. L.R.C.P.Lond.,
M.R.C.S.Eng., of Stsinton Lodge, Blnokheath.

Cknyon—Kilroy. —On July 3rd, at All Salats Church, Ryde. Lesli©
KeDvon, to D.ilsy, youngest daughter of the late Philip LeFeuvro
Kllrov, Lieut.-Colonel., R-A.M.C., and Mrs. Kdroy, Falrfleld. Hyde.

1TOCKDALB— BULTIN.-On June 29th. at 8 t James'Church, Dundee,
Natal, Frederick Rlsley, ninth son of the late Charles Candngton
Rtockdale, of Highbury, of H.M. Civil Service, to Gertrude Eveline,
elder daughter of Charles Heary Butlln, M.R.C.S., of Plymouth,
late of Camborne, Cornwall.

Wr.BSTER-MuRPHY.-On July 3rd, at St. Mary Shandon Churdi.
Cork, the Rev. James Henry Webster, fifth son of George
Webster, of Bondon, to Harriet Dora, onlv daughter of the
late Major F. H. 8 . Murphy, M.D.. R.A.M.O., and of Mrs.
Murphy, Cork.

■Btath b.

SVRY.— On July 5th, at Havering Hoase, Abergavenny, Norris
Fasham Davey, M.R.O.B., L.R.C.P., late of Romford, Essex, In hla

jrsimii/l—O n July 6 th. at 12, Southwood Lane, Hlgbgate, Francis
Hyde Fcrsball, M.R.C.S., aged 74. .

ellt.— On June 29, at 13, Mallifont Avenue, Kingstown, co. Dublin,
suddenly, from heart failure, Lieut.-Colonel James Bennett Kelly.

R. A,M.C., Retired, „ 4 , . ... ... .

LOYT Owen.—O n July 4th, at Kent Lodge, Southeea, Alfred
Lloyd Owen, M.D., aged sixtyone years.

Digitized by L^ooQie

The Medical Press and Circular.

“SALUS POPUU SUPREMA LEX."

Vol. CXXXV. WEDNESDAY, JULY 17, 1907. No. 3

Notes and Comments.

Notes and Queries has lost none of
Sarfeoi its interest even though the hand
and of its founder and editor has alas 1

Botcher. been removed. A correspondence
M 1 has been learnedly and briskly rag¬

ing in its columns of late as to whether the alleged
custom of not putting surgeons and butchers on
juries to try murder cases ever had a de facto
existence, and, if so, what was its origin. It
seems doubtful whether a regular custom actually
existed, but there seems to have been some
feeling on the subject, the alleged reason being
that surgeons and butchers were so much habituated
to cruelty that they would not be good judges of
the moral enormity of murder. Surgeons to whom
the information comes as news will, we hope, be
duly appreciative of their association with butchers
in this connection, and still more so of their
supposed brutality. In the innocence of our
hearts we have hitherto believed that the medical
men are excused jury service in recognition of
their arduous toil for the benefit of our common
humanity, and because of the amount of un-
remunerative labour they devote to the State in
the exercise of their profession. But in future
we must not lay this flattering unction to our
souls, for it seems that the real cause for exemption
from jury service is to be found in the moral
depravity which was supposed to be an indis¬
soluble accompaniment of the surgeon’s art.
That some such feeling did actually exist seems
beyond doubt, and the pre-anaesthetic operative
surgeon must necessarily have been a man who
could subordinate his natural feelings of mercy
to the prosaic and sanguinary requirements of
the moment, but if only for the sake of his own
practice it is hardly likely that the surgeon of old
days would have cultivated deliberate callousness.

' "I D However, the pursuit of natural
-“Dressed like a knowledge used generally to be cre-
Mcdlcal dited with a tendency to make men
Stadcat.” irreligious, and that of medicine
with making them both brutal and
unmannerly. The great Dr. Arnold, of Rugby,
who in his generation was accounted one of the
most ardent reformers, and who possessed a more
open mind than most of his contemporaries,
strongly opposed the admission of medical students
to Oxford because of the strong tendency of their
presence and manners to debase undergraduates
reading divinity and polite letters—an objection
which was vigorously supported on all sides.
It savours perhaps of unctuous rectitude to say,
with the snail, that we have changed all that, but

even if it is the fact, as we ourselves unhesitatingly
believe, the old tradition dies hard. Any auda¬
cious lark or low street trick is the work of the
medical student still in the eyes of mentors of
the press. A more than usually amusing instance
of this gratuitous assumption occurred in connec¬
tion with the “ Strand Baby ” case last week. As
most readers know, a young man and woman
entered the West Strand Post Office one evening
with a baby, and after some preliminaries de¬
spatched the infant to a lying-in hospital by
messenger boy, and then decamped. As the in¬
cident furnished good copy, there was a tre¬
mendous clatter in the yellower organs of the
press, and many puerile theories and clues
were put forward to keep the public agog.
One reporter had an “ interview ” with
one of the Post Office clerks, on the strength
of which he obtained details of the costume
of the couple. The man wore a tweed
suit and a large baggy cap such as is the
fashion of the moment, being, in fact, said the
account, dressed like a medical student. A
medical student, then, on this conclusive evidence,
must have done the dark deed. We did not know
that there was anything particularly distinctive
about the dress of medical students, and whatever
there may have been in this particular instance
was rendered nugatory by the event, for, when the
man was found two or three days later, it turned
out that he was a postman.

The recent proceedings of the
One Inspector, new L° n( ion County Council with
One Microbe.’ re 8 ard to the milk-supply of the
metropolis pass the wit of man
to understand. In the first place,
on taking office the Council withdrew from their
Bill then before Parliament all the clauses giving
them greater powers of inspection and supervision
of the milk-trade ; then a few months afterwards,
recognising that this move was a mistake, they
proceeded to refer the matter to the Public Health
Committee with a view to obtaining such powers
from Parliament. Last week, when the report of
this Committee came up for discussion, they
passed an amendment which amounted practically
to a decision to do nothing beyond making re¬
presentations to the Local Government Board
about the unsatisfactory state of the milk-trade.
By way of illustrating the practical knowledge
possessed by the Council in the matter, one mem¬
ber got up and moved an amendment demanding
that no milk should be sold in London except in
glass-bottles, hermetically sealed, and having on

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52 The Medical Pan.

LEADING ARTICLES.

July 17, 1907.

them the name of the farmer and the stamp of
an authorised inspector guaranteeing the purity
of the contents. He pointed out that to be
certain of the freedom of milk from contamination
under any proposal, an army of inspectors would
have to be employed all along the line, but accord¬
ing to his proposal the inspectors would only be
needed at the source. We shudder to think what
the price of milk would mount up to under such a
system, and also at what hour in the day it would
reach the consumer. A speaker who followed
made play with this visionary proposal, and said
that its chief virtue consisted in the amount of
work it would provide for the unemployed.
Indeed, it seemed to him to be a case of one
inspector, one microbe. The amendment was
lost on a division, it is true, but the ugly fact
remains that the Council exhibit every symptom
of being possessed with a desire to burke the
main question, and there seems no way of getting
them up to scratch and keeping them there.

The Reverend H. Tracey, of St.
The Doctor Saviour’s, Dartmouth, is, we ga-
88 ther from a recent article from his

Parson. pen, one of those enlightened

members of the clerical profession
who see mat the Church has a social, as well as a
spiritual duty to the State, and that in its per¬
formance important help will be readily forth¬
coming from medical men. Mr. Tracey, it seems,
has long liked to have doctors read the lessons in
his church, but this passive use of their energies
he would now like to see supplemented by the more
active one of preaching. The late Dean Stanley
frequently invited distinguished laymen to preach
from the lectern in the Abbey, and Mr. Tracey
advocates the extension of this principle to medical
men. “To have expert testimony to the value of
cleanliness, purity, sobriety, simplicity of living,
the ease of extracting the greatest nutriment from
the simplest and cheapest food, the beneficent
effect of sunlight, fresh air, pure water, regular
work, regular play, and similar topics would”
he writes, “ be of infinite value, and would ' save ’
the bodies of many who would then see how
rational it was to * save ’ their souls as well.”
There is, we believe, no reason why medical men
should not be licensed to preach in churches, but
we do not know of any instance in which any
one of them is. That the advocacy of such
principles as Mr. Tracey suggests would do more
for people’s lives than many of the platitudinous
utterances that pass for sermons would hardly be
denied by anyone conversant with the facts.

The death of Sir William Broad-
Death af bent removes from the medical
Sir William world a big figure, for although to
Broadbent. the public Sir William was known

chiefly as a Court physician, by
his colleagues he was respected as a particularly
sound and accomplished physician. He had
formed his views not on intuitions and ideas, but
on the broad basis of accurate clinical study, and
they were therefore not only firmly held, but well-
grounded in commonsense. He knew his own
mind and spoke it with Yorkshire-like direct¬
ness, but he was generally right and invariably
high-minded. His promotion to Court circles at
the time of the Prince of Wales’s illness was some¬
thing of a surprise when it occurred, as he had not
trodden in the Jennerian footsteps, but not only

did his skill soon recommend him to the friends of
his Royal patient, but, we believe, the King and
Queen entertained a very high regard for him
both personally and professionally. Sir William
Broadbent had many of the qualities that make
a leader of men, and he would have been sure of
success in almost any line of life, but it is as a.
leader of good causes in the profession that he
will be most immediately and truly missed.

LEADING ARTICLES.

THE GENERAL MEDICAL' COUNCIL AND
THE DENTAL COMPANIES’ BILL.

The General Medical Council is the only body
to which we can turn hopefully as the active
instigator and framer of legislation calculated
to protect professional interests. Undoubtedly
the great want of medical practitioners at the
present moment is an Act that will put an effectual
stop to the unlawful practice of medicine for gain
and the sale of quack medicines. By satisfying
that demand Government would also be taking a
step of unmeasurable importance towards the
better safeguard of the welfare of the public.

The legislature that draws up stringent medical
Acts providing for the efficient education and
legal qualification of medical practitioners recog¬
nises the absolute need of careful special training
for the practice of medicine. If the same legis¬
lature permit quacks and charlatans to perform
medical functions, then it nullifies its former
position, assumes the right of any man ta
practice medicine at his own free will, and
practically says that the public does not
require to be protected against irregular
practices. The State, in other words, declares
that a thing can both be and not be : that the
man in the street requires to be protected against
ignorant medical men, but not against ignorant
quacks. Yet the Government of this country
is not without some saving grace, so far as the
attempt to keep in touch with medical aims, ideals
and aspirations is concerned. The General Medical
Council occupies an advisory position of great
weight by virtue of its connection with the
Privy Council. The opinion of the great so-
called governing body of the profession is sought
upon medical questions that may come under
the consideration of the legislature. It is always
of interest, therefore, to ascertain as far as possible,
in what directions that influence has been brought
to bear. The interests of the dental profession
are in charge of the General Medical Council.
They are professedly involved in the Bill now
before Parliament to restrict the practice of
dentistry by private or public companies.

The General Medical Council has promoted
the Bill known as the Dental Companies’ (Re¬
striction of Practice) Bill. The opinion of the
dental profession with regard to the Council’s
championship of their rights may be gathered
from a leading article in the British Dental
Journal for July 1st, 1907. “ We wish to speak
in terms of moderation,” it says, “ but desire

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CURRENT TOPICS.

The Medical Press. 53

at the same time to rouse the dentists of the
country to a sense of the injustice and injury
which that Bill will inflict upon them and the
people should it unfortunately pass. . . .

The Bill is careful enough to provide for some¬
thing which never has occurred and never is
likely to occur, viz., the formation of a company
to carry on dental practice by means of qualified
men ; and careless enough to legalise by a few
ill-considered words the practice of dentistry in
one of its most important branches by un¬
registered men. There can be no doubt that if
this clause stands, hundreds of qualified dentists
who have spent much time, money, and exertion
in obtaining a registrable diploma will be ruined.”
These strong words, coming from a responsible
and authoritative source, can hardly fail to
engage the earnest consideration of the General
Medical Council. If it be the serious intention
of the Government to defend the interests alike
of the qualified dentists and of the public by
fresh legislation, then it is evident the present
Bill will have to be recast. But the attitude of
the General Medical Council has an important
bearing upon the interests of medical practitioners
who find themselves hampered by competition
with companies formed to carry on all sorts of
medical treatment, and to sell all kinds of nos¬
trums claiming to cure all sorts of ailments.
Will the General Medical Council be able to
frame a better Bill for the protection of medical
men than it has for dental surgeons ? Pre¬
cisely identical principles are involved in both
cases, and just the same zealous sympathy,
informed wisdom and resolute determina¬
tion are demanded in the one instance as in
the other. The present position appears to
emphasise the inherent weakness of the Council
in its virtually non-representative constitution.
In conclusion the following passage from the
British Denial Journal may be quoted :—“ We
are by this Bill most shamefully entreated. We
have for long been used to being ignored, flouted
and misunderstood by the Medical Council, and
in spite of it all we have displayed to that body
a passionate loyalty that in the light of this Bill
is truly pathetic. The memorandum states that
the Bill has the support of the General Medical
Council! We are indeed wounded in the house
of our friends.”

CURRENT TOPICS.

For London or for the United Kingdom ?

When the Royal Society of Medicine was
constituted we looked forward with special
pleasure to its probable effect upon the Obstetrical
and Gynaecological Societies. We expected that
nothing but good could come from such a union,
that the Obstetrical Society would gain very
materially by the broadening of its views conse¬
quent on the influx of new members, and that
the Gynaecological Society would also profit by
acquiring an equal share in the prestige of the
older Society. No one could doubt that both

consequences were very much to be desired.
The Obstetrical Society had always something
in its atmosphere which seemed to stifle
those who would have levelled up London
obstetrics and gynaecology. The Gynaecological
Society lacked the prestige of age and associa¬
tions which one naturally looks for in the
case of an important institution. It is therefore
with very keen regret, and we confess with not
very hopeful forebodings, that we have read
the list of “ officers recommended by the Council ”
for election at a Special General Meeting to be
held in October. It is at once apparent from this
list that so far from this particular section of the
Royal Society of Medicine being one which will
seek to attract to its ranks prominent obstetricians
and gynaecologists from all parts of the United
Kingdom, it is to be again a mere repetition of
the Obstetrical Society. For the new Council
there have been nominated, by the existing
Council, twenty-nine members from London,
six members from the English provinces, one
member from Scotland, and not even a single
Irish representative. Now, Scotland is very
well able to look after its own interests, and
therefore we shall not comment on the curious
manner in which its specialists have been wel¬
comed to the ranks of the new section. We
turn now to the case of Ireland. We believe we
are correct in saying that in the list of past
and present officers of the British Gynaecological
Society there are the names of at least two
Irish ex-presidents, and at least three Irish ex¬
vice-presidents, not to speak of others who have
been members of the Council. We believe we
are also correct in stating that these gentlemen
were invited to join, and did join, the new section,
together with other Dublin obstetricians and
gynaecologists who were members of the Gynae¬
cological Society. Yet of them not a single one
has been considered by the existing Council to
be worthy of a place on the new Council. When
policy, civility, and ordinary fairness unite to
point out a certain course of action there must
be a very definite reason why the course is not
followed. What that reason is time will
show. We trust it is not due to a desire to
maintain the traditions of the Obstetrical
Society.

Instruction for Mothers.

We are glad to learn that some recent ventures
in the Metropolis directed toward the instruction
of mothers are progressing satisfactorily. For
some years, in Paris, Brussels, Ghent, and other
continental cities, centres have been established
where mothers could obtain proper advice as to
the care and feeding of young children. More
recently the Marylebone Health Society and the
St. Pancras Mothers’ and Infants’ Society entered
on similar work in their respective districts of
London. Mothers and expectant mothers are
taught how to wash, clothe, feed, and generally
tend young infants, and the importance of

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CURRENT TOPICS.

July 17. 1907 .

natural feeding is emphasised. In cases where
artificial feeding is necessary', the mother is given
instructions on the preparation of the most
suitable foods. It is claimed that the result in
the shape of healthy, well-nourished children is
most gratifying, and we can well believe it. It is
a commonplace that the greater part of infant
mortality is due to ignorance rather than careless¬
ness or crime, and any effort to dissipate this
ignorance deserves the hearty support, not only
of the medical profession, but of all interested
in the welfare of the race.

The Adequacy of Pines.

The necessity of enforcing high standards of
purity in food and drugs has been recognised in
many Acts. There are many ways, however, in
which the intention of the legislature may be
frustrated. In some cases the machinery of the
local authorities for the collection and testing
of samples is defective. In others the limit of
the penalty that may be imposed is too small to
be of any real deterrent effect upon offenders, or
magistrates may be too lenient in the matter of
fines. It is notorious that certain fraudulent
milk-sellers find it a paying business to go on
selling adulterated milk and to charge against
profits the fines that are constantly imposed
•upon them. In the matter of meat and tinned
goods magistrates, as a rule, are inclined to im¬
pose full penalties. Last week a penalty of £50
and £2 2s. costs was imposed upon the keeper of
some stores in Camberwell for exposing for sale
tinned and bottled goods unfit for human con¬
sumption. Were all fines for this class of offence
fixed on a similar scale of adequacy, the safety of
the public would be proportionately increased.
In a matter of this kind, above all others, it is
desirable to have some sort of concerted action
amongst the magistracy in their administration
of the law.

A Year’s Trade Accidents.

The Annual Report of the Chief Inspector of
Factories and Workshops for the year 1906
was issued, on the 10th inst., in the form of a
Parliamentary paper. The document registers
a great advance in the condition of industrial
labour. At the end of the year there were
109,065 factories and 146,124 workshops upon
the registers. The number of persons employed
in factories is about 4,150,000, in workshops
700,000, and in laundries 100,000. The total
number of accidents reported in the year 1906
reached the great number of 111,904, of which
1,116 proved fatal. These figures show an
increase of 11,295 accidents, or 112 per cent, as
against the preceding year ; while the fatalities
are greater by 53 or 5 per cent. It is interesting
to note that the greatest number of fatal accidents >
namely, 149, occurred in the making of machines,
engines, &c., while 145 occurred in the construction
of buildings, and 143 in docks. The cases of
industrial poisoning totalled 707, of which 54
ended fatally. Only one case of phosphorus
poisoning was reported. Attention is called to

the coming into force of the Workmen’s Com¬
pensation Act, 1906, which it is pointed
out, broadens the scope of the earlier Acts, and in
particular extends compensation to certain
scheduled industrial diseases. In view of the
importance of the new Act, the attention of
medical practitioners may be drawn to this
important Parliamentary paper.

Medical Practice by Companies.

Parliamentary proceedings with regard to
medical practice by companies are of vital im¬
portance to the medical profession. Some
weighty evidence has been laid before the Lords
by the chairman of the London and Counties
Protection Society and the Secretary of the
Medical Defence Union. Dr. G. Heron pointed
out forcibly that the limitation of the scope of
the proposed Bill to joint stock companies would
render it almost valueless, as the majority of such
companies were of a non-joint stock nature. Dr.
A. G. Bateman went to the root of the matter when
asked whether he had any suggestion or amend¬
ments in connection with the Bill. “ I am afraid,”
he replied, “ that the only amendment we should
like would be a complete alteration of title and a
complete alteration of the clauses, so as to put
a stop to medical practice for gain by persons
who are not qualified.” That is the bed-rock of
the question. The legislature is asked to stop
medical practice by companies who collectively
perform acts that individually performed would
be illegal. If the safety of the public demands
that unqualified practice of medicine by com¬
panies be abolished, why not also that of indi¬
viduals ? The view so clearly and courageously
advanced by Dr. Bateman would come naturally
and gracefully from the General Medical Council.

Ingenious Milkmen.

A certain class of milk vendors exercise a
fiendish ingenuity in devising methods for adding
to their legitimate income a profit obtained by
fraud. It is, of course, highly important (to the
offender) that the method adopted should not
bring him within reach of the law, and hence,
while he courteously supplies the stranger w’ith a
genuine article, his long-suffering regular cus¬
tomers do not obtain milk ” of the nature, sub¬
stance, and quality demanded.” The procedure
of some sinners within the Borough of Portsmouth
in the sophistication of their milk is mentioned
by the Public Analyst, Mr. F. W. Arnaud, in his
annual report. The milk vendor carries two
churns on his cart, one containing skim, and the
other whole milk. The former chum is duly
labelled “ separated milk,” but the label is stuck
so near the base of the chum as to pass unobserved
by anyone not standing immediately over the cart.
Customers are served from a small can, which
never contains much more than is required by
the next customer. For regular customers a
special mixture from the two churns is supplied,
while a suspicious-looking stranger is supplied
from the churn containing genuine milk. I f
necessary, the milkman obligingly points out the

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label " separated milk ” to the inspector. When
it is remembered that an average genuine milk
can be diluted with 30 per cent, of separated
milk without bringing the fat below the 3 per
cent, standard, it will be seen that the vendor will
not be liable to prosecution if the small can con¬
tains a little of the “ regular customer’s mixture,”
when the genuine article is run in for the in-
spictor. Mr. Arnaud suggests the necessity for a
new Act rendering it illegal to carry both whole
and separated milks on the same cart. Mean¬
while, the inspector is baffled, and the offender
grows rich at the expense of the consumer.

PERSONAL.

Ox July 13th, Degree Day at Liverpool University,
the following honorary degrees were conferred 1Pro¬
fessor F. Gotch, D.Sc. ; Professor W. Osier, D.Sc.

The Court of Governors at Guy’s Hospital sanc¬
tioned the formation of an orthopasdic department,
and appointed Mr. R. P. Rowlands, M.S., as surgeon
to the hospital in charge.

Lady Broadbent on July nth received the follow¬
ing telegram from Sir Arthur Bigge :—“ The Prince and
Princess of Wales are grieved to hear of the irreparable
loss which you have sustained, and desire me to assure
you and your family of their true sympathy in your
sorrow. ”

Lieutenant-Colonel Sir J. Fayrer, medical officer
of the Duke of York’s School, has been appointed to
the medical charge of the Union Jack Club.

Sir Alfred Jones, K.C.M.G., the president of the
Liverpool School of Tropical Medicine, has received
a grateful letter of thanks from the President of the
Republic of Peru, acknowledging copies of a report
in Spanish on the “Health of Iquitos,” by Dr. H.
Wolferstan Thomas, member of the yellow fever
expedition of the school.

On July nth the members of the Birmingham
Medical Benevolent Society presented an address and
a handsome service of silver plate to Mr. W. F.
Haslam, who recently retired from the post of
honorary secretary to the society, after sixteen years’
service.

Dr. J. Ll. Williams, of Wrexham, has been
appointed medical referee under the Workmen’s Com¬
pensation Act, 1906, for the County Court districts of
Corwen and Bala and Wrexham and Llangollen.

Dr. Robert Barnes, whose death, at the age of 89,
was recently referred to in these columns, has left
estate valued at £183,074 gross, with net personality
£175,176. He left £500 each to St. George’s Hospital
and St. George’s Hospital School, London ; the Medical
Benevolent College, the Dreadnought Seamen’s Hos¬
pital, and St. Thomas’s Hospital; £300 to the Royal
Maternity Charity; and £200 each to the School of
the London Hospital and the Princess Alice Memorial
Hospital, Eastbourne.

Dr. G. G. Shattock has been appointed to deliver
one Erasmus Wilson lecture on Ovarian Teratoma,
and Dr. J. W. H. Eyre,M.S., Dub., andMr. Leonard S.
Dudgeon, lectures on other subjects.

Mr. James Taylor, F.R.C.S., has been made the
recipient of a handsome testimonial on his retirement
after forty years’ service on the surgical staff of the
Chester Infirmary.

Dr. George W\ Crowe, of Worcester, was enter
tained at dinner and presented with a piece of plate
by his fellow-members of the Worcestershire and
Herefordshire Branch of the British Medical Associ¬
ation at the end of last month.

Lady Duckworth-King is to open the recently
erected electrical department of the Royal Devon and
Exeter Hospital, presented by Mrs. Sanders, on
Friday next.

Mr. Hudson E. Kearley, M.P., will distribute the
prizes to the students and nurses of the London Hos¬
pital this afternoon at 3.30 in the library of the Medical
College.

The prize distribution at St. Mary’s Hospital, which
was to have taken place on July nth, has been
indefinitely postponed in consequence of the death of
Sir William Broadbent.

Dr. C. E. Underhill presided over a luncheon on
July 6th given by the Royal College of Fhysicians of
Edinburgh to the medical officers of the Channel
Fleet.

Dr. W. F. Surveyor has been appointed to the chair,
of bacteriology at the Grant Medical College, Bombay.

The Duke and Duchess Karl Theodor of Bavaria
have just arrived in this country. For many years
the Duke has performed operations for cataract, the
total of which has already exceeded 5,000. He is
assisted in his work by the Duchess.

The Science Committee of the British Medical
Association has adjudicated the Middlemore Prize to
Mr. Sydney Stephenson, for the outstanding merit
of his essay upon Ophthalmia Neonatorum. This prize
is awarded every three years for an ophthalmic sub¬
ject.

Mr. Henry Morris has been re-elected President of
the Royal College of Surgeons of England.

Mr. Watson Cheyne, C.B., F.R.S., and Mr. Rick¬
man Godlee, F.R.C.S., have been elected vice-presi¬
dents of the College of Surgeons of England for the
ensuing collegiate year.

MR. W. S. Handley, M.S.London, has been ap¬
pointed Hunterian lecturer for one lecture on the
Therapeutic Criteria of Cancer, and Dr. V. Bonney,
M.S.London., for three lectures on the Connective
Tissues in Carcinoma. Mr. B. Armour, M.B.Toronto,
Mr. A. R. Thompson, M.B.Vict., and Dr. F. C.
Shrubsall, are to give other lectures.

Dr. F. A. Bainbridge, M.A.Camb., has been appointed
Arris and Gale Lecturer, to give one lecture on the
Pathology of Acid Intoxication, and Mr. Major
Greenwood, junr., two lectures on the Physiological
and Pathological Effects which follow Exposure to
Compressed Air.

A portrait of Dr. John Beddoe, F.R.S., has been
formally presented to the City of Bristol by the Right
Hon. Lewis Fry.

In our “ Births, Marriages and Deaths ” column to¬
day are two announcements which read side by side
appear almost tragic. On the 9th inst., the son of
Mr. Samuel Benham, M.R.C.S., of Hampstead was
married ; the next day the sudden death of the
father occurred.

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CLINICAL LECTURE.

July 17, 1907.

56 The Medical Prb<s

A Clinical Lecture

ON

THE TREATMENT OF CARCINOMA OF THE GREAT INTESTINE, (a)

By SETON PRINGLE, M.B., B.Cfa. (Univ. Dub.), F.R.GS.I.,

Surgeon to Mercer’s Hospital, Dublin.

Gentlemen. —The subject about what I wish
to speak to you this morning is the treatment of
carcinoma of the great intestine exclusive of the
rectum. The great intestine, as you know, is a
common site for malignant disease, and it is
gratifying to be able to state that the treat¬
ment of this condition by early operation is
attended by success in a great number of cases.
You note that I lay emphasis on the word early,
for unfortunately we generally get these cases,
at least in hospital practice, only when the disease
is far advanced and one or other complication has
set in, therefore I want to impress on your minds
the importance of making a full and careful
examination of every elderly patient coming to
you complaining of vague abdominal symptoms
such as colicy pain, constipation, diarrhoea, or
the passage of mucous, blood or pus in the motions.
I believe that at present we do not attach nearly
enough importance to the microscopical and
chemical examination of the faeces in abdominal
cases. You all know how much can be learned
from careful examination of the urine, sputum,
or gastric contents in diseases of the kidneys,
lungs or stomach, and yet in how very few cases
of intestinal disease do the faeces receive similar
attention ? Professor Nothnagel states that in
only two conditions are pus, mucus and blood
persistently found together in the stools. These
two conditions are carcinoma of the great in¬
testine and dysenteric ulceration. The latter
disease is usually easily diagnosed, and therefore
the discovery of these three abnormal con¬
stituents of the faeces would be of the greatest
assistance in arriving at the diagnosis of cancer
in cases presenting symptoms of intestinal
stenosis, but in which no tumour could be felt.
Leaving faecal impaction out of the question,
the presence of a palpable tumour in an elderly
person with symptoms of complete or partial
intestinal obstruction, of course practically settles
the diagnosis of cancer, but as in many cases the
growth is situated at an inaccessible part of the
intestine, such as the splenic flexure, or is too
small to be felt, the importance of the knowledge
gained by examination of the fseces cannot be
over-estimated.

The cases of cancer of the great intestine,
which present themselves for treatment, may
be divided into two main groups, namely, cases
which are not and cases which are suffering from
acute intestinal obstruction at the time of examin¬
ation, and the latter are at least, in my experience,
by far the more numerous.

First then as regards the treatment of the cases
coming into the former class. As soon as the
diagnosis is made, and except the disease is very
far advanced and the patient evidently rapidly
on the down grade, it is certainly the surgeon’s

(a) Being » Lecture delivered at Mercer’i Hoepltal on April 10th,
1907.

duty to advise immediate laparotomy, and then
to be guided in the course he pursues by the
conditions found in the abdominal cavity. If
the tumour be movable and the lymphatic glands
be either apparently normal or enlarged only in
the vicinity of the growth, the affected part
of the intestine, and at least two inches of
normal gut on either side, should be excised.
(It is not my intention this morning to describe
in detail any of the operations I may advocate,,
but merely to outline them in a few words).
Along with the tumour we must remove either a.
wedge-shaped piece of the mesentery or, if the
intestine at the situation has no mesentery, then
as much of the fatty bed on which the bowel rests
as can be taken away without endangering the
blood supply of the normal gut. In either case
our endeavour is to remove in one piece with the
growth the lymph channels and glands draining
the part. When the growth has been cut away,,
an end to end anastomosis by suture should be
performed in those parts of the intestine which
are almost completely surrounded by peritoneum..
In other parts, such as the ascending or descend¬
ing colon the divided ends of the bowel should
be closed and a lateral approximation carried
out. In the case of the caecum, where the ileo-
caecal valve has been removed, it is well to close
the lower end of the ascending colon and implant
the cut end of the ileum into the lateral aspect of
the colon, preferably incising the latter in the
line of one of the longtitudinal muscle bands.
Frequently we find on exploring the abdomen
in these cases that although the patient has not
suffered from acute intestinal obstruction, yet a
chronic condition of obstruction is present, and
here the gut above the stricture will be distended,
often enormously so, and the mucous membrane
ulcerated, while the intestine below will be con¬
tracted. In these cases it is necessary to perform
a lateral anastomosis, or sometimes even a
temporary colostomy to allow of the distended
upper segment of bowel regaining its healthy
condition before proceeding to excision of the
growth at a later sitting. Of course if another
portion of the intestine or the omentum is found
adherent to the growth the adherent structure
must be removed in one piece with the growth
itself. Occasionally in this first class of case we
find a growth which is obviously irremovable, and
then I consider it is best to perform a lateral
anastomosis between the afferent and efferent
loops of bowel so as to short circuit the current
of intestinal contents, and thus obviate either
the occurrence at a later date of acute obstruction
or the formation of an artificial anus above the
site of the tumour. This operation is comparable
to that of gastro-enterostomy for inoperable
carcinoma of the stomach involving the pylorus,
and even if it is not attended with such obviously
beneficial results to the patient, surely it is pre-

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July 17 , 1907 .

CLINICAL LECTURE.

The Medical Press. 57

ferable to the establishment of a permanent
colostomy ? In this connection I may mention
that anastomosis of the transverse to the pelvic
colon has been frequently successfully carried out
for irremovable growth of the splenic flexure or
descending colon.

The consideration of the treatment of the
second group of cases, viz., those in which acute
intestinal obstruction is present as a complication
of the malignant stricture, is more interesting,
as here we have to note the very marked advance
of surgical procedure and technique of com¬
paratively late years. Formerly in these cases
it was the recognised practice to, if at all possible,
excise the growth and perform an immediate
end to end anastomosis ; but this line of treat¬
ment was found to be attended with a mortality
of something like fifty per cent. This result
is just what might be expected, if you consider
the condition of the intestine in an acute ob¬
struction. The gut above the stricture is
enormously distended with decomposing faecal
material and gas, the mucous membrane is
ulcerated and the wall in its entire thickness
inflamed. How then could we expect to obtain
satisfactory union at the line of suture ? Is
it not evident that the sooner the toxic products
of decomposition be allowed to escape the better
the patient’s chance of recovery ? Remember
that in the great majority of cases of acute in¬
testinal obstruction the patient is killed by toxaemia
and not by any local condition. It is therefore
now recognised that the important part of the
operative treatment of acute obstruction from
growth is the immediate provision of a free outlet
for the toxic intestinal contents which relieves
the patient’s toxaemia and allows the gut to
regain its tone and normal structure. It is not
justifiable to undertake a prolonged operation
with the object of immediate removal of the
tumour and restoration of the continuity of the
bowel, since the result can be much more safely
obtained by carrying out the operative treatment
in two or three stages. The number of separate
operations is determined by the possibility or
impossibility of delivering the growth out of the
abdominal cavity. In the first class— i.e., when
the growth can be so delivered, the best procedure
is to lift the involved loop of intestine out on to
the abdominal wall and then, after suturing the
parietal peritoneum around the two limbs of the
loop, to excise the tumour with a wedge-shaped
piece of the mesentery, and tie a large Paul’s
tube into either cut end of the gut to permit of
the free escape of the intestinal contents. If
at the same time we stitch together the mesenteric
borders of the afferent and efferent limbs of the
loop of bowel, then, after some weeks elapse, the
spur between the two segments can be safely
destroyed by an enterotome, and the artificial
anus can be closed, as Paul himself says, “ by
separating the rosette of mucous membrane from
the skin, turning it in and bringing the freshened
edges of the latter over it.” If the mesenteric
borders are not sutured together, then the second
and final stage of the operation consists in closing
the artificial anus in the usual way.

On the other hand, if we find at the primai y
operation that the tumour cannot be delivered
out of the abdominal cavity, it is best to perform
a colostomy above the site of the growth, to
relieve the urgent symptoms of obstruction ; and
then, some weeks later, the abdomen is again

opened over the position of the tumour which is
excised, and an end to end or lateral anastomosis
carried out. In such a case the third or final
stage consists in closing the colostomy by a
suitable operation. If considered advisable the
colostomy can be closed at the same sitting in
which the tumour is excised ; but personally I
consider it is wiser to carry out the treatment in
three stages, as we are much more certain of
getting satisfactory union at the line of anasto¬
mosis if no fie cal material travels over it for a
few days.

Within the last few months you have had an
opportunity of seeing three cases of carcinoma of
the great intestine under my care. All three
came into hospital in a condition of acute ob¬
struction.

The first case was that of a man, jet. 65, who
some six months previously had been admitted
under my care. On that occasion he complained
of colicky abdominal pain for the twenty-four
hours before admission ; he had also vomited
several times, and there had been no movement
of the bowels ; but as he was habitually consti¬
pated he attached no importance to the latter
fact. His general condition was very good and
abdominal distension not a marked feature. I
ordered him a large enema, and remained in the
hospital to learn the result. The injection
brought away a large motion and all his symptoms
subsided ; therefore, as on careful examination
no tumour could be felt in any part of the ab¬
domen, I was inclined at the time to consider
his condition as due to faecal impaction. He was
consequently'discharged from the hospital in a
few days, and remained well except for the
troublesome constipation, till he was admitted
the second time, six months later, with acute
intestinal obstruction. 1 immediately operated
and performed a caecostomy, but unfortunately
he gradually sank and died a fortnight later. At
the post-mortem a tight malignant stricture at
the splenic flexure was found.

The second patient was a woman, aet. 60, who
had suffered from constipation for some time,
but otherwise had enjoyed very good health till
some thirty hours before admission, when acute
obstruction suddenly set in. In her case the
growth was situated in the lower end of the
pelvic colon, and again colostomy was performed
immediately, but failed to save her life.

The third case furnishes a good example of the
“ three stage ” operation, and I will therefore
enter into more detail in recalling it to your
memories. The patient, a labourer, aet. 60, was
admitted late one night some months ago, and
then gave the following history :—For some years
he had been more or less constipated, and for the
three weeks preceding admission he had been
unable to obtain a satisfactory movement of the
bowels, although the very day before coming here
he had passed a small motion. After this motion
severe colicky pains commenced in the abdomen,
and these pains persisted up to the time of ad¬
mission twenty-four hours later. During the
same period he held also vomited frequently.
I saw him an hour after his arrival, and found
the abdomen greatly distended, while by both
palpation and percussion the caecum and entire
length of the colon down to the pelvic brim could
be easily demonstrated to be in a very dilated
condition. From this it was evident that the
obstruction was either situated in the pelvic

by Google

58 The Medical Press.

ORIGINAL PAPERS.

July 17, icor-

colon or rectum. I then passed a finger up the
rectum and was just able to feel that there was a
tumour in the pelvis lying slightly to the left of
the middle line. 1 could not feel the tumour
directly, but there seemed to be several thick¬
nesses of gut between the examining finger and
the mass. By this time the colicky pains had
ceased, no doubt because the intestine was passing
into a condition of paralysis or ileus. The diag¬
nosis of cancer of the colon, situated probably
about the junction of the pelvic colon and rectum,
was easily made, and I had the patient at once
prepared for the operation. It is always a wise
precaution in these cases to have the stomach
washed out preparatory to anaesthesia, as it
lessens the risk of the patient developing an
inspiration pneumonia should he vomit during
the administration. At the operation I opened
the abdomen in the left inguinal region by the
muscle splitting method, and on passing my hand
down into the pelvis I easily found the growth,
but was unable to draw it up out of the wound ; ;
and consequently I performed a colostomy in
the following manner :—I passed as much of the
pelvic colon as possible down into the pelvis, so
that if I came to attempt excision of the tumour
afterwards, the tumour would not be fixed, and
thus increase the difficulty of the manipulation.
This procedure of selecting as high a part of the
bowel as possible for the colostomy also obviates
to a great extent the occurrence of prolapse
through the artificial opening. I then sutured
the parietal peritoneum round an oval area on
the free aspect of the selected piece of colon, and
finally inserted a large Paul’s tube in the centre
of the area thus shut off from the general peri¬
toneal cavity. During the next twelve hours
some four and a half gallons of fluid faeces escaped
through the tube. The patient reacted well,
and his general condition improved so much that
I decided to, if possible, remove the growth.
Consequently, three weeks after the first operation
I opened his abdomen in the mid line above the
pubis after temporarily sewing over the colostomy
to prevent soiling. On passing in my hand I
was able to grasp the tumour and draw it up till
it was between the lips of the wound in the
parietes. I then divided the gut on either side
of the tumour between clamps and quickly did
an end to end anastomosis by suture; fortunately
I was just able to leave enough of the gut below
the growth completely covered with peritoneum
to allow of this method to be carried out with
safety. Again he made a good recovery, and
finally some weeks later I successfully closed
the colostomy.

These three cases exemplify, at least, one very
important point. In all of them we see the
insidious manner in which the disease may pro¬
gress, so very insidious indeed that in two of them
the onset of acute obstruction was the first
symptom which caused them to consult a medical
man. In all, indeed, we find a history of consti¬
pation for some time, but this is a very common
complaint in old people, and too much stress must
not be laid on it. In only one an attack of colicy
pain preceded the obstruction by several months,
while from none of them could we obtain a history
of the alternating attacks of diarrhoea and consti¬
pation described as typical of intestinal stenosis.
In the third case a gratifying result followed the
employment of the “ three stage ” method of
operating, and we may be reasonably certain that I

had a radical removal of the growth with im¬
mediate end to end anastomosis been attempted
in the first instance the case would have had a
rapidly fatal termination, considering the con¬
dition of the bowel at the time of the first opera¬
tion.

In conclusion, therefore, gentlemen, let me
again remind you (1) of the great importance of
making a full and painstaking examination of all
patients past middle life who complain of any
abdominal symptoms at all referable to narrowing
of the lumen of the bowel, for only by early
diagnosis of these cases can the results of treatment
be improved, and (2) of the necessity to provide
an immediate means of escape for the toxic
intestinal contents in all cases of acute obstruction.

Note.— A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture
for next week will be by Purves Stewart, M.D., F.R.C.P.
Lond., Physician to Westminster Hospital and to the
Royal National Orthoperdic Hospital. Subject: “ Dis¬
orders of Sleep.”

ORIGINAL PAPERS.

THE GENERAL PRACTITIONER.

II.—HIS CLAIM TO RECOGNITION.

By J. LIONEL TAYLER, M.R.C.S., L.R.C.P.

Lond.

I particularly do not wish to claim more
than what is obviously the general practitioner’s
due, but it seems to me there are three aspects
that are particularly his own—(1) as an expert
in the beginnings of disease ; (2) as an expert in
common diseases which the consultant and hospital
practitioners seldom see; (3) he is the only
first-hand observer in the influence of environ¬
ment on healthy and diseased individuals.

(1) An Expert in the Beginnings of Disease .—
It is unquestionable that the majority of patients
are seen in the first stage of their illnesses by the
general practitioner. It may, however, be argued
that, in proportion to the much smaller number
of specialists, their experience is nearly as large,
though I think few would venture to assert this.
Were it so, however, it would still be true that
the ordinary medical man is in this respect at
least as entitled to speak and write authoritatively
on this aspect of medicine as the consultant.

As a student, I remember the scarcely-veiled
contempt that the young house physician or
surgeon and occasionally the senior staff dis¬
played for the general practitioner’s skill, and
to me the feeling at the time seemed wholly
justified. Cases of appendicitis sent in too
late ; obvious abscesses that were pointing and
had been unopened ; advanced cases of phthisis
undiagnosed ; tumours not discovered that were
almost visible to the naked eye, and other like
conditions passed over apparently ignorantly
or carelessly.^ •

When, however, I went into practice myself
I learnt otherwise. I was informed by a colleague
that text-book and hospital information would
help me little. I asked why ? He said he did
not know, but cases in hospital seemed to be
different from those outside. And his conclusion
I was soon able to verify.

In fevers, where it is necessary to distinguish
the notifiable from the unnotifiable diseases.

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July 17, 1907.

ORIGINAL PAPERS.

Tbk Medical Pkus. 59

and the slight cases of fcbricula from the more
defined infections and from the beginnings of
tubercular disorders, I discovered that these
early symptoms, which are of common every-day
occurrence, are scarcely alluded to in our text¬
books. I accordingly wrote to the superintendent
of one of the large fever hospitals, where I had
been trained, stating my difficulty, and asked if
he could recommend me a work that gave more
attention to this subject. In his reply, while
regretting that he was unable to suggest any
book that would be valuable, but thinking of one
the kind needed, he writes that the fever hospital
physicians get their cases “a little later than
the certifying general practitioner and so have
to deal with a more developed disease.” It
is this conclusion that I had myself reached
which is characteristic of the whole aspect of the
ordinary medical man’s practice. He sees every
disease a little or a great deal earlier than the
specialist.

In no acute disease, if the onset is sudden,
does the hospital physician or surgeon see the case
before the local one, for the patient either is in
bed or goes there as soon as grave symptoms
appear. Where the disease is less acute a few
cases are sometimes seen at the hospital drawn
from its local surroundings, but these are neces¬
sarily small in number, and as they are distributed
over many wards and are first seen by students
and transient resident medical officers they make
too small an impression on the general class of
patient to affect the visiting physician or surgeon,
and it is he who writes on medical subjects.
In acute disorders, therefore, the general practi¬
tioner sees the patient before any other professional
man, and since he has to make some sort of
diagnosis in order to tell how to describe the
illness and determine where to send the case to,
it is evident that this field is his alone and yet it
is unrepresented by him in medical literature.

In chronic disorders this is, perhaps, less true,
but even in these the family practitioner is usually
first consulted and later, with or without his
advice, a specialist is seen.

This, then, is partly why the young student
is so unfavourably impressed with the outside
medical man. Hospital cases are nearly always
in a more developed condition, and hence are more
readily diagnosed than when they are first seen.
In the interest of medical science this aspect
requires more detailed treatment than it has yet
received, but until such a province is recognised
as belonging to the general practitioner there
is little hope of improvement

(2) An Expert in the Commoner Diseases. —These,
though less characteristic, are still a distinctive
element in general practice, and what are alluded
to as " slight ailments ” have been, and are still,
quite exclusively within this field and are scienti¬
fically perhaps the most important group of
diseases to study. These slighter maladies shade
almost imperceptibly into the beginnings of the
more serious diseases, and where this is not so
they prepare for them by weakening the resistance
of the patient The relation of repeated “ colds ”
to tuberculosis in some form is close both in children
and adults, and the gradual passage of “ eccen¬
tricities ” into recognised forms of insanity
has never, as a subject of research, received even
a small part of the attention it deserves. If the
ordinary medical man were encouraged to study
his cases more carefully and scientifically there

can be no doubt whatever that all members of
the profession would gain in knowledge as a
result.

In the more pronounced illnesses such as
bronchitis, consumption, nephritis, alcoholic and
dyspeptic states, the experience of the general
practitioner, though, of course, much inferior
to the true specialist on his own line, is from a
different point of view as worthy of consideration
as that of the general consultant, for if he has
less time to study the case at the moment of
consultation he has yet followed the development
of the disease in his patient for a much longer
period, and he is often well acquainted with the
family history and the circumstances that may
have contributed to its onset. In such cases,
therefore, the family medical man’s opinion
should receive more attention than is usually
given to it, and if it is less valuable than it ought
to be, this is largely due to the fact that it is
so often disregarded and is consequently care¬
lessly formed.

(3) Environmental Influence on the Healthy and
Unhealthy. —The admission to the home of his
patients, the gradual increase of friendly relations
between them and himself, gives the general
practitioner opportunities for research into pro¬
blems of heredity, health and environmental
influence that are absolutely unrivalled. He sees
a patient, perhaps a young girl or boy, knows
something of the parents, and sees afterwards
this same patient when recovery has taken place
in a few years, married and a parent. He
can then trace with his own eyes influences
through three, and in some cases, four genera¬
tions, and he has not, therefore, entirely to rely
upon mere spoken evidence, which is so often
misleading. To see people under the various
educational, vocational, and marital tests of
life reacting differently according to different
constitutions; to note differences of weather
influences ; the effect of poverty or of wealth,
these, and a hundred other opportunities, are all
before him. And it is mainly because he has not
been encouraged to express his opinion that the
average doctor fails to give satisfaction to his
patients on many questions that they legitimately
inquire about and with which our literature deals
so slightly.

One may then sum up the position as follows :—
The general practitioner is no longer a mere
subordinate, but has his own particular sphere
of investigation, due to his experience of the
earliest stages of all diseases, and his exclusive
study of disorders of a mild character. To this
his information on hereditary endowment, personal
habits, and environmental conditions must be
added. It is upon such aspects of the health
problem that his judgment should be sought,
not only by the public, but also by other medical
men (a), and this place in medical literature ought
to be reserved for him.

It may be argued that these differences of
experience should have been preceded by differ¬
ences in early training. With this question
I am not at present concerned, but I simply
point out that whether he should or should not
have been educated differently as he has in practice

(a) 1 have, I hope, made It quite clear that the positions of the
specialist and general consultant remain unaffected by the arguments.
My claims belDg lhat there are certain distinitive features of general
practice, which, for the benefit of the medical profession as a while
should b: better recognised.

Digitized by LaOOQle

60 The Medical Puss.

ORIGINAL PAPERS.

July 17. *5<>7-

a different, not an inferior, position to the con¬
sultant and specialist it is imperative that this
difference should be recognised.

A NOTE ON

FRIEDREICH'S ATAXIA AND
SYPHILIS.

By GEORGE PERNET,

Assistant to the 8kln Department, University College Hospital,
London.

In connection with Dr. F. S. Palmer’s excellent
clinical lecture, which appeared in The Medical
Press and Circular for May 8, 1907, I should like
to be allowed to make a few remarks from the
point of view of prophylaxis.

Dr. Palmer states that evidence of syphilitic
transmission has been rarely traced, and adds that
there are few facts recorded to support the connec¬
tion. As regards the syphilis factor, I should like
to call attention to the four cases recorded by

A. Bayet, of Brussels, as they appear to me to be
important. (1) Shortly the details are as follows. The
father stated he had never had a venereal com¬
plaint. That does not go for much, histories being
so fallacious. Nor had he any discoverable morbid
nerve condition. The mother, set. 44, impression¬
able, no definite nerve complaint. In her first mar¬
riage : two pregnancies, the first bein^ cut short
by a miscarriage; the second ending in a female
child, still living. As to her second marriage : lour
children, the subject of Dr. Bayet’s communica¬
tion :

A. A boy, aet. 17.

B. A girl, aet. 14.

C. A girl, aet. 11.

D. A boy, aet. 9.

E. A girl, twin-sister, of D., but she died

of convulsions.

Above followed by five miscarriages.

An examination of the father and mother did
not reveal any sign or symptom of syphilis. But I
should like to insist in passing on the miscarriage
in the first pregnancy (first husband). One mis¬
carriage does not make syphilis, any more than
one swallow makes a summer, yet it is a fact to
bear in mind. As to the five subsequent miscar¬
riages, they do not necessarily mean syphilis; on
the contrary, for in syphilis it is the rule for mis¬
carriages to occur in the earlier stages of the
disease in the mother. Although the mother
exhibited in herself no signs of syphilis, that does
not exclude the possibility of the infection. But
when we turn to the children we find evidence of
syphilis in them. In all of them there were
numerous scars all over the body, apparently the
result of old ulcerating lesions. In all of them
again there were radiating scars at the angles of
the mouth. Moreover, in B. and D. there was
diffuse opacity about the cornea, and in both these
patients there were ulcerating gummata, of the
tonsil in B. and of the foot in D. These gum¬
matous lesions rapidly improved on iodide of
potassium. In D. there was mapped tongue,
which Bayet considers is a condition that may be
connected with congenital syphilis, though not
constantly so. I may add here that I have fre¬
quently seen mapped tongue quite apart from
syphilis; nor do I consider it has any significance
in that direction.

It is not necessary to go into the details of symp¬
toms pointing to the family disease known as
Friedreich’s Ataxia, but suffice it to say that A. was
most affected, next in order being C., and D. ;

B. exhibiting but slight signs, which becane signi¬
ficant, however, when taken with the other three

children’s condition. The details can be read at
large in Bayet’s paper. On the face of it, the
probabilities are that syphilis played an important
part in the production of the Friedreich symp¬
toms, not that I desire to make out that syphilis
is always responsible for that disease; possibly a
variety of infections and toxaemias may lead up to
it. Primd facie, the mother had had syphilis, for
all evidence points to so-called inherited or con¬
genital syphilis as being communicated to the
child through the mother. But that is another
story, too elaborate to go into now.

My point is that when a child is the subject of
Friedreich’s Ataxia, careful search should be made
for any clues pointing to syphilis, and the mother
treated secundum ariem by means of mercury in
her next pregnancies. In women, be it remem¬
bered, syphilis turns up unexpectedly at times
(2). But even apart from any positive
indication, this procedure would perhaps be
worth trying, in order to prevent, if possible, the
development of the Friedreich condition in future
offspring once a child had been affected by the
ataxia. In the latter case, too, the offspring of
future pregnancies might themselves benefit by the
early administration of mercury to them. The
cases recorded by Bayet do not appear to have
had any treatment of the kind, nor does he sug¬
gest prophylactic treatment of the pregnant
mother.

Bibliography.

(1) Bayet: “Maladie de Friedreich et Her^do-

syphilis.” (Jour, de Neurologie N. 8. 1902,

Bruxelles.)

(2) Pernet : The Differential Diagnosis of Syphi¬
litic and Non-syphilitic Affections of the Skin.
Vide pp. 5, 49 . 93 - " 5 » 160.

ON THE CHOICE OF GELATINS FOR
BACTERIAL CULTURE MEDIA.

By T. THORNE BAKER, F.C.S.

Much attention has been devoted to the pre¬
paration of gelatin and other culture media for
bacteriological work, but too little attention has
been paid to the choice of the gelatin itself.
During the past five years we have had to make
a very extensive study of gelatins, and although
our primary object was not the preparation of
culture media, much information applicable to
that work was obtained.

Gelation culture media should be perfectly
transparent, and not in the least cloudy, and the
jelly should be of such consistency that it does not
too easily liquefy. Many gelatin media liquefy
so readily that after forty-eight hour’s cultivation
of a liquefying organism the tubes must be watched
almost hourly, as the shape and character of the
growths is soon lost owing to the liquefaction.

Gelatins rich in the bony matter known as
chondrin precipitate this substance during the
boiling after neutralisation, and hence the filtra¬
tion of the sterile medium through papier Chardin
is difficult, as the pores of the paper soon become
clogged ; moreover, the setting power of a gelatin
rich in chondrin seems to deteriorate readily on
its losing this constituent.

When selecting a gelatin it is desirable to test
it for acidity and for hardness. A one per cent,
solution in distilled water may conveniently
be used, phenolphthalein solution being added,
and the necessary quantity of decinormal caustic
potash solution ascertained for its neutralisation.
All gelatins contain a large number of bacteria,
mainly air organisms, cocci and bacilli of various

Digitized by GOCK^IC

July 17, iqo7.

ORIGINAL

RS.

The Medical Pees*

sizes, but some are due to the water in which
the hides are soaked; in the manufacture of
gelatin the hides are steeped in water containing
lime for several weeks, and a bacterial analysis
we made of this water showed- it to contain an
excessively large number of bacteria, chiefly
motile bacilli. The acidity of the gelatin depends
largely upon the number of bacteria it contains,
and the setting or melting point also, hence it is
very desirable to choose a gelatin as free as
possible from the presence of micro-organisms.

The melting point is most conveniently deter¬
mined in the following way: A 10 per cent,
solution is prepared by soaking ten grains of the
sample in 100 ccm. distilled water for an hour,
then dissolving it with the aid of heat, not, how¬
ever, letting the temperature rise above ioo° F.
A test-tube is one-half filled with the gelatin
solution, and allowed to thoroughly set, dur¬
ing twenty-four hours if possible ; it is then
laid horizontally on the shelf of a small hot-
water oven, the door of which is left open, and the
oven gradually heated, the thermometer being
carefully watched. At some temperature between
88° F. and no° F. the jelly will begin to melt,
and the surface half-way up the tube will sag more
and more until it begins to run ; the temperature
at which this takes place will be the melting-
point of the solution.

If a specially hard medium is required, a
very small percentage of chrome alum may be
used provided, of course, that it does not cause
inhibition or involution of the micro-organisms
to be cultivated. The effect of potash and
chrome alums on the melting point of a ten per
cent, solution of a certain brand of gelatin was as
follows :—•

Quantity per cubic
centimetre.

.0024 gm.

.0048 „

.0003 „

.0006 ,,

.0010 „

Potash alum
Chrome alum

Melting
Point.
97 - 5 ° F.
102.0° F.

119.5° F.

133 - 0 ° F.
above 180°

F.

It may be assumed that the resisting power to
liquefaction by bacteria is directly proportional
to the melting point.

Coignet, Drescher, Heinrich, Simeon, Koepfl
are the principal continental makes of gelatin ;
Heinrich’s brand the hardest as far as our tests
have shown ; Nelson and Luton are the English
makes of first importance, and the latter needs
special mention, since it is unusually free from
bacteria, and its melting point is high ; it is also
exceptionally transparent and filters readily.
In many instances where we have had to make
several sub-cultivations without examination,
we have used a medium prepared by adding one
grain per cent, each of somatose and peptone,
•5 gm. sodium, sodium chloride and ten grains
Luton gelatin, neutralising and boiling for thirty
minutes. The medium has been so clear that no
filtration has been necessary and it has proved
satisfactory for all organisms so far experimented
with ; the low percentage of chondrin in this
gelatin is also in its favour.

At Guy’s Hospital Mr. F. Newland-Pedley,
F.R.C.S., L.D.S., has been appointed consulting
dental surgeon to the hospital ; Mr. H. L. Pillin and
Mr. M. F. Hopson dental surgeons; and Dr. J. W. H.
Eyre bacteriologist.

SOME FURTHER REFLECTIONS

ON S

CANCER AND ITS TREATMENT-

By J. A. SHAW-MACKENZIE, M.D.Lond.

The local atrophy and degeneration of a cancerous
growth induced by subcutaneous injections of trypsin
in the neighbourhood of a tumour or into the substance
of the tumour itself cannot be accepted as evidence of
the successful treatment of cancer. This statement is
based upon the experience of actual facts as proved in
cases which have been under my care, or which have
come under my observation. Moreover, in a large
number of cases the growth itself is inaccessible to
local injection. Again, in the instances in which direct
injection into the tumour or into its periphery has been
practised—a method of treatment I have never person¬
ally recommended—the extreme amount of physical
suffering has been the invariable result.

Presuming, as I have done, that the causative factor
in the cell proliferation of cancer was a deficiency of
trypsin, the natural inference seemed to be that the
difficulty of reaching inaccessible growths would be
met by injections of a solution of trypsin at a distance
from the growth, the assumption being that the trypsin
would reach the site of disease through the circulation,
or supplement the general defi iency underlying its
manifestation. But that assumption does not now
seem so easy of acceptation, inasmuch as this
method of administration does not accord with the
view generally admitted that the blood possesses or
acqu'res certain anti-tryptic properties.

(1) According to S. G. Hedin, (a) normal serum has a
decided anti-tryptic action, and trypsin and its anti¬
body undoubtedly in more than one respect behave
in a way similar to some toxins and their anti-bodies.
He shows moreover that the anti-body can be com¬
pletely saturated by using a sufficient amount of tryp¬
sin, though on the other hand it has been found im¬
possible to completely neutralise all trypsin by an ex¬
cess of anti-body. Attention has recently been drawn
by more than one observer to this view, viz., that
trypsin acting as a toxin, the production and use of
its anti-body cannot be lost sight of in the therapeutic
employment of trypsin in the treatment of cancer.

As long ago as November, 1905, Mr. F. W. Gamble
drew my attention to this aspect of the problem.
He advanced the opinion that the deficiency or absence
of trypsin would imply the non-production of its anti¬
body, a substance which might be regarded as physio¬
logically essential, the absence of which might conduce
to cell proliferation. In such cases, trypsin, regarded as a
toxin, if injected in too large doses, would damage the
cells before they were able to produce its anti-body,
whilst small doses would bring about a considerable
increase of anti-tryptic power. In accordance with this
view, he further observed that the reaction of indi¬
viduals to trypsin might differ according to their
capacity to produce its anti-body, while, even in some
this capacity might be absent, necessitating the resort
to the administration of anti-bodies, prepared after
the well-known methods for obtaining anti-toxic sera.

The question of dosage and the proper control
of this toxic agent, therefore, as also from the first,
have claimed my most serious attention, and
in proof that such caution is necessary, coma,
following injections of trypsin, has been reported
to me in at least two cases in the actual practice
of others. In other cases it has been obvious that
reaction, both locally and in the tumour itself,
varies in different individuals, the dosage and strength
of the solution remaining the same. In truth, my
experience has taught me that each case can only
be treated, so far as the dosage of trypsin is concerned,
in accordance with its special requirements, that is
to say, that in some more trypsin is requisite, in others
less. Moreover, in a certain proportion of cases my
experience has taught me that trypsin is contra-indi¬
cated, as proved by the apparent advance of the disease
instead of its retrocession, through trypsin having un¬
fortunately and inadvisedly bee.i given to the patient.

Digitized by GoOgle

62 The Medical Pies*.

ORIGINAL PAPERS.

July i7, 1007.

I have myself attempted to draw a clinical differentia¬
tion between those cases of carcinoma in which glyco¬
suria is present, or a history of diabetes is present in
one or other member of the same family and those in
which it does not obtain, but rather a long history of
constipation or gall stones. In the former, the liver
or pancreas” (b) is presumably at fault (glycogenic
theory) and trypsin indicated ; in the latter, the liver
(cholesterinic theory) and the method of treatment
introduced by Mr. J. H. Webb by sodium oleate injec¬
tions and oral administration of purified ox gall, indic¬
ated. Furthermore, my impression is that in cases in
which there is a “ specific ” history, trypsin is not
indicated. I desire to lay particular stress on these
points because it seems to have been assumed by
many that the administration of large doses of trypsin
is a method which I advise, and that I recommend
trypsin alone to the exclusion of other methods of
treatment.

For some considerable period a large number of ex¬
aminations of the opsonic index of the blood to m.
neoformans has been made for me by Dr. Aylmer
May, and by Dr. J. C. Matthews, in patients under¬
going the trypsin treatment under my care. From
these examinations it has been shown that the index
may be raised slightly but for the most part remains
normal, in contradistinction to the irregular and
characteristic indices in cases of advanced and untreated
carcinoma ; in other words, auto-inoculation appears
to be prevented, coincident with freedom from fnetor
and pain. They have seemed to show also that in
certain cases the dosage might be increased. How far
these results may be due to chian turpentine injections
—a method of administration originally introduced by
Col. T. Ligertwood, C.B., M.D., and myself (c), and
which I generally use in addition—I cannot say. At the
same time these examinations have not shown the
characteristic curves witnessed in cases after inocula¬
tions of the m. neoformans vaccine. It has seemed obvi¬
ous from this that the increased leucocytosis, following
the use of chian turpentine injections, which I have
demonstrated, bears no relation to the opsonic
index ; that whereas by analogy to other toxins the
trypsin injections should be “ interspaced,” the index
to m. neoformans is not the " tryptic ” index.

In this regard, I may point out that the treatment
of inoperable cancer by the method of Sir A. E.
Wright (d) with vaccines of the m. neoformans controlled
by its opsonic index, coupled with the probability, as
it seemed to me, that this micro-organism belonged to
the tryptic group, led me to consider that the same
control might be applicable to the trypsin injections, (a)
The results show, however, that the tryptic index must
be sought for in other directions. For example, a
direct method of estimating the tryptic or anti-tryptic
power of the blood in vitro has been introduced by Sir
A. E. Wright, and it will therefore be possible to deter¬
mine not only the normal anti-tryptic value of the blood
under different conditions, but also the action of trypsin
administered subcutaneously, and its precise dosage.
In this connection it may be pointed out that the
digestive properties of leucocytes are considered by
Sir A. E. Wright to be due to a ferment apparently
identical with trypsin.

(2) There is, however, another aspect of this question
which cannot be lost sight of - viz., the natural pro¬
duction of trypsin in the body and its aids.

Admitting that a presumed deficiency in the intestinal
tract may be supplemented by the therapeutic employ¬
ment of trypsin orally; recognizing beneficial local and
general effects by its local application and introduc-

(0) Since the above wat written I hare received an Interesting let'er
from Dr. D. Montgomerie Paton, of Melbourne, In which the quest!.n
of anti-bodies an I anti-trypsin is considered. Hi* view is that by
trypsin injections and the use of It and other digestive agents orally,
an active resi-tance to the m. neoformans, which he regards a* a
variety of staphylococcus, in some measurj may be obtained, whereas
by the oral use of antl-dlphtherltic serum, which be has long advocated
in carcinoma and In some bacterial Infections, a similar result Is
obtained, passively. Me demonstrates the passive raising of the
opsonic index to staphylococci by the action of normal and Immune
serums, orally administered, and believes that trypsin Injections
would do tne same actively. (Vide “New Rerum Therary,” by D
Montgomerie Paton. Ballllere, Tindall and Cox, London.)

tion into the circulation by one means or another, the
problem of treatment, in all probability, resolves itself
into the best means of increasing its action or its pro¬
duction in the body or tissues.

It is known that the stimulus of food and acids
excites the alkaline saliva. This promotes the gastric
acidity, and the acid chyme in turn excites the alkaline
secretions of the pancreas, liver and intestinal glands.
The supply is regulated by the demand till equilibrium
is established. Professor E. H. Starling, in the Croonian
Lectures on “ The Chemical Correlation of the Func¬
tions of the Body ” (The Lancet, August, 1905) not
only drew attention to this mechanism, but showed
that the pancreas is stimulated to secretion, chemically,
by the substance secretin, while the trypsinogen of
the pancreas is converted into trypsin by the ferment
of the intestinal glands. Professor B. Moore (e) has
shown that the presence of free hydrochloric acid in the
gastric contents is diminished or absent in cases of
malignant disease of organs other than the stomach.
Obviously, therefore, inhibition of the pancreatic,
liver and intestinal functions follows on the diminution
or absence of the gastric acidity. It is known also that
ingestion of hydrochloric acid doubbs the amount of
the pancreatic secretion (/),though the secretion itself is
devoid of proteolytic qualities till activated by the
intestinal juice, the activity being still further increased
by the bile.

Such considerations no doubt in part explain the
value of hydrochloric acid recommended as treatment
in cases of carcinoma no less than the beneficial
results obtained by my recommendation of prepara¬
tions of the intestinal glands and further administra¬
tion of the bile salts. The power of the intestinal
secretion, however, does not end here, for it plays an
important rile in carbohydrate metabolism.

A similar adaptation or correlation in all probability
takes place in the tissues themselves. As Professor
Starling has pointed out, the stationary condition of
any given cell is the result of equilibrium between two
sets of processes, one causing a building up of the cell,
the other a breaking down. Dr. H. M. Vernon (g), to
whose researches on another and, in all probability,
the most important proteolytic ferment of the body,
erepsin, universally present in animal tissues, and com¬
mon to all animal tissues and organs, I have elsewhere
drawn attention (A), holds that probably the various
intra-cellular proteolytic ferments, whether those acting
in an acid medium or those acting in an alkaline, form
a fairly constant constituent of each individual tissue.
In this respect quantitative comparison is made between
the lineo-j8-protease or proteolytic ferment, which acts
in an acid medium (S. G. Hedin), and erepsin or proteo¬
lytic ferment, which acts in an alkaline.

The first class of adaptations noted by Professor
Starling includes those reactions of the body to chemi¬
cal poisons produced by bacteria, “ and represents one
of the most important means by which the body main¬
tains itself in the struggle for existence.” Such adapt¬
ation, correlation, and reaction is witnessed, as it seems
to me, in the increase of ereptic power of the tissues in
septicemia (one case) and in miliary tuberculosis (one
case) noted by Dr. Vernon.

The same increase exists in carcinoma. As far as
the limited number of cases indicate, noted by Dr.
Vernon, in two cases of cancer (stomach, bladder),
the ereptic power was markedly increased in the
kidney, liver and cardiac muscle; in a third case
(secondary, liver) an increase was observed in the liver
tissues alone. In this it would seem to me that we have
a condition comparable to the adaptation, correlation
and reaction of the healthy tissues to bacteria and their
toxins and opsonins. Viewing the autolytic acid ferm¬
ent (or ferments) of cancerous tissues (Petry ; Blu-
menthal ; “ peptic,” (J. Beard) (») as a toxin it would
appear as it seems to me to call forth the ereptic ferment
irregularly, uncontrolled and unequal to the demand,
save in rare instances of spontaneous cure. Presuming
initial, local or general deficiency of the ereptic ferment
in carcinoma, as well illustrated in a fourth case (rectal)
noted by Dr. Vernon, in which presumably also the tis¬
sues were not capable of reaction, preparations of the

July 17. 1907.

OPERATING THEATRES.

The Medical Press. 63

intestinal glands and liver rich in this ferment were
made for me by Mr. F. W. Gamble for therapeutic
use in the treatment of cancer, in the same way as
originally he prepared trypsin injections (Allen and
Hanbury’s) and pancreatic preparations. (/).

In this connection it is of interest to note that
Professor von Leyden, of Berlin, holds that cancerous
growth is due to insufficiency of a proteolytic fer¬
ment of the liver.

In originally drawing attention to the increased
ereptic power of the tissues noted by Dr. Vernon in
the above cases, I suggested also that it might
be compensatory to an increased autolytic acid
ferment. The converse position cannot be lost
sight of, viz., that this increased autolytic condition
of the tissues may be correlated or adapted to
an increased alkalinity. If so, by analogy with the
mechanism of peptic secretion a direct stimulus, psychi¬
cal, or amylolytic, may be presumed. In such respect
Dr. Francis Hare notes in his work “ The Food Factor
in Disease,” section 708, “achemical, bio-chemical, or
metabolic hypothesis for the etiology of cancer ” in
referring to the work of John Rogers, Junr. (New York),
that “ it has been known for some time that cancerous
tissue contains enzymes, but Dr. Buxton, of the
Cornell Medical College, has shown that the most
abundant and constant enzyme present is the amylo¬
lytic. Conformably, glycogen is found in all tumours
in a quantity varying directly with the malignancy
of the disease.” Again, on the other hand, according
to M. Hartog ( k ), in addition to a saccharoid substance,
a t eptonising ferment, active only in presence of dilute
acids, is present in the developing blastoderm of the
chick, and Dr. Vernon notes that the ereptic power
of the tissues of the guinea-pig, rabbit, and cat, is at a
minimum in the earliest stages of development; that
it increases steadily during intra-uterine life and for
the first few days of postnatal existence, after which
it remains constant.

It would appear, therefore, that from the earliest
stages of development the intra-cellular proteolytic
ferments which act in an alkaline medium are adapted
or correlated to those which act in an acid medium ; that
chiefly associated with failure of the alkaline proteolytic
fer r.ents, due to various causes, local, congenital, or
advancing years, reversion to the peptonising fer¬
ment, which is active only in presence of dilute
acids, obtains, whilst cell proliferation proceeds in
the presence of glycogen and amylolytic ferment, for
the latter by itself is unable to break up the proteid-
glycogen molecule of the living tissues, or still further
in the absence of the intestinal ferments convert
maltose into glucose.

Not long after the appearance of Professor Starling’s
lectures, in which he further concludes that the growth
of the mammary glands during pregnancy was due to
the assimilatory, building up, or inhibitory effects of
a specific hormone or stimulus produced in the foetus,
I received a letter from Mr. J. H. Webb, of Melbourne,
to whose original work (/) on the treatment of cancer
I have so often drawn attention.

He wrote that he had read Professor Starling’s
lectures in the Lancet with the greatest interest; that
some eight years previously he had seen a woman
suffering from a large intrathoracic, sarcomatous
growth involving the shoulder, and pushing the scapula
out of place. She did not suffer much acute pain, but
she had considerable dyspnoea, and the heart was dis¬
placed ; it was of course inoperable, and he treated
her with freshly prepared animal foetal extracts. To
his astonishment the tumour began to slowly diminish ;
in about a year’s time it had entirely disappeared and
eight years later the patient was apparently in perfect
health, though the superficial veins remained dilated.
He remarked that though one case goes for little, he
fancied the remedy for sarcoma must be in the foetal
tissues. In this case it is not improbable that in thus
administering an acid extract he may have been
administering a foetal secretiVn, and that one or
other excited the dissimilatory, breaking down,
ereptic, or tryptic ferment in his patient. In this
connection it is of interest to note that in some rare

instances the occurrence of pregnancy has been known
to arrest, even to cure, pre-existing carcinoma in the
mother. The admitted fact of spontaneous arrest
and cure of the disease not connected with pregnancy,
inspires the hope that, if so, "it is by no means im¬
probable that the curative process may be forwarded
by a recourse to those measures with which art is
furnished.”

Regarding therefore the alkaline proteolytic ferments
as defensive factors, and the cell proliferation of
cancer due chiefly to their deficiency or absence,
the proper method of administration would seem to
be the use of small doses subcutaneously, with larger
doses orally ; or alternatively, and suggestively the
opposite, viz., the use of the acid toxins of the tissues,
animal foetal extracts, or of the growth itself.

References.

(a) " Antitryptic action of Serum Albumen Attached
to the Albumen Fraction,” Journal of Physiol )gy, 1905 ;
" Trypsin and Antitrypsin,” The Bio-Chemical Journal,
1906; by S. G. Hedin.

(b) " Local Irritation and Cancer,” by J. A. Shaw-
Mackenzie, M.D., The Lancet, Jan. 14th, 1905.

(c) “ On Relief and Apparent Arrest of Disease in
Two Cases of Inoperable Cancer,” by T. I igertwood,
C.B., M.D., and J. A. Shaw-Mackenzie, M.D., Journal
of the Royal Army Medical Corps, July. 1904.

( d ) "Treatment with a Factorial Vaccine of Neofor-
mans,” by Scanes Spicer, M.D., and Professor Sir A. E.
Wright, F.R.S., Journal of Laryngology, June 19th,
1906; "The Digestive Powers of Leucocytes,” by
Sir A. E. Wright, Pathological Society of London,
The British Medical Journal January 19th, 1907.

(e) “ On the Absence or Marked Diminution of Free
Hydrochloric Acid i:i the Gastric Contents in Malignant
Disease of Organs other than the Stomach,” by
Benjamin Moore, D.Sc., in collaboration with Drs. W.
Alexander R. E. Kelly, and H. E. Roaf, Royal Society,
March, 1905.

(/) “ A Text-Book of Physiological Chemistry.”
By Charles^E. Simon, M.D.

(g) “ The Universal Presence of Erepsin in Animal
Tissues ” ; " The Peptone Splitting Ferments of the
Pancreas and Intestine,” “ The Ereptic Power of the
Tissues as a Measure of Functional Capacity,.” By
H. M. Vernon, M.A. (Oxon.), M.D. Journal of physio-
logy, 1904-5.

(h) “ Trypsin and Erepsin in Cancer,” The British
Medical Journal, March 24th, 1906. "The Nature
and Treatment of Cancer,” 4th Edition, by J. A.
Shaw-Mackenzie, M.D.

(1) "The Cancer Problem,” by J. Beard, D.Sc., The
Lancet, February 4th, 1905.

(/) "The Cancer Problem and Cancer Research,”
by J. A. Shaw-Mackenzie, M.D., The Lancet, February
nth, 1905.

(k) " Some Problems of Reproduction,” by Marcus
Hartog. (Quarterly Journal of Microscopical Science,
Vol. xlvii., 1904.

(/) " Cancer : Its Nature an ! Its Treatment.” By
J. H. Webb, M.R.C.S., L.R.C.P. The Lancet, October
12th, 1901.

OPERATING THEATRES.

ROYAL FREE HOSPITAL.

Two Operations for Appendicitis after Subsid¬
ence of Ac .te Symptoms.—Mr. James Bf.try oper¬
ated on a boy, set. 15, who had been admitted nineteen
days previously on the third day of a very acute first
attack of appendicitis with peritonitis. On admission
his temperature was 100.4, pulse 128, the abdomen
tender, rigid and painful; vomitin' also was present.
He was kept quiet in bed, purgatives and enemata
were avoided, care was taken not to give any fx>d by
the mouth for the first ten days. All the acute sym¬
ptoms rapidly subsided and operation was now under¬
taken, as Mr. Berry pointed out, at a much more
favourable period, than on the patient’s admission

Digitized by GoOgle

64 The Medical Press.

TRANSACTIONS OF SOCIETIES.

July 17, 1907.

there being at present no acute symptoms of any kind.
On opening the abdomen, numerous recent slight adhe¬
sions over a large portion of the abdomen afforded
abundant evidence of the extensive peritonitis that
had existed when the boy was first seen. The appendix
was found deeply seated below the caecum ; the tip
was firmly adherent, perforated, and surrounded by a
small abscess cavity, evidently the remains of the pre¬
viously widespread inflammation. Removal of the
appendix presented no difficulty and the wound was
closed without drainage.

The second case operated on was similar, but much
less severe. The patient was a woman, aet. 24, who had
been admitted on the secon 1 day of her fourth attack
of acute appendicitis. The present operation was per¬
formed eight days after admission, when the temper¬
ature and pulse, which on admission had been 101 to
and 108, had both fallen to normal, 96 and 70. The
intervening treatment had been similar to that em¬
ployed in the preceding case. At the operation the
appendix was found greatly thickened, adherent, per¬
forated, and connected with a small abscess. The
mesentery was tied, the whole appendix removed, and
the stump buried in the caecum by means of a purse¬
string suture. The wound was closed without drainage.
Mr. Berry said that this was a method he employed in
the vast majority of cases of acute appendicitis in his
wards. He thought that operation was very rarely
needed in most cases of acute appendicitis during the
acute stage, provided they were properly treated from
the beginning. Absolute rest in bed, no food by the
mouth for the first few days, and abstention from pur¬
gative; and enemata were the main points in the treat¬
ment. The injudicious and indiscriminate use of pur¬
gatives and enemata he considered responsible to a
great extent for the modern mortality of the complaint,
whilst he was afraid that indiscriminate and hasty
operation undertaken in the early and acute stage was
also responsible for a good deal of it. Localisation of
the inflammation would be found to occur in nearly
all cases, provided the parts were kept strictly at rest,
and this was not possible if they were frequently
irritated or disturbed by purgatives and enemata.
He thought that when the inflammation had become
localised operation could be undertaken with much
less danger to the patient and a far greater prospect of
a successful issue. There were, however, a few—a very
few—cases of acute appendicitis in which immediate
operation was demanded—cases of so-called fulminating
appendicitis, cases of sudden rupture of an abscess,
cases with acute intestinal obstruction, and some few
cases of general peritonitis. In the latter condition,
however, the less done at the operation the better, a
small incision being all that is usually required.

It is satisfactory to state that a week after opera¬
tion both patients are doing well in every way.

TRANSACTIONS OF SOCIETIES.

OPHTHALMOLOGICAL SOCIETY OF THE
UNITED KINGDOM.

Meeting held Friday, July I2th, 1907.

The President, Mr. Priestley Smith, F.R.C.S., in
the Chair.

Dr. Fukala, of Vienna, read a paper dealing with
the

treatment of a variety of eye conditions.

For marginal blepharitis he advocated an 8 per
cent, to 10 per cent, solution of silver nitrate applied
to the edges of the lids daily, care being taken that
none of the solution enters the_eye. For scleritis,

both of the superficial and deep types, he recom¬
mended the daily application of a 1 in 4,000 solution
of perchloride of mercury. The procedure being to
first anaesthetize the eye by cocaine, and then with
a pledget of cotton wool dipped in the solution to
gently rub the sclerotic with a circular movement
around, but not touching the cornea. This was
thought to influence the ciliary blood vessels. Similar
treatment was stated to be effective against chondritis
with vitreous opacities, and also occasionally against
embolism of the central artery of the retina.

Mr. \V. H. Jessop read a paper on three cases of

ACUTE UNI-OCULAR OPTIC NEURITIS

in boys, accompanied by great loss of vision and
complete recovery. The cases were three public
school boys, aet. 12, 17 and 14. In each there was in
one eye marked papillitis, the swelling of the optic
disc being about 1 mm., and the vision was reduced
to counting fingers. No cause could be found in
two of the cases ; but in one of them two months
after the commencement of the papillitis an abscess
discharging a quarter of a pint of pus broke into the
rectum. He was operated on afterwards for appendi¬
citis. The probability is that all cases are due to
toxaemia. In each case the acuity of vision returned
to the normal, in two patients after two months, and
in the third after four months. In two cases there
was a marked central scotoma, and probably also in
the third. So that besides papillitis there was also
retrobulbar neuritis. The treatment adopted was
mercurial inunctions, iodide of potassium and pro¬
tection of eyes by peacock green glasses. The great
point is the prognosis, as though the vision is much
reduced there is complete recovery with normal
acuity of vision and normal fields, but the optic
nerves remained slightly pale.

In the discussion on this paper, in which Messrs.
Marcus Gunn, W. Holmes Spicer, Arnold Lawson,
J. Taylor, and others joined, several similar cases
were mentioned. The condition was held to be one of
retrobulbar neuritis, possibly upon a toxasmic basis,
and the prognosis on the whole good, with little or no
diminution in visual acuity.

Mr. A. Lawson showed a case of “ Thiersch grafting
for symblepharon, the result of pemphigus seven
years after operation.” The left eye has kept well,
and although some slight shrinkage has gone on,
movements and vision remain good. In the right
eye the shrinking process went on somewhat more
rapidly, so that two years ago it was necessary to do a
further grafting operation, since when the eye has
remained well.

Cases were also shown by Messrs. L. V. Cargill
(‘‘Solitary Quiescent Tubercle of the Choroid”),
S. Stephenson (‘‘ Curious Ophthalmoscopic Change ”),
and A. McNab (“ Congenital Opacity of the Cornea in
three members of one Family ”).

ROYAL SOCIETY OF MEDICINE.

The Therapeutical Section on Saturday, July 6th,
met at Oxford University. The visit was arranged
for the Therapeutical Society before it dissolved, and
much regret was felt at the absence of Dr. French, who
was hon. secretary of that Society, he was prevented
from being present through illness, from which he is
happily now recovering.

The members were received at the entrance to
Queen's College by Sir Thiselton-Dyer, the first
president of the old Society. After a glance at the
buildings and some of the other colleges, he con¬
ducted the party to the Museum, where Professor
Osier was already waiting ready to point out the
beauties of the library and show the way to the
laboratories.

The first visited was that of Professor Gotch, who
explained some of his most recent investigations of
the action of the heart. He pointed out that his
predecessor, Professor Burdon Sanderson, had con¬
ducted his experiments on the empty heart, which
revealed that the ventricular contraction began at
the base and terminated at the apex. However,

Digitized by Google

July I’’, 1907 .

CORRESPONDENCE.

Professor Gotch has by delicate electrical experiment
on the active heart 11 situ, shown that the contraction
commences at the base, travels to the apex and
terminates at the aortic base, this was graphically
displayed, and many interesting diagrams and photo¬
graphs were shown.

He next demonstrated a means of at once deter¬
mining the point of near vision of anyone, the method
depending on the different focal lengths of the red
and violet rays.

Dr. Ramsden in the same laboratory had arranged
a number of beautiful experiments, which he described
determining the “ Separation of Solids in the Surface-
layers, of Solutions and Suspensions.”

Proceeding to the Anatomical Rooms, Professor
Arthur Thomson showed a thorax with complete
transposition of the viscera ; and a dissection of a
calf’s heart displaying to perfection the auriculo-
ventricular bundle (Hiss), and demonstrating how
important a structure it is; also some enlarged
photographs (stereoscopic) of the very early human
embryo.

In the Pathological Rooms there was an exhibition
of macroscopic and microscopic specimens, and Dr.
Gibson gave a demonstration of Jacquet’s Polygraph
(modified) on a lad.

Lunch followed in Queen’s College, and in the
afternoon many places of interest including the
Botanical Gardens were visited.

Professor Osier gave a garden party at his home, to
which all were invited, he had laid out for inspection
some of his choicest, rare and interesting folios, which
everyone thoroughly enjoyed the privilege of examin¬
ing-

The Section dined in the evening at Queen’s College.
Sir James Sawyer proposed the health of the President,
Dr. T. E. Burton Brown, C.I.E., he referred to the
good work done by the Society of which he was the
"Father,” remarked on the fitness of seeing him
president of the new Section, and hoped for greater
things in the future.

Dr. Burton Brown replied and thanked the
officials of Queen’s College for their courtesy in
inviting the members to that College, and in placing
rooms at the disposal of those who desired to remain
until Monday.

Dr. Cecil Wall, through whose good offices the visit
was rendered possible, acted as cicerone, and showed
every attention and kindness to the party.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Parla. July 14 th 1907,

Treatment of Metritis.

For cauterising the cavity of the uterus, liquid
caustics are preferable to solid caustics. They should
be applied by means of a plug of cotton, wet with a
solution of iodine, 6 dr., phenic acid 4 oz., glycerine,
8 oz. ; or chloride of zinc, 1—2 ; nitric acid ; pure
phenic acid ; formol, 1—3.

Curettage, according to Pozzi, is the rational treat¬
ment of chronic metritis where the simple treatment
(vaginal and intra-uterine injections) fails, and should
not be delayed too long for fear of exposing the paren¬
chyma of the uterus to follicular degenerescence, and
the possible propagation of the lesions to the tubes.

Certain authors, on the contrary, consider the opera¬
tion of curettage absolutely counter-indicated. “ Cu¬
rettage,” says Marion, “ should be prescribed in non-
hsemorrhagic acute, or chronic metritis, and in cases
where haemorrhagic metritis is complicated with
lesions of the Fallopian tubes.”

For Professor Loubeyran, the operation was only
indicated in those cases of chronic metritis, where all
other treatment had been given a long trial and
without success.

Ulcerations of the os should be touched every two

The Medical Press. 65

days with tincture of iodine, weak nitric acid, or
chloride of zinc, 1-10. After cauterising, the vagina
should be irrigated and a plug of antiseptic gauze in¬
serted. Where the cervix was much jagged or hyper¬
trophied from follicular degenerescence, the parts
should be excised.

Haemorrhagic metritis is best treated by rest in bed.
prolonged vaginal injections with very hot water
(122 0 F.), and the administration of hydrastis cana-
diensis, viburnum prunifolium, hamamelis virginica, or
ergot of rye. If the haemorrhage does not cease,
plugging of the vagina with antiseptic gauze will be
necessary.

The operative treatment is reserved for the cases
where retention of the placenta is suspected. The os
is dilated and the cavity irrigated, after which a digital
curettage is made, or, if necessary, a curettage. In case
of degenerescence of the mucous membrane, curettage
is also necessary. In rebellious cases, hysterectomy
should be performed.

For chronic painful metritis, the cervix should be
painted, two or three times a week, with the caustics
above-mentioned and plugs of glycerine or ichthyol
applied. Hot vaginal injections and scarifications of
the os are very useful. Where every treatment fails,
hysterectomy is the only resource.

The Paralysis of Diphtheria.

According to Professor Comby, the most efficacious
treatment of paralysis as a complication of diphtheria
is that of injections of the serum of Roux. It always
succeeds if employed promptly. Three drachms
should be injected each day until improvement takes
place.

A Differential Sign of the Origin of Pain.

Pain is either of organic or psychic origin, and
frequently the distinction is difficult. M. Lorvi
observed that the dilatation of the pupil was in direct
relation with painful sensations. In the healthy
man, if strong pressure is made on the testicle, this
sign is observed, while in an individual suffering from
ataxy, where the testicle is insensible, dilatation of
the pupil is not observed.

According to the same author, dilatation of the
pupil produced by pain allows distinction to be made
between pain of organic origin and that of hysteria.

Another author made numerous experiments along
these lines and came to the same conclusion. In
healthy persons, the painful reflex invariably existed,
the dilatation of the pupil was affected more or less
rapidly, according to the intensity of the pain itself,
and after the cessation of the pain, the pupil returned
slowly to its first dimensions.

In pneumonia, pleurisy, articular rheumatism,
sciatica polyneuritis, Pott’s disease, appendicitis,
ulcer of the stomach, 'pressure exercised on the
painful regions provoked dilatation of the pupil.

On the other hand, in ten cases of hysteria, no
enlargement of the pupil was observed when pressure
was made over the usual points. Similar negative
results were observed in two patients suffering from
chlorosis, and eight men affected with traumatic
neurosis.

The above facts are of great importance, as by
them a distinction can be made between the characters
of pain.

GERMANY.

Berlin. July 14th. 19 o 7 .

At the German Society for Surgery, Hr. Riesinge
read a paper on the

Operative Treatment of Dilatation of the
(Esophagus.

He showed a patient who for twelve years had
suffered from a deeply-situated diverticulum of the
oesophagus. The patient, a female, often vomited in
the following morning the remnants of the dinner of
the day before, whilst the food of the evening before
did not come up. Of two sounds introduced, one,
usually the thicker, reached the stomach readily;
the other generally passed for a distance of 32 cm.
below the line of teeth, but no farther. A Rontgeno-
gram when the oesophagus was filled with a bismuth

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66 The Medical Press.

CORRESPONDENCE.

July 17, 1907

porridge showed a wide shadow reaching from the
second dorsal vertebra to the oesophagus, the lower
end of which distinctly bulged out to the right. An
operation was decided on on account of the patient’s
starved condition and the great discomfort caused
by the diverticulum. After a preliminary gastric
fistula had been formed the whole oesophagus was
exposed from the posterior mediastinum ; resection
of a portion was performed 7 cm. in length from the
fourth to the seventh rib, the pleura was separated
from the lateral surface of the spine, and the trsophagus
was isolated almost to the diaphragm ; the pleura was
not injured. It was intended to diminish the lumen
of the oesophagus by forming folds, but the patient's
collapse prevented this. The extensive wound was
tamponnaded. After several weeks a strip 15 cm.
in length and 1-2 in width was excised ; the suture
was done in two stages. The operation was quite
successful ; swallowing was undisturbed and the
vomiting ceased.

Hr. Schmitt (Munich) reported a case of
Complications after Resection of the Stomach.

The cases were rare. (1) An extensive resection
of the pylorus was performed for carcinoma after
Billroth’s method. Recovery was uninterrupted, and
increase of weight took place. A year and a half
afterwards the patient got double pneumonia after a
very violent long coughing bout. A small red fluc¬
tuating spot formed in the cicatrix of the abdominal
wound and opened of itself in a few days, whereupon
a large quantity of bile escaped. Within a few days
a complete fistula formed from the stump of the duo¬
denum with casting off of the ligature placed there
a year and a half before. Gastric digestion remained
undisturbed. After freshening the edges, turning in
and suturing, healing took place. Probably in con¬
sequence of the violent coughing a backward movement
of the bile had taken place between the sutured end
of duodenum and the gastric fistula, whereby in¬
fection of the bile possibly took place. He had seen
fistulae occur twice after such resections of the stomach ;
lately he had therefore preferred Kocher’s method
where technically possible.

(2) Total necrosis of the omentum invaginated into
the colon with secondary fistula. Extensive resection of
the stomach after Kocher’s method had been performed
with good recovery and good action of the bowels.
Three weeks after the operation the abdominal wound
opened and a large piece of omentum the size of the
hand was cast off. For the next week the evacuations
were normal; then suddenly great distention took
place on the right side of the abdomen. A small
shred of necrotic tissue showed at the opening. On
slight traction on the piece of tissue a lump the size
of an apple was expelled as by an explosion. This
was followed by a great quantity of gas and faeces
forcibly expelled. The fistula of the transverse colon
closed of itself. The omentum first became gangrenous
three weeks after the resection of the stomach, and it
had worked its way into the transverse colon which,
however, performed its function normally until com¬
plete occlusion of the bowel took place. It reminded
the speaker of the wanderings of foreign bodies in the
intestines.

AUSTRIA.

Vleana, July 7th. 1907.

Cardia-Carcinoma of Stomach.

Eiselberg presented a man, aet. 36, who came to
the clinic suffering from inability to swallow food.
The sound was applied, but would go no further than
the upper part of the cardiac end of the stomach, no
matter how fine the sound. Notwithstanding this
mechanical inability to pass a sound the patient could
sometimes pass food into the organ in the usual way.
Carcinoma of the oesophagus was at once diagnosed,
but when the weight of the patient was considered,
and that he had lost only 9 kilos, or 19 lbs., in two years
while this had been going on all the time, such a con¬
clusion as carcinoma was doubtful.

Could it be a “ Divertical,” forming a sac in the

wall of the oesophagus ? The patient was given a
solution of bismuth, and the Rbntgen rays applied,
when a large sac of enormous distention was dis¬
covered immediately above the cardiac end of the
stomach in the oesophagus. Considering the loss of
flesh and the probable increase in this direction, the
longer it was allowed to remain, Witzel’s form of
gastrostomy was resolved on as the best operation for
this case. After the patient had rested in hospital for
a time and appeared to recover, the oesophagoscope
was again applied to confirm the diagnosis of a diver¬
ticulum in the oesophagus, but nothing further could be
discovered. The day before the operation, another
examination was made with the rays, when a well-
defined sac was observed at the cardiac end of the
oesophagus in form of a finger pointing towards the
stomach. As no opening from the oesophagus could
be detected either by the instrument or the rays, it
was now doubtful if the diagnosis were correct, as it
might be dilatation caused by spasms of the oesophagus.
After comparing the first radiograms with the last,
the spasm theory was abandoned and the operation
performed. After making the fistular gastrostomy,
spasm in the lower end of the oesophagus did set in
and complicated the results, sj that after another three
weeks laparotomy of the stomach had to be performed.
The hand was then entered and the oesophagus explored.
At first a very fine catheter could only be inserted,
w-hich was gradually increased until the thumb could
be passed, and after it was fairly dilated the organ
was closed and healed up favourably. A No. 24
bougie can now be passed easily by the mouth into
the stomach and deglutition is normal.

Contractional Phenomenon of the Stomach.

Kaufmann, from his experiments on animals, dis¬
tinguishes two separate functions of the stomach
occurring one in the cardiac and the other in the
antral portion of the organ between which a constrict¬
ing ring actually makes two water-tight compartments.
The antral portion is much more active and vigorous
thanlthe cardiac. He found that the food taken into
the stomach was concentrated and rolled together in
the cardiac end and almost covered with a fine mucous
coating, while the fluid was quickly transmitted to
the antral portion. To obtain this phenomenon he
injected physostigmine, which acts and stimulates the
smooth fibres of the stomach and alimentary canal.
This produces three contractions (a) circular motion,
(6) longitudinal, and (c) cardiac and antral.

Kaufmann considers this an important factor in all
operations on the stomach and particularly in gastro¬
enterostomy, where the functional part of the organ
should be considered whether in the cardiac or antral
portion.

LETTERS TO THE EDITOR.

THE TKERAPEUTICS OF HARROGATE
WATERS.

To the Editor of The Medical Press and Circular.

Sir—I have lately noticed persistent statements in
several newspapers hinting at the diminution of the
effects of Harrogate waters, and The Illustrated
Journal of Health Resorts, May-June, 1907, in par¬
ticular, has published some misleading data regarding
the constituents of the waters, and comparing them
with several other spas, gives an erroneous statement
of their strength and composition.

Under these circumstances I have been prompted
to go into the matter, and will show that so far from
there being any material alteration in the waters they
have not changed in any appreciable degree for a
great number of years.

Having compared the different analyses given in
the journal referred to, I drew the attention of the
authorities here responsible for the management and
distribution of the waters, and they have given
me sufficient statistics to prove my case.

Allow me to place alongside each other the state¬
ment made by the Journal, and an analysis made by
the eminent chemist, Professor J. E. Thorpe, C.B. :—

y Google

July i7. 1007.

OBITUARY.

Professor Thorpe.

_ „ . Old Sulphur Health Resort

Saline Constituents Well Statement.

Grains per Gallon. Pump Room

Sodium Sulphydrate .. 5.215 6.50

Barium Chloride .. .. 6.566

Strontium Chloride .. trace

Galcium Chloride .. .. 43.635 16.75

Magnesium Chloride .. 48.281 >7-75

Potassium Chloride .. 9.592

Lithium Chloride .. .. .753

Ammonium Chloride .. 1.031

Sodium Chloride .. .. 893.670 .236

Magnesium Bromide .. 2.283

Magnesium Iodide .. .113

Calcium Carbonate .... 29.768

Magnesium Carbonate .. 5.953

Sodium Carbonate .. .. u.

Sulphuretted Hydrogen
Carbon Dioxide.

The Medical Press. 67

5.215

6.566

6.50

trace

43-635

16.75

48.281

17-75

9 - 59.2

•753

1.031

S« 3.670

.236

2.283

-11 3
29.768

5-953

11.

1047.561

288.

10.16
40.10

50.26

In the first place it will be noticed that the sum
total of grains per gallon does not agree with the
sum of the different constituents, and as the Journal
apparently quotes an analysis by Mr. West, I find the
total amount given by him in the official record is
1047.01, and not 288.0-.

The amount given by Professor Thorpe (at a later
■date than Mr. West’s analysis) is 1047.01, so that it
■can be seen at once that the statement contained in
the Journal is entirely wrong, both in total and
individual constituents, thus seriously misrepresenting
the strength of the Harrogate waters. °

Might I be allowed to give a list of the analyses
given by leading men since 1794, which shows that
the strength of the waters has been consistently
maintained, and also that the salts in grains per
gallon have scarcely varied during the last seventy
years, and they now appear to be as reliable and
efficient as ever.

Old Sulphur Well Analyses :—

Total Salts in Grains per
gallon.

1794 Dr. Garnett. 754-0

1819 Sir C. Seudmore .. .. 848.10

1830 Dr. Hunter .. .. .. 1010.5

1844 Mr. West .1047.0

1854 Professor Hoffman .. .. 1096.0

i86 7 >. Muspratt .. 1108.78

l8 75 ^ ^ _Thorpe. 1047.01

1048.25
1025.4

1881 Mr. Davis, F.C.S.

1899 „ Townsend, F.C.S. .. 1025.4

In fact without wishing to appear presumptuous it
may be fairly said that taken as a whole the treatment
here now (waters and baths included) will favourably
compare with any other spa, either British or foreign.

I am. Sir, yours truly,

D. D. Brown, M.R.C.S., L.R.C.P.Lond.

Harrogate.

DENTAL AND COSMETIC QUACKS.

To the Editor of The Medical Press and Circular.

Sir, I am glad that in the fight against quackery—
the attempt to expose the whole system before a
Royal Commission—dental and cosmetic impostors are
not to be overlooked. If the operations of these
rogues did not, as they certainly do, inflict injury
upon health, it would be still the duty of the State to
guard simple and foolish women, the majority of
victims, against the robbery, the system of thinly
veiled blackmail, which it often really constitutes, and
to which they are now helplessly exposed. The safety
of this species of quack lies in the fact that there is
hardly any maltreatment a nervous woman would not
condone rather than expose her folly publicly in a
Law Court, as plaintiff in an action for damages. ;

The quack, moreover, in the few cases when pressed,
always refunds his plunder and pays damages rather
than go into court ; hence exposure of this nefarious
traffic is now never effectually made. It cannot be made
without the help of a Royal Commission. Within the
past few weeks there has been published in a medical
paper analyses of fat cures, under cloak of selling
which many quacks are making fortunes. These
cures, when not made up of slightly perfumed fat, were
composed of water strongly acidulate with the cheapest
of chemicals. Retailed at about 2s. 6d. an ounce, the
intrinsic value of this mixture of which the uselessness
for its purpose could be easily demonstrated, was a
small fraction of a farthing. The cheap artificial
tooth fraud could be as easily exposed. If the Food
and Drugs Acts and the Merchandise Marks Acts have
been devised for prevention of much less dishonest
practices in trade, is it too much to ask the Legislature
to protect the public against the far more hurtful forms
of medical fraud which you, Sir, are exposing ? It is
to be hoped that Mr. Sewill’s suggestion of a Royal
Commission will speedily be taken up by professional
organisations.

I am, Sir, yours truly,

A Hospital Dentist.

July 13th, 1907.

OBITUARY.

SIR W. H. BROADBENT, PHYSICIAN-IN¬
ORDINARY TO THE KING.

We regret to record the death, on the 10th instant,
of Sir William Henry Broadbent, K.C.V.O., M.D.,
F.R.S., Physician in Ordinary to the King, at his
house in Brook Street, London. Sir William Broadbent,
some nine months ago had a severe attack of influenza,
which was followed by an attack of pneumonia and
empyema, necessitating an operation. From this
illness his recovery was slow, and he never resumed his
active occupation.

Sir William was a son of the late Mr. John Broadbent,
of Longwood Edge, was bom in January, 1835, and
received his general education at Huddersfield and at
Owens College, Manchester. His professional studies
were carried on in Manchester and partly in Paris,
and later at St. Mary’s Hospital, London. He became
M.B. of the University of London in 1858, and M.D.
of the same University in i860, and a member of the
College of Physicians in the year following. At a later
date the latter body elected him a Fellow, and on two
occasions appointed him to the important office of
Censor. One of his first appointments in London was
in connection with the Western General Dispensary,
but it was not long before he was appointed to the
staff of his own hospital, St. Mary’s, working in its
medical school for many years as lecturer on clinical
medicine.

He completed two terms of office as honorary
physician and later as consulting physician. Sir William
became connected with the Court at a comparatively
early date. He was summoned to attend the Prince
of Wales, then Prince George of Wales, when brought
to Marlborough House from Sandringham, suffering
from typhoid fever in 1891. He was also one of the
physicians in attendance on the late Duke of Clarence
i n the following year. Similarly he was frequently at
the bedside of Queen Victoria during her last days in
1901, and more recently took part fin the treat¬
ment of King Edward during the illness which
led to the postponement of his Coronation in 1502.
Some three years before her death the late Queen
appointed him to the position of Physician Extra¬
ordinary, and the King on his accession confirmed him
in the office of Physician in Ordinary, which he held
when the King was Prince of Wales.

Sir William Broadbent was closely connected with
the professional life of London. He filled the office of
President of the Harveian Society, the Clinical, the
Neurological Societies, and the Medical Society of
London. He was also a vice-president of the Cancer

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68 The Medical Press.

SPECIAL REPORTS.

July 17, 1907.

Research Fund, and President of the British Medical
Benevolent Fund, besides playing an important part
in the organisation and conduct of the National Asso¬
ciation for the Prevention of Tuberculosis. He re¬
ceived honorary degrees from Edinburgh, Leeds, St.
Andrews, Canada and the United States, and was a
Fellow of the Royal Society of England. He was
also honorary member of a great number of learned
societies of Berlin, Vienna, and other continental
cities.

Sir William’s contributions to literature were
numerous and he wrote several books, some of which
have gone through many editions. The best known and
most popular was that upon “ Heart Disease,” while
among others may be specially mentioned “ The Pulse,”
and “ The Mechanism of Speech and thought.”

Sir William was created a baronet in 1893, and in
the year of the Coronation he was created K.C.V.O.
He was also made Commander of the Legion of Honour,
on the occasion of the visit of a number of distinguished
English medical men to Paris, some years since.

In 1863 Sir William married a daughter of Mr. John
Harpin, who survives him with a family of five chil¬
dren. He is succeeded in the title by his eldest son,
John Francis Harpin, who was bom in 1865, and is
in practice as a physician.

Before his death Sir William Broadbent had been
away in the country for five months, having had to
abandon practice during that period. In his last
illness he was attended by Sir Thomas Barlow, Prof.
Osier, and Mr. Edmund Owen. It was only in January
last that he celebrated his seventy-second birthday.

By his death one of the foremost figures in the pro¬
fession has been lost to us. His intellect was essentially
that of the sane and wholesome type that confers upon
the medical life of our nation its peculiar excellence.
A forcible testimony to the personal worth of this great
physician is afforded by the warm personal interest
and friendship which the Royal Family have always
shown in his career. ^

At the memorial service, held on Saturday last at
the Church of St. Peter, the King and Queen were
represented by the Hon. Sidney Greville, and the
Prince and Princess of Wales by Sir James Reid.
Practically all the medical institutions and societies in
London were represented, the coffin was covered with
wreaths, one being from the Queen, inscribed, “In
grateful remembrance, from Alexandra ." The funeral
afterwards took place at Wendover Churchyard,
Buckinghamshire.

SPECIAL REPORTS.

ROYAL COLLEGE OF SURGEONS—
ELECTION OF PRESIDENT.

A quarterly meeting of the council of the College
took place last Thursday, Mr. Mansell Moullin, Mr
Frederick Eve, Mr. Bruce Clarke, and Mr. C. J. Symonds
the successful candidates , at the recent election of
Fellows to the Council, were introduced and took their
seats as members of the Council.

Mr. Henry Morris was re-elected president, and Mr.
Rickman J. Godlee and Mr. Watson Cheyne, C.B.,
F.R.S., were elected vice-presidents of the college for
the ensuing collegiate year. The following professors
and lecturers were appointed :—Dr. Wm. S. Handley,
one lecture on therapeutic criteria in cancer; Dr.
Victor Bonney, three lectures on the connective tissues
in carcinoma; Mr. Donald Armour, three lectures on
the surgery of the spinal cord and its membranes;
Mr. A. R. Thompson two lectures on the anatomy of
the long bones relative to certain fractures, and Dr. F. C.
Shrubsall, three lectures on the physical anthropology
of the pigmy and negro races of Africa. Arris and Gale
lecturers: Dr. F. A. Bainbridge, one lecture on the
pathology of acid intoxication ; and Mr. Major Green¬
wood, junr., two lectures on the physiological and
pathological effects which follows exposure to com-
ressed air. Erasmus Wilson lecturers: Mr. S. G.
hattock, one lecture on ovarian teratoma; Dr.
W. H. Eyre, one lecture on the surgical importance of

the pyogenetic activities of diplococcus pneumonia;
and Mr. L. S. Dudgeon, one lecture on infection of the
urinary tract due to bacillus coli.

The president reported that by the death of Miss
Moncrieff Arnott the legacy of £1 ,000 bequeathed to the
college by Mr. James Moncrieff Arnott, a former presi¬
dent of the college, became payable to the college, and
that by her will Miss Arnott had left to the college an
oil painting of her father. The Museum Committee
submitted the revised edition of the catalogue of the
physiological series of comparative anatomy in the
museum, and also submitted a revised edition of the
catalogue of the osteological specimens (man).

The President reported that the vacancy on the
Court of Examiners caused by the retirement of Mr.
Golding-Bird, would be filled up at the next meeting
of the Council on the 25th instant. Mr. Golding-
Bird does not intend to seek re-appointment to the
office.

A vote of thanks was presented to Sir John Tweedy
for presenting Rymer’s Fcedera, twenty volumes folio,
published in the year 1711, to the library. The council
accepted the resignation of Mr. C. R. Hewitt, assistant
in the library, and expressed their thanks to him for his
services to the college during the past twenty-two
years. Mr Hewitt has accepted a librarianship in the
Royal Society of Medicine.

In accordance with the recommendation of the com¬
mittee of management of the two Royal Colleges, it
was decided to add the following schools to the list of
institutions recognised by the examining board in
England for instruction in chemistry and physics :
Aldenham School, Elstree, and the Municipal
Technical School, Birmingham.

ROYAL COLLEGE OF SURGEONS, IRELAND.—
ROYAL VISIT.

On the occasion of the recent Royal visit, the
following Address was presented by the College :—
“To His Most Gracious Majesty, Edward VII.,
King of Great Britain and Ireland and all the Domi¬
nions beyond the Seas, Emperor of India ; and to Her
Most Gracious Majesty, Queen Alexandra. May it

f lease your Majesties,—We, the President, Vice¬
resident, and Council of the Royal College of Sur¬
geons in Ireland, desire to avail ourselves of the presence
of your Majesties in Dublin to offer the assurance of our
allegiance to your Majesties and our respectful and
loyal welcome on the occasion of your gracious visit
to Ireland. It is the object of our Royal College to
provide highly qualified surgeons who may serve their
country in the naval or military services, as well as
those others who will devote their lives to the care of
the sick in the civil community. Know’ing the deep
interest your Majesties take in all that concerns the
welfare of your subjects and the progress of surgical
science, we feel confident that our Royal College may
rely on your Majesties’ favour in our continued efforts
to secure the efficiency of those who seek diplomas.—
Signed, on behalf of the Council, Henry R. Swanzy,
(President), John Lentaigne (Vice-President), Charles
A. Cameron (Secretary). July nth, 1907.”

His Majesty’s General Reply.

A copy of his Majesty’s general reply was handed to
each deputation, and at the conclusion of the presen¬
tation of addresses, the King said :—

" Gentlemen,—I thank you for the hearty greetings
and cordial welcome which you have tendered to the
Queen and to myself, and I accept with sincere gratifi¬
cation your loyal assurances of devotion to my Throne
and person. I am pleased to hear of your success in
your various spheres of public duty, and I trust that a
blessing may continually follow your labours for the
prosperity of the country and the welfare of the people.
I regret that time does not admit of an individual
acknowledgment of your addresses, but I ask you to
accept from the Queen and from myself an assurance
of our gratification at your kindly reception of us and
of our hearty sympathy with you in your efforts for
the good of the various communities which you re¬
present.”

Digitized by GoOgle

July 17, 1907.

REVIEWS OF BOOKS.

The Medical Peess. 69

LABORATORY REPORTS.

PLASMON BISCUITS.

Many articles of food can now be obtained in which
the amount of protein has been increased by the
incorporation of that valuable proteid, Plasmon.
These preparations can be confidently relied on where
it is desired to administer protein matter in an easily
assimilable form. There are now nine varieties of
Plasmon biscuits—plain, sweet, wholemeal, rusks,
ginger nuts, fancy, oat, wafer, and cracker, and in
these biscuits there is considerably more protein
matter than in ordinary kinds. Long experience of
Plasmon preparations has caused us to expect a very
high standard of excellence from foods bearing this
name, and cur expectations are not disappointed.
So far as these biscuits are concerned, it is evident that
careful attention has been paid to the details of their
composition and manufacture, with the result that
not only are their nutritive values high, but their
appearance and flavour will commend themselves to
patients.

We have submitted the plain biscuit and the rusk
to a chemical examination, and we find the former to
contain 20-83 per cent, of protei s, 2-94 per cent, of
ash, and 6-38 per cent, of moisture. Plasmon rusks
contain 16 27 P er cent, of proteins, 6-18 per cent, of
moisture, and 1 -56 per cent, of mineral matter. The
flavouring of this biscuit is excellent. The ratio of
albuminoids to carbon-hydrates is, therefore, satis¬
factorily high. The sole manufacturing rights for
Plasmon biscuits have been secured by Messrs. Mac¬
kenzie and Mackenzie, of Edinburgh, who have made
special arrangements to conserve the full qualities of
the Plasmon proportion. Our analyses show that
Messrs. Mackenzie and Mackenzie are keeping these
preparations up to a high level.

ARMOUR'S EXTRACT OF RED MARROW.

The value of red marrow in certain forms of anamia
has become one of the established facts of modern
therapeutics. It is therefore of advantage to medical
practitioners to have a trustworthy preparation on
the market. An excellent product of the kind is the
glycerine extract of red marrow, a bottle of which has
just reached us from the well-known laboratories of
Armour and Co., Ltd., of London. It is guaranteed to be
made from carefully selected fresh material, a!nd to
contain all the essential ingredients of red marrow.
We have pleasure in drawing the attention of our
readers to this elegant and valuable preparation as a
remedy in chlorosis and various forms of anaemia and
perverted nutrition.

REVIEWS OF BOOKS.

DISEASES OF THE NOSE AND PHARYNX, (a)

This excellent handbook has now reached its fifth
edition, a fact which speaks for itself. The plan of the
book is very good. It is divided into four parts.
The first treats of general considerations, including
anatomy, physiology, general diagnosis, and methods
of treatment ; the second, diseases of the nose and
naso-pharynx; the third, diseases of the accessory
sinuses ; the fourth, diseases of the pharynx.

Written chiefly for the use of students and prac¬
titioners, it gives a clear and more or less dogmatic
account of the diseases of which it treats. Though
aiming at conciseness, the descriptions of the various
conditions are very thorough and up-to-date. Indeed,
far more so than in some much more pretentious
works lately published—for instance, a very good
account of the operation for submucous resection of
the septum is given in Chapter XVIII., and the latest
treatment of that distressing and intractable malady—

(a) “ A Handbook of Diseases of the Nose and Pharynx.” By
James B. Ball, M.D.Lond., Physician to the Department for Diseases
of the Throat, Nos’, and Ear, West London Hospital, tic., &c. Fifth
Edition. Pp. xii. and 388; illustrations, 78. ^ Price 7s. 6d. net.
London: Bailliere, Tindall, and Cox.

hay-fever—in Chapter XIII. Some useful formula?
and a good index are added. The binding, printing,,
and general get-up of the book are excellent.

AN.FSTHETICS (a).

We extend a cordial welcome to the new edition
of Dr. Buxton’s book, not only as a sign of the in¬
creasing interest taken in the subject, but also as it
has enabled the author to give us his experience and
judgment of the recent advances which have taken
place in the practice of anaesthetists. The use of
ethyl chloride as a general anaesthetic was in its
infancy when the last edition was published, and
consequently the book contained a very meagre
account of its uses and administration. One can
hardly say that the place which this anaesthetic is
permanently to assume has been settled yet, but its
advantages and limitations are becoming every day
more definite. We agree with our author that its
field of usefulness is much more circumscribed than
it was believed to be by many five years ago, but we
cannot agree with him altogether in the comparison
which he institutes between it and other anaesthetics.
To compare ethyl chloride with ether or chloroform
as to safety is, in our opinion, to endeavour to com¬
pare things which are not comparable. The con¬
ditions under which the administration takes place
make all the difference. Under suitable conditions
we believe ethyl chloride to be a safe and very useful
drug, but one must always bear in mind that it is a
most powerful and rapidly acting drug, much more
so probably than either ether or chloroform, and
consequently its safety will depend to a large extent
on a knowledge of its limitations.

Another subject the treatment of which is quite
new in this edition of the book, is the dosimetric
administration of chloroform, and here Dr. Buxton
speaks with the authority of an experience which is
probably unrivalled among anaesthetists. Since the
introduction of the Vernon-Harcourt and other
regulating inhalers the chloroform controversy has
assumed a new phase ; the dispute is no longer between
the merits of ether and chloroform, but between the
methods of administration of the latter. Dr. Buxton
has demonstrated that, in his hands, at all events,
the new method can give excellent results. He says,
“ From an experience of three years and some thou¬
sands of cases, many of the gravest character, I may
say, I have found the inhaler fulfils all the purposes
for which it was constructed. ... It is easy to
manage, and when once learned will prove reliable
and satisfactory. There have been no dangerous
symptoms due to the anaesthetic in the cases in which
I have used the inhaler, and no failures.” This is
strong testimony in support of the method, but it is
an individual and not a general experience, and other
workers have not been so fortunate. In our opinion
this phase of the controversy will end as did the
former, for it is neither the method nor the drug
which constitute the safety, but the knowledge and
attention of the administrator. Undoubtedly a
careless administrator may be less dangerous with a
regulating inhaler than with a Skinner's mask a id
drop bottle, but the condition is one of less danger
and not safety. We believe, as is pointed out in
Gill’s work on the CHC, 3 -Problem, reviewed in these
columns a few weeks since, and as maintained by the
Hyd -rabad Commission, that safety in chloroform
administration depends on the maintainence of the
integrity of the respiration. With the regulating
inhalers, unless this is maintained free, either no
anaesthesia or dangerous symptoms will follow, the
former most probably, hence the safety. With the
drop method of administration if the respiration is
kept quite free, an overdose can scarcely be given ;
but with any obstruction to the breathing danger is
more likely to follow if this obstruction is not recog¬
nised, and at once corrected, than with the regulating

(S) “ Amith:tics: Their Uses and Administration.” By Dudley
W. Buxton, M.D., Administrator oi Anesthetics and Lecturer in Uni¬
versity College Hospital. Fourth Edition. London: H. K. Lewis.
1907. 8vo, pp. viii. and 415.

Digitized by G00gk

70 The Medical Press.

REVIEWS OF BOOKS.

July 17. 1907.

apparatus. It is in the recognition of the various
forms of this obstructed breathing that the skill and
attention of the administrator are shown, and it is
this that confers the element of safety to the adminis¬
tration in his hands. We should like to see more
space devoted in works on anaesthetics to this subject,
and believe it would be very much more useful to the
beginner than elaborate dissertations on different
methods. Dr. Buxton has added to this edition of
his work a chapter on local anaesthetics which will
make the book much more valuable and complete
from the point of view of the general practitioner.

SKIN DISEASES, (a)

Of the many dermatological text-books extant
few meet the needs of the busy practitioner in dealing
adequately with treatment, and being at the same
time concise. Dr. Whitfield’s handbook should
speedily become popular in this respect, for it contains
much of practical interest from the therapeutic
standpoint without being too bulky. The various
diseases of the skin are dealt with in twenty chapters,
considerable space being devoted to eczema and its
allies. The author has struck the right note here
when he says, with regard to treatment, that “ the
first thing to do is to discover how much is due to
external and how much to internal influence.” He
does not mention, however, the necessity for caution
in the application of strong remedies for the eczema
of infants, owing to the danger of absorption of such
medicaments as carbolic acid, strong mercurials, &c.,
though the risk of inducing pneumonia from applying
evaporating lotions over large surfaces is stated.
The alleged danger resulting from the too rapid cure
of an inf an tile eczema is touch, d upon, and infection by
pyogenic organisms, among other factors, is warned
against. Most will agree in the reservation of arsenic
for eczema of the nails only.

In the matter of classification of skin diseases there
are differences of course of opinion but we confess
that we do not view with favour the inclusion of
seborrhoea capitis under the heading of pityriasis alba
among the “ Diseases due to Vegetable Parasites other
than Bacteria,” still less do we agree with the descrip¬
tion of true seborrhoeic dermatitis as one variety of
chronic eczema. In this connection may be noticed
a good account of the special form of dermatitis
known as discoid eczema, which has been made a
special study of by Dr. Whitfield. The various
parasitic affections receive considerable attention.
We note that the author states that “ there is no
justification ” for the use of formalin in the treatment
of ringworm of the scalp, an assertion with which
we are in the fullest accord. A good description is
given of the X-Ray technique to be carried out in
this class of case. The author is, perhaps, a little
inclined to be pessimistic in treatment, in such affec¬
tions as pityriasis rubra and feigned eruptions, but
this is better than being too sanguine. There is a
lull account of the injuries which may be wrought
upon the skin by the use or mis-use of the X-Rays,
but we do not find any mention of radium as a thera¬
peutic agent nor of the employment of cataphoretic
medication for such conditions as rodent ulcer. Never¬
theless, the book is full of good points, well got up,
and illustrated by some really telling photographs
taken by the author.

SANITARY ENGINEERING AND WATER
SUPPLY (6).

This volume is the latest addition to Messrs. Long¬
mans’ famous Civil Engineering Series, and it forms
a worthy addition to this collection. The preparation
of the work has occupied the spare time of the author

(а) “ A Handbook of Skin Disaascs and their Treatment." By Arthur
Whitfield, M.D., F. R.C.P., Professor of Dermatology at King's College.
Pp. xii., 320, with jo photographs. London : Edward Arnold. 1907.
8s. 6d. net.

(б) " Sanitary Engineering with Respect to Water Supply and Sewage
Disposal." By Leveson Francis Vernon-Harcourt, M.A., M.Inst.C.E.
Emeritus Professor of Civil Engineering and Surveying, University
Callege, London. Price 14s. net. Pp. 419 and xxi., with 287 illustra¬
tions. Medium 8vo, London : Longmans, Green and Company. 1907.

for the last five years. That these periods of leisure
have been well spent is obvious, and although there
is not very much that is novel or new in the book,
Mr. Vemon-Harcourt has served his generation well
in writing on a subject so important to the public
health. As little as possible technical language has
been employed, with the result that those who have
hitherto been deterred from a serious study of the
subject because of the technicalities, have now at
their disposal a trustworthy guide to engineering as
applied to water and sewage matters. In the part
relating to Water Supply, the sources of supply, its
purification, and distribution, are fully discussed, as
also is the construction of wells, reservoirs and dams.

The second part dealing with sewage disposal
contains a mass of judiciously selected information
as to house drainage, the construction of sewage
works, the various ways of disposing of the crude or
purified sexage and other matter relating to the
subject.

The illustrations are clear and well show the points
they are intended to illustrate. It is a book that
will be of immense service to medical officers and sani¬
tary authorities, as well as to water and sewage
engineers, and we can heartily commend it to such.
The author is an eminent authority on his subject,
and he fully realises the points and details on which
it is necessary to lay emphasis. His wide knowledge
of the subject enables him to give examples that not
only form interesting reading, but are of great service
in helping the reader to appreciate the point at issue,
and to differentiate between the different methods.
We should not be far wrong in characterising the
volume as a collation of examples, judiciously inter¬
spersed with theory.

BRAIN SURGERY, (a)

This volume is an expansion of the author’s Lett-
sonian Lectures for 1906. He seems to have aimed at
making it a book of that valuable type that, without
giving a complete text-book account of a subject,
presents certain aspects from a personal standpoint,
and illustrates these aspects from a special experience.
It is encouraging to find that this important class of
books is increasing, and tend to replace to some extent
the stereotyped manuals.

Chapter I. deals from the surgical standpoint with
various affections of the meninges. Our increasing
knowledge of these affections is illustrated by a de¬
scription of well-chosen cases, most of which had
occurred in the author’s own experience. Original
contributions to this knowledge are inconspicuous, but
the amount given forms a readable summary. We
note that the author uncompromisingly advocates
progressive methods, in the form of readier recourse to
operative measures, in the case of the suppurative
meningites. He is hopeful about the future advances
that will certainly be made in this direction, and even
sees ground for the belief that tuberculous meningitis
may yield to similar treatment. Perhaps the most
interesting part of this section is the account given of
the treatment of hydrocephalus, where the author’s
personal experience is particularly valuable. On the
matter of diagnosis he is less happy, and many of his
statements are very open to question. To say, for
instance (p. 61) that optic neuritis is, as a rule, a late
sign in tuberculous meningitis and an early one in
suppurative meningitis, is to render oneself open to
misinterpretation. It is only true in so far as tuber¬
culous meningitis is of longer duration than the other,
but there is no evidence that relatively optic neuritis
is an early sign in the latter, and a late one in the
former. Far more important is the fact that optic
neuritis is greatly (more than twenty times) more
frequent in the former case than in the latter, and this
is not even mentioned by the author. On page 5 7
is the astonishing statement that in a suspected case
of typhoid fever an absent knee-jerk or early disc

(-1) “ Some Poiats in the Surgery of the Brain.” By Charles A.
Ballance, M.S., F.R.C.S. 1907. Pp. 405. Loudon: Macmillan and
Company, ijs. net.

zed by G00gk

Tuly 17. 1907.

The Midk ai. Press 71

REVIEWS OF BOOKS.

changes would be pathognomonic of intra-cranial in¬
flammation. Rolleston has shown that the knee-jerk
is absent in 10 per cent, of ordinary cases of typhoid
fever; the presence of optic neuritis is, of course,
by no means rare in typhoid fever, and is far commoner
in cases free from intracranial complications, such as
typhoid meningitis, than in those with such com¬
plications.

Chapter II. deals with abscess of the brain, and is,
perhaps, the most valuable section in the book. A
good account of the course of symptoms is given,
the classic description by Brissand and Souques being
closely followed. The frequency of tuberculous ear
disease followed by tuberculous meningitis is insisted
on, and the importance of it in diagnosis pointed out.
Naturally the author is a strong advocate of the treat¬
ment of cerebral abscess according to the principles
of surgery now established.

Chapter IV. deals with tumor cerebri, and com¬
prises nearly two-thirds of the volume. A large
number of cases are described in detail, many being
taken from published records.

It is unfortunate that the author suffers, like many
other medical writers, from a lack of interest in English
composition, for the smoothness of reading is greatly
marred by the results of this. The opening sentence
contains a split infinitive, and the impression there
created is not effaced by such sentences as that on
page 20, in which the following ambiguous or libellous
passage occurs: “ I successfully removed such a

cyst . . . from a patient of Dr. James Taylor, who
had narrowly escaped being consigned to a lunatic
asylum, where he might possibly have been labelled
* general paralysis,’ and died without relief.” There
are also many verbal inaccuracies, a few of which
may be cited. On page 173. “ insolvable ” occurs in
place of “ insoluble.” M. Lejonne is called Lejeune
on pages 319 and 375. In a reference on page 375 to
the " Revue de Neurologie,” it is not stated whether
the Revue Neurologique or the Journal de Neurologie is
meant; as a matter of fact, the reference indicatSd
is in the former of these, but on page 846, not page 840,
as stated by the author. Archiv fur Psychiatrie und
Neurologie, on page 376, should be Archiv fur Psy¬
chiatrie und Newenkaukheiten. Deutsche Zeitschrift
fur Neurologie (page 377) should be Deutsche Zeit¬
schrift fur Newenheilkunde. The references given are,
however, interesting historically. On page 236, the
author makes the same mistake that Holmes and
Stewart made in their important article on cerebellar
tumours of speaking of diadocokinesis as a physical
sign of disease. Diadocokinesis is a term invented
by Babinski to indicate the capacity rapidly to perform
successive movements ; impairment of this capacity
is a physical sign of disease.

The volume is profusely illustrated with excellent
photographs and drawings, many of which, such as
those on pages 44. 45. 288, 289. &c., are, however,
totally superfluous. It does not pretend to be a
systematic treatise on the subjects dealt with, and,
naturally, will not be read for this purpose. Its value
for any other purpose is greatly lessened by the dis¬
orderly arrangement adopted. The book would have
been better had the author dealt concisely and fully
with the matters on which he is specially qualified to
speak, and had he checked his tendencies to range
diffusely over a multitude of subjects, fiom Aphasia
to the Evolution of Right-handedness, many of which
could be dealt with only superficially and have only
at indirect bearing on the questions at issue.

HUMAN PHYSIOLOGY, (a)

Professor Tigerstedt's “ Lehrbuch der Physio¬
logic des Menschens.” since its first publication in
1897, has found much favour with teachers of physi-

<ai *• A Text-book of Human Physiology." By Dr. Robert Tigcrstedt,
Professor of Physiology in the University of Helsingfors, Finland.
Translated from the German and Edited by John R. Murlin, A.M.,
Ph.D., Assistant Professor Physiology in the University and Bellevue
Hospital Medical College, New York. London: Sidney Appleton.
1906.

clogy. It is but fitting that the field of its influence
should be widened by an adequate presentation in
English form. This has been ably provided by Dr.
Murlin. It is a pleasure to be able to acknowledge
the debt of gratitude due to the energy and enterprise
of American translators and publishers by English-
speaking students for such works as this which we are
becoming accustomed to welcome almost as a matter
of course from trans-Atlantic sources.

Tigerstedt’s work, as Professor Lusk points out in
his introduction, is a reliable picture of the scientific
structure upon which modem medical practice is
based. It is certainly true that good physiology is
the only preventive of bad medicine. A work such
as this affords that intellectual training which best
fits the students to understand and rightly interpret
the phenomena of both health and disease. Special
attention is devoted, as might be expected, to the
mechanism of circulative and nutritional processes,
but there is a lack of due proportion in presentation
which is disadvantageous to the student. Dr. Murlin
states that his purpose has been to bring the work
within the reach of the second-year medical student.
Whether this object will be attained in America we
cannot say, but with the numerous modern well-
balanced manuals by recognised teachers now avail¬
able in this country we fear Professor Tigerstedt’s
bulky work will have difficulty in securing anything
like a position of popularity among the examiner-
fearing students of British universities and colleges.

The work, however, is one which should be welcomed
by all physiologists and both teachers and students
should regard it as a reliable, attractive and judiciously
illustrated work for general reading and reference.

THE PHILOSOPHY AND PATHOLOGY OF
WORRY, (a)

“ Worry is. in general, a wholly futile and evil
thing.” This is the dictum of Dr. Saleeby, who writes
as a philosophic medical observer, well trained in the
methods of the scientist and yet with keen intuitive
perception of life's perplexities and problems, as they
appear to the ordinary layman. It is a misfortune
that it is given to but few writers on matters medical
to have the happy gift of presenting scientific truths
in form and language suited to the understanding of
“ the man in the street.” Dr. Saleeby is one of the
few who possess the gift of imparting sound knowledge
in a popular and acceptable manner without the
sacrifice of scientific precision. He writes with a
wealth of diction and grace of style which mark his
works with distinction. In this, his latest volume,
he deals with a malady which sooner or later overtakes
us nearly all. The study is timely and in this day of
stress and strain demands serious attention. It is a
work which should be read by every physician and
may well be considered by each burden-bearer in
life’s busy workshop. The nature, significance, and
consequences of worry and its associations with bodily
and mental disease are thoughtfully dealt with. The
evil effects of dulling care by drugs and drinks is
graphically portrayed. The worries of childhood and
old age. the connections of worry with sex, and psycho¬
logical states are dealt with in a manner helpful and
suggestive. Dr. Saleeby is a bold writer and does not
hesitate to express his views dogmatically. An older
essayist would doubtless have qualified many of the
statements relating to religious worry, and worry as
a maker of religions, in regard to which Dr. Saleeby
has allowed himself much freedom of thought and
liberty in expression. The work throughout is planned
on broad and comprehensive lines, and is imbued with
a sense of responsibility, a spirit of reverence for man
and his noblest manifestations and highest aspira¬
tions, and a scientifically-directed altruism which
projects itself into the future. We commend the book
to all worriers and worried.

(a) " Worry: The Disease of the Age.” By C. W. Saleeby, M.D.,
F.R.S.Edin. Pp. 312. London, Paris, New York, and Melbourne:
Cassell and Company, Limited. 1907. Price 6s.

,ed by Google

72 Thx Medical Press.

WEEKLY SUMMARY.

July 17, 1907

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT MEDICAL LITERATURE.

Albuminuria of Adolescence. — Heywood (The
Manchester Medical Chronicle, June, 1907) discusses
the conditions under which serum albumin appears in
the urine in otherwise healthy young people. With a
view to discovering the frequency and character of
residual albuminuria following scarlet fever, the urines
of 39 children, all of whom had suffered from scarlet
fever, were examined. All the children were appa¬
rently perfectly healthy, and in at least 36 of them
there never had been any anasarca or symptoms of
uraemia. In 21 cases, the urine was examined at some
period during ;he first year following the freedom from
isolation ; in 15 cases the interval was from one to
three years, and in three cases was over three years.
The patients’ ages varied from 3 to 18 years. In 19 of
these patients, the urine was found to contain albumin
which was easily demonstrable by ordinary clinical
tests. It was further found that the percentage of
albuminous cases was about the same for those tested
during the first year and for those tested during the
second and third years. Further, it was found that
the early and late residual albuminuria did not differ
much in type. Sex did not appear to have any
influence, but the younger the child was when attacked
by scarlet fever the less liable did he appear to be to
suffer from residual albuminuria. In only one case
was the albumin constantly present, and in that case
it was subject to cylic variations. Various writers
differ considerably as to the number of scarlet fever
patients who suffer from al uminuria. The returns
from the Metropolitan Asylums Board, dealing with
66,871 cases, put the percentage at 13.67, while
Grainger Stewart and Thomson put it at 60 per cent.
Heywood concludes that about 50 per cent, of patients
attacked by scarlet fever suffer from albuminuria
during the course of the disease. As regards prognosis,
he believes that the vast majority of cases of albumi¬
nuria in the young recover; the minority, which
include those cases in which granular and epithelial
casts are found, remain unaltered or pass on to chronic
granular nephritis. K.

The Prognosis in Transient Glycosnria.— Barringer
and Roper (Amer. Journ. of the Med. Sciences, June,
1907) discuss this very important question and the
relation of this condition to alimentary glycosuria.
The writers define transient spontaneous glycosuria
as that which occurs occasionally in patients on ordi¬
nary diet, and for which none of the various causes of
glycosuria can be discovered. Von Noorden has ex¬
pressed the opinion that such glycosuria is in most
cases the warning signal of latent diabetic disease.
In order to estimate the value of this opinion, the
writers have examined 20 such patients, and find that
four of them in from five to eight years have developed
mild diabetes, while a considerable number of the
remainder showed sugar in the urine on the ingestion
of 100 grams of glucose. Of these later cases, the
majority eventually became diabetic. The writers
consider that “ these various facts may be explained
by an assumption, which readily suggests itself, that
is, the division, broadly, of spontaneous glycosuria
into two types : (1) A class essentially diabetic from
the onset, in which sugar recurs, which shows con¬
stantly glycosuria, and which, at the end of five or
more years has become diabetic or probably diibetic.
(2) A class quite harmless, in which sugar does not
recur after the first weeks, and which does not show a
glycosuria c saccharo except, perhaps, during the first
weeks, and does not develop diabetes. The glucose
test would, therefore, seem to give important help in
differentiating these two provisional types of spon¬
taneous glycosuria at a relatively early date.” Such

a differentiation is of considerable importance not only
for prognosis, but also for treatment, for it is of im¬
portance that the former should be kept on a restricted
diet even though the glycosuria has not recurred, while
the latter need not be subjected to such restriction.

K.

Treatment of Diabetes by Drugs. —Parsons (Prac¬
titioner, July, 1907) reviews the use of drugs in this
disease under the following heads : (1) To control the
glycosuria; (2) to avert or remove coma; and (3) to
relieve symptoms and complications. He concludes
that opium is the best anti-glycosuria drug at present
available, and it is most useful in t e severe cases in
which a rigid diet fails to remove all s ;gar from the
urine. Sodium salicylate and aspirin in 15 grain doses
three times a day are both useful in mild cases, and
jambul may be used as an alternative to either of these.
Sodium bicarbonate in doses from 150 grains up, is
useful to avert coma, and an int avenous injection of
35 ozs. of a 3 or 4 per cent, solution of the carbonate
of soda affords the best chance of restoring conscious¬
ness in diabetic coma. Constipation should be guarded
against in all stages of the disease. K.

Infantile Paralysis. —Numerous attempts have been
made of late years to bring about a cure of loca¬
lised paralysis due to acute anterior poliomyelitis by
surgical methods. The more important of these
methods have consisted of tendon transplantations
and of nerve grafting. Nerve grafting has been
principally carried out in cases of upper-arm paralysis,
and the operation has usually co isisted of implanting
the diseased trunk of the brachial plexus into a neigh¬
bouring healthy trunk. Babcock now reports a case
in which a novel method was adopted (Journ. of Amer.
Med. Assoc., Vol. 48, No. 21, p. 1742), to which he
applies the term of transbrachial anastomosis. The
case was that of a boy, aet. 4, who suffered from very
extensive paralysis of the right arm, and also of the
trapezius muscle. Owing to the extent it was found
impossible to perform the more usual operations,
and in consequence both brachial plexuses were ex¬
posed and a bundle of healthy nerve fibres was sepa¬
rated from the sixth left cervical trunk and cut across.
A tunnel was then bored between the anterior muscles
of the neck and the trachea, and through this the
bundle was brought across the neck to be sutured to
the distal end of the atrophied right sixth cervical
trunk. The child was seen three and a half months
after the operation, and it was then found that the
left arm had not suffered in any way, and that the
right arm was considerably improved, the scapular
muscles, the pectorals, and the extensors of the fingers
showing most beneficial change. The writers discuss
the way in which the improvement may have taken
pi ice, and suggest the following : (1) That the splitting
of nerve trunks reduces the pressure in individual
nerve fibres, thus enabling compressed fibres to again
functionate. (2) That in splitting of nerve trunks
many fibres must necessarily be cut. Some of these
cut fibres may be normal and some degenerated ; if
the:i new anastomoses occur, function might be partially
restored to paralysed parts. (3) That new fibres
actually grew from the left brachial plexus into the
right. This they regard as the most likely explanation
of the improvement in this case. M.

Treatment of Gastric Adhesions by Fibrolysin. —As

is well known, Hebra demonstrated some fifteen
years ago that thiosinamine was an agent capable of
softening cicatricial tissue. The drug, however, never
came into extensive use, owing to its general insolu-

gitized by CjOCK^Ic

July 17, 1907.

WEEKLY SUMMARY.

The Medical Press. 73

bihty, and owing to the pain caused by its hypodermic
use. Mendel has, however, succeeded in combining
a molecule of thiosinamine with half a molecule of
sodium salicylate, and producing a soluble substance,
to which he has given the name of fibrolysin. This
drug has the same action on scar tissue as thiosinamine,
and is quite pain'ess when given intravenously or
hypodermically. Herschell has employed this drug in
cases of dyspepsia resulting from gastric adhesions
(Folia Therapeutica, No. 3, 1907, p. 85). He points
out that in many cases of chronic dyspepsia there is a
history suggesting the previous existence of ulceration,
and that sometimes even pyloric thickening can be
felt. The fibrous tissue which causes such thickening
and the fibrous tissue that necessarily results from the
healing of ulcers may, he thinks, be the site and cause
of the pain complained of, and he believes that many
cases would be improved if such tissue could be softened
and the strictured pylorus dilated. To enable the
stricture to be dilated he has employed Zabludowsky’s
gastric massage, and also electricity, with the object
of improving the general tone of the stomach muscu¬
lature. To soften the scar tissue he has given hypo¬
dermically fibrolysin and reports some successful cases.

I a three cases all pain disappeared after from twelve
to thirty injections. In other cases no improvement
was noted. M.

Acute (Edema of the Lung in Ether Narcosis.—

Stevenson reports a case of the above indicated rare
condition (South African Med. Record, Vol. V., No. 10).
The patient was a boy, aet. 16, who was being operated
on for appendicitis. He was anaesthetised with ethyl
chloride followed by ether. Everything went well
till towards the end of the operation, which had only
lasted about forty minutes. Then respiration became
hurried and difficult, and general cyanosis appeared.
The diaphragm continued to contract and relax
actively, while almost all movement of the thoracic
muscles ceased. Auscultation at the same time de¬
monstrated the presence of crepitations all over the
lungs. Strychnine was injected, and warm applica¬
tions applied to the chest, and after an hour of con¬
tinued artificial respiration, i nprovement began, and
recovery finally took place. The writer believes that
the condition is due to vaso motor spasm of the pul¬
monary arterioles, which embar.asses the right heart,
and leads to the oedema. About ten cases have been
recorded, and nine of these have died. The writer
believes that the best treatment consists in the exhi¬
bition of nitro-glycerine or anyl nitrite. M.

Emotional Epilepsy. —Bratz and Leubuscher (Deut.
Med. Woch. Berlin and Leipzig, 1907) have had occa¬
sion to observe for years twenty patients with what
they call “ Affekteplepsie,” for which they claim a
place apart. The patients have occasional attacks,
suggesting petit mal, but with characteristics of hys¬
teria. These attacks develop under the influence of
long-continued emotional stress, and occur at times
from early childhood onwards. The persons affected
are always those with a neuropathic inheritance, and
they are distinguished by a peculiar pallor, evidently
a vaso-motor phenomenon. Like alcohol epilepsy, it
never develops into genuine epilepsy. D.

Sodium Phosphate In Neurasthenic Conditions and
in Exophthalmic Goitre. —Vetlesen (Norsk. Mag. for
Laeg., Christiana) has been proclaiming for some years
the advantages of sodium phosphate in exophthalmic
goitre. His later experience fully confirms his first
assertions in regard to the efficacy of this remedy,
which, he says, was first suggested by the success of
organotherapy. He has now a record of 40 cases of
exophthalmic goitre in which it has been applied. He
tries it in every case, and generally derives great benefit
from it. His present article relates his experience with
it in neurasthenic conditions. He gives the details
of 6 out of 30 cases in which he has administered it
in his private practice, while it has been given to
hundreds at the hospital. No by-effects were observed,
but the tonic action on the nervous system was striking |

in many instances. He adds that the drug is a wel¬
come addition to the usual measures at our command
in treating the protean manifestations of neurasthenia.
The examples he gives show marked benefit under
sodium phosphate administration and its harmlessness
even when continued for months. He orders one
tablespoonful four times a day of a solution of 15
parts sodium phosphate in 250 parts water. D.

The Blood in Rheumatoid Arthritis.— Bullmore
and Waterhouse (Edinburgh Medical Journal, June,
1907) have summarised the results of their obser¬
vations on the blood in rheumatoid arthritis. Ana?mia
is almost always present in rheumatoid arthritis.
There is, as rule, a slight diminution (to betwee 1
75 and 95 per cent.) in the number of the red blood
corpuscles, and a slightly greater (70 to 90 per cent.)
diminution in the amount of haemoglobin. In the
great majority of cases, the leucocytes are not in¬
creased in number, and the normal proportions of the
different varieties to one another are preserved.
Myelocytes in small numbers are present in a few
cases only.

Lactic Acid Bacilli to Combat Intestinal Fermen¬
tation. —Dunn (Archives of Pedriatics, New York,
April, 1907) pasteurized buttermilk, then inoculated
it with a pure culture of lactic acid bacilli, allowing
the mixture to ripen until the development of the
organism had brought about the proper acidity and
precipitation of the casein. In the majority of the
cases the buttermilk was given only after all ordinary
and routine measures had failed. Of 35 selected cases,
there was evidence of a favourable result in 23 ; in 3,
there was immediate cessation of diarrhoea and favour¬
able change in the character of the dejecta, without
gai.iing weight; in 9, no effect was produced. In 14
resistant cases of the fermentative type, the butter¬
milk was first given in the pasteurized form, and after
a sufficient trial had demonstrated a failure to improve,
the pasteurization was omitted. Immediate improve¬
ment followed in each case. In 4 cases of acute diar¬
rhoea the only treatment was the administration of
unpasteurized butter-milk. No castor oil or calomel,
no bismuth or irrigations, and no period of starvation
were employed. Two of these cases were successful ;
one patient improved slightly, and one case was a
failure. Dunn says that the only conclusion that may
safely be drawn from this study is that the use of
living lactic acid bacilli is a harmless method of treat¬
ment. and that it may do good in cases of intestinal
fermentation. He promises to investigate further
and report later. D.

Derbyshire Royal Infirmary—New Medical Appointments.

At a special meeting of the governors of the
Derbyshire Royal Infirmary held a few days since,
Mr. R. Knowles, the president, in the chair, the
Weekly Board recommended a number of altera¬
tions of rules, the most important being the
appointment of an honorary pathologist. For some
years past the policy of the governors had been
to specialise the different departments of the
institution. That was being done in other insti¬
tutions throughout the country, and it was un¬
questionably the proper policy to pursue. The Board
thought the time had arrived when they should bring
this work under the supervision of one gentleman,
who would attend to both the medical and surgical
sides. They also suggested the appointment of a
pathologist as a saving of time and money. Other
proposed alterations had to do with the medical
staff in regard to the restriction of voting, &c., the idea
being to divide them into seniors and juniors, who
should serve on the Elective Committee for appoint¬
ment of paid medical officers, but in other appoint¬
ments only the senior section should act. Sir Arthur
Heywood, in expressing his approval of the policy
of the Board said they were only copying the practice
of the best hospitals in the country. The motion
was carried.

74 The Medical Press.

MEDICAL NEWS IN BRIEF.

July 17. 1907.

Medical News in Brief.

The King's Visit to Ireland.

During the past week their Majesties paid a brief
visit to Ireland for the purpose of seeing the Inter¬
national Exhibition which is now in full swing. Al¬
though the time at his Majesty’s disposal was so
limited, he was graciously pleased to accept addresses
from many public bodies, amongst whom were the
Royal College of Physicians, the Royal College of
Surgeons, and the Apothecaries’ Hall. The address
presented by the last-named body was as follows :—

“To His Mos' Excellent Majesty Edward VII. of
Gr at Britain ar.d Ireland, and the British Dominions
bey01 d tie Seas, King, Defender of the Faith, and
Emperor of India, and Hi? Most Gracious Consort
Queen Alexandra,—May it please your Majesties, We
the Governor, Deputy Governor, and Court of the
Apothecaries’ Hall of Ireland, representing a large
and important branch of the Medical Profession, and
one of the oldest qualifying bodies in this country,
respectfully render to your Majesties our loyal and
hearty greeting and welcome on your visit to our
shores. May God Who has so abundantl/ blessed
your reign, and given us in you a bright example of
all that is good and benevolent, vouchsafe to your
Majesties His best gifts, and His continuing protection.
We bid your Majesties a most grateful welcome, and
we fervently pray that your visit may be a happy
one, and leave nothing lut most pleasant memories.—
We are your Majesties most humble, dutiful and faith¬
ful subjects, F. G. Adye-Curran, Lieut.-Col. F.R.C.S.,
J.P., Governor ; George Seymour Stritch, L.R.C.P.
&S., J.P., Deputy-Governor; H.W. Mason, L.R.C.S.I.,
Secretary.

Davos Sanatorium.

A satisfactory report in connection with the Queen
Alexandra Sanatorium at Davos Plata, was presented
at the recent annual meeting of supporters, under
the chairmanship of Lord Burghclere. The object
aimed at is to provide a cheap sanatorium in an
alpine climate for consumptive patients of small
means belonging to any English-speaking nation¬
ality. The report stated that a sum of ^5,264 18s. .‘d.
was raised last year—the largest received in any one
year since the start of the fund. This gratifying result
was due to a special appeal made by the president,
Lord Balfour of Burleigh, in Scotland, and to a bazaar
held at Davos.

The chairman, in moving the adoption of the report,
said at the present time the Council had in hand nearly
£ 20,000, but they required £ 15,000 more before they
arrived at the goal of their hopes. They had been able
to commence building, and expected that the roofing
would be completed during the present season. All
the expenses up to this point would be paid for out of
funds in hand. They aimed at having sixty beds, at
making the sanatorium completely self-supporting, and
at keeping the fees as low as possible, say, a guinea and
a half a week, or at most 35s. They intended it to be
under English management, and for English-speaking
patients alone, and they had no wish that it should be
a rival to the excellent sanatoria which now existed in
this country, but rather to act as a help and necessary
adjunct. The battles against disease and suffering were
the crusades of the twentieth century, and no one had
preached these holy wars more effectively, or led them
with greater influence, than their Majesties the King
and Queen, to whose patronage the Queen Alexandra
Sanatorium owed a deep debt of gratitude.

Mr. E. C. Simmons seconded, and the report was
adopted. The council were unanimously re-elected.

Royal Hospital for Incurable*, Dublin.

The annual meeting of the Royal Hospital for
Incurables, Dublin, was held on Thursday, the 4th
inst., at the hospital, the Chairman, Mr. William
Fry, presiding. The annual report stated that there
are in the hospital 213 beds, and during the year the
average daily number occupied was 210, being the
largest amount of relief afforded for a number of years.

Eight elections were held during the year, 162 can¬
didates applied for admission, and 47 were elected—
18 suffering from consumption, 8 from cancer, 8 from
paralysis and nervous diseases, 5 from heart disease,

4 from rheumatism and arthritis, the remaining four
being afflicted with various other forms of incurable
disease. The number of deaths (40) is the lowest on
record since 1889, when the hospital was considerably
smaller than at present.

The following resolutions were adopted ;—(1) “ That
this hospital is worthy of the public support.” (2)

“ That the best thanks of this meeting are due, and
are hereby tendered, to the citizens and other suppor¬
ters who have hitherto aided the good work carried
on in this noble institution.”

The speakers included the Chairman, Sir John
Nutting, Sir Thornley Stoker, Sir J. W. Moore, Dr.
Finney, Mr. L. Malone, and Alderman Lyon.

Royal College of Aurgeona.—Fellowship Bxa ail nation.

Notice is hereby given that on and after January 1st,
1910, all Examinations for the Fellowship of this
College will be conducted under the Scheme of Exami¬
nation now known as Grade I. No candidate after
above date will, under any circumstance, be admitted
to examination for the Fellowship of this College under
the scheme now known as Grade II., which will then
cease to be used.

University of Birmingham.—Dental Department.

The Council of the University of Birmingham have
appointed Mr. Alfred William Wellings, B.D.S.Birm..

L. D.S.Edin., as Lecturer in Dental Histology and
Dental Pathology in place of Mr. H. P. Pickerill.

M. B., B.D.S.Birm., who has been appointed Director
of the Dental Department of the University of Otago,
New Zealand.

Doctor’s Suicide.—Remarkable Evidence In the Hcanor Case.

The inquest on the body of the late Dr. P.S. Harris,
who was found shot in his lodgings on July 1st, was
held by the District Coroner. Some remarkable
evidence was given by Dr. Eames, with whom the
deceased had been an assistant for the past five years.
Asked by the Coroner if he had noticed anything
peculiar about him of late, the witness said the
deceased had been addicted to drink. Witness said
that the previous Tuesday the deceased had eighteen
or twenty patients to see. The next day witness
found he had only seen four people, and when asked
for an explanation he made answer, “ I went to bed.”
Witness told him that would not do, and that he could
not stand it much longer. The same evening a
telephonic message came from Codnor to attend an
urgent case whilst witness was away at another case.
The deceased refused to answer the telephone, and
said he would not go. Witness on his return sent him
his notice of dismissal, telling him to go at the end of
the week, and enclosing a cheque for work done.
Subsequently witness gave him permission to stay on
until the 18th, telling him he would do the best he
could for him to obtain another situation. Witness
wrote giving him permission to stay on condition that
he became a teetotaller, adding that if he continued
on his present course he would soon go to the dogs.
Proceeding, witness recalled one or two incidents
that would seem to point to the giving way of the
deceased’s mind. Witness was now satisfied that the
deceased was not himself during the past week. He
had heard of him telling patients that he was being
persecuted and poisoned. Witness went on to depose
to the injuries sustained by the deceased. There
was evidence, he said, of three distinct attempts
having been made on the man’s throat. Tremendous
force must have been used.

Another witness was Mrs. Moore, the deceased's
landlady. She spoke to a conversation with the
deceased late on Saturday evening. Dr. Harris then
asked her what the people outside the windows were
talking about him for. Witness told him that nothing
of the kind was taking place. Describing the finding
of the body, witness stated that when she could obtain
no reply, she opened the bedroom door, and saw the
deceased, partially dressed, lying in a pool of blood

ized by Google

July 17. 1007.

PASS LISTS.

The Medical Pbes*;. 75

across the bed. He had the razor (produced) in his
hand, and his head was nearly severed. She raised an
alarm, and assistance promptly arrived.

Was he in the habit of taking more than was good
for him ?—Sometimes.

During the past fortnight ?—He took middling,
but I’ve never seen him drunk.

Had he seemed strange in his manner lately ?—
I’ve noticed bits of things about him. Once he told
me he had had a letter from his brother in Canada,
and that it had upset him.

Did he ever threaten to do away with himself ?—
No.

By the Foreman : Deceased lay on the bed wearing
his trousers, shirt, and socks. He had pushed the
bedclothes on one side, and had turned up both
shirt sleeves.

Dr. Eames : You told me yesterday you had a
terrible job with him the night before.

Witness : He said there was someone talking about
him outside ; he said there was a scandal, and he would
have a stop put to it.

By the Coroner : There was not a better conducted
gentleman anywhere, and a nicer man in the house
could not be wished.

The coroner having summed up, the jury found that
the deceased committed “ Suicide whilst of unsound
mind.”

PASS LISTS.

Royal talkie ol Snryoona la Ireland.— Summer Session,
1907.

Barker Anatomical Prize.—£31 10s., G. S. Levis.
Carmichael Scholarship .—£\$, J. Menton.

Gold Medals in Operative Surgery.—P. G. M. Elvery
and T. Sheeley (equal).

Stoney Memorial Gold Medal in Anatomy.—Miss

I. M. Clarke and G. C. Sneyd (equal).

Practical Histology.—F. W. Warren, First Prize
(£2) and Medal; J. S. Pegum, Second Prize (£1) and
Certificate.

Practical Chemistry.—H. C. Gilmore and J. Kirker
(equal), First Prize (£2) and Medal.

Public Health and Forensic Medicine.—H. Hunt,
First Prize (£2 ) and Medal; Miss C. F. Williamson,
Second Prize (£1) and Certificate.

Materia Medica.—J. Menton, First Prize (£2) and
Medal ; Miss C. F. Williamson, Second Prize (£1) and
Certificate.

Biology.—J. T. Duncan, First Prize (£2) and Medal;
P. V. Crowe, Second Prize (£1) and Certificate.

The lectures and practical courses of the Winter
Session will commence on Tuesday, October 15 th.

Royal University of Ireland.

The following candidates have passed the under¬
mentioned examinations :—

The First Examination in Medicine .—Christopher
Barragry, Daniel J. Barrett, John L. Brown, Peter A.
Clearlcin, Maurice J. Cogan, Ernest J. Colgan, Patrick

J. Corcoran, John F. Craig, Thomas P. Davy, Joseph C.
Denvir, Bernard Doyle, B.A., Gerald Fitzgerald,
Thomas F. S. Fulton, Michael J. Gallagher, Joseph
Gorman, M.A., Thomas D. Graham, Gerald S. Harvey,
James Hill, Joseph 0. Hodnett, Norman L. Joynt,
Francis J. Keane. James J. Keirans, John L. Kilbride,
James Laverty, Hugh T. S. McClintock, Robert J.
McConnell, Laurence J. J. McGrath, Michael McGuire,
Aloysius D. MacMahon, Robert C. McMillan, Daniel
McSparron, Cornelius Martin, William Megaw, William
M. Millar, Alexander G. Mitchell, John J. H. Mitchell,
Henry H. Mulholland, Henry J. V. Mullone, Daniel
O’Brien, John P. O’Brien, James O’Connor, Thomas F.
O'Donoghue, William M. O’Farrell, Joseph A. O’Flynn,
Patrick J. O’Grady, Oriel J. O. O’Hanlon, Hugh
O’Neill, Joseph Patrick, Joseph Porter, Joseph H.
Porter, James M. Rushworth, Walter N. Rushworth,
Maurice J. Roche, John M. Rowe, Hugh A. Skillin,
Thomas Smyth, Francis J* D. Twigg, William Wilson.

The following candidates may present themselves for

further examination for honours, Thos.> qualified in
two or more subjects may present themselves in all;—
Daniel J. Barrett, E nest J. Colgan, Thomas P.
Davy, Joseph C. Denver, Bernard Doyle, B.A., Gerald
Fitzgerald, Gerald S. Harvey, Joseph O. Ho nett,
Norman L. Joynt, Francis J. Keane, James J. Keirans,
Robert J. McConnell, Michael McGuire, Aloysius D.
MacMahon, Daniel McSparron, William McGaw,
William M. Millar, John J. H. Mitchell, Henry J. V.
Mullone, Hugh O’Neill, Joseph Patrick, Joseph H.
Porter, James M. Rushworth, Hugh A. Skillen, Thomas
Smyth, William Wilson.

Trinity College, Dublin.

The following passed the Intermediate Medical
Examination during Trinity Term, 1907 :—

Part I .—Adrian Stokes and Charles M. Finny,
passed on High Marks.

The following names are arranged in order of merit:
Marius A. Diemont, Hilgard Midler, Roclif A. Albertyn,
Vicars M. Fisher, Beatrice M. Hamilton, Perceval G.
Leeman, Victor G. Best, David Duff (Sch.), John H.
Woodroffe, Edmund F. Lawson (Sch.), John G.
Ronaldson, Arthur C. Hallowes, Benjamin A. Moly-
neux, Louis Trichard, John G. Dods, Edward P.
Allman-Smith, Edwin B. Bate, Brinsley H. Moore,
Charles Pentland.

Part II. —Albert J. Stals (passed on High Marks),
John D. Kernan, Cecil P. Smyly, David Duff (Sch.),
Benjamin A. Molyneux, Edwin B. Bate, Alexander K.
Cosgrave, Louis Trichard, Hugh S. Metcalfe, William
A. Nicholson.

Preliminary Science Examination.—Physics and
Chemistry. —Bernard G. Quinlan, Ronald G. M‘Entire,
Henry L. W. Woodroffe, Patrick Murphy, James M.
Elliott, Thomas G. Harpur, Arthur Chance, Edgar LI.
F. Nash, Thomas L. Bookey, Francis C. Crossle,
Arthur F. Shaw, Leonard Shiel, Osward C. Tandy,
Edward H. H. Lloyd-Dodd, Francis Breen, Albert E.
Malone, George M. Maybury, Robert W. Murphy,
Hugh E. Williams, Hugh M‘C. Fleming, Matthew
M‘Knight, James C. Kelly, Andreas A. Louw, Robert C.
M’Kelly, Humphry L. Blackley.

Botany and Zoology. —Henry I.. W. Woodroffe,
Arthur F. Shaw, Francis C. Crossl6, Thomas G. Harpur,
Georgina Revington, Hubert T. Bates, Eileen M.
Hewitt, Frederick B. M’Carter, Gerald G. P. Beckett.
(The former passed on High Marks.) Dorothy K.
Milne, Francis Usher, Percy D. Long, Robert W.
Murphy, John T. Higgins, Thomas King-Edwards,
Henry S. Champion, Arthur Chance, Marjory Chap¬
man, Francis T. G. Corscadden, Richard Grandy,
Richard P. Pollard, James N. G. Nolan, Cecil Ruther¬
ford, Brian D. Crichton, Bernard G. Quinlan, Robert G.
Ball.

The following candidates passed the Final Med : cnl
Examination, Part I. :—

♦Johannes C. Pretorius, *John A. W. Ponton,
♦Richard P. Hadden, Henry H. Ormsby, Charles W.
Laird, Albert, E. Wynne, William E. Hopkins, Samuel
F. Charles, Frank Smartt, David G. Madill, Albert
V. J. Richardson, James F. Clarke, George Halpin,
Herbert V. Stanley, Gerald G. Mecredy, Dixie P,
Clement, Arthur H. Laird, George B. M'Hutchison,
Ernest C. Lambkin, Alexander S. M. Winder, James
P. S. Dunn, Norman P. Jewell, William H. M’Carthy.
(♦ Passed on High Marks.)

The Medical Travelling Prize was awarded to
Robert E. Wright.

The Medical Scholarships in Anatomy and Institutes
of Medicine to Adams A. M’Connel (Trinity) and
Thomas A. Hughes (Stewart).

Prizes in Physics, chemistry, Botany, and Zoology
to Henry J. Smyly (Trinity) and Herbert de L. Craw¬
ford (Stewart).

The Purser Medal in Institutes of Medicine to
Charles M. Finny.

Previous Dental Examination : Anatomy and
Institutes of Medicine.—George Elliott.

Physics and Chemistry.—Arthur A. Campbell and
Kenneth C. MacNaught.

, y Google

76 The Medical Press. NOTICES TO CORRESPONDENTS.

July 17, 1907.

NOTICES TO
CORRESPONDENTS, &c

&ftr CoRKBsroNDBKTa requiring a reply lo this column are particu¬
larly requested to make useol a DiMinetioe Signature or Initial, and
to avoid the practice of signing themselves “ Reader,” “ Subscriber,”
“Old Subscriber,” Ac. Much confusion will be spared by attention to
this rale.

SUBSCRIPTIONS.

Subscriptions may commence at any date, bnt the two volumes
each year begin on Jaouary 1st and July 1st respectively. Terms
per annnm, 21s.; post free at home or abroad Foreign subscriptions
must be paid in advance. For India, Messrs. Thacker, Bplnk and Co.,
of Calcutta, are our officially-appointed agents. Indian subscrip¬
tions are Rs. 15.12.

ADVERTISEMENTS.

For One Insertion Whole Page £5; Half Page, £2 10s.;

Quarter Page, £1 5s.; One-eighth, 12s. 6d.

The following reductions are made for a series;—Whole Page. 13
Insertions, at £3 10 «. ; 26 at £3 3s.; 52 Insertions at £ 3 , and pro
rata for smaller spaces.

Small announcements of Practices, Ass'stxncles. Vacancies, Books,
Ac.—Seven tines or under (70 words), 4s. 6d. per insertion ; 6d.
per line beyond.

M.R.C.8.—The question of a doctor's degree for the London
student is a very old one, and as long ago as 1885, at a meeting
of Fellows of the Royal College of Physicians of London, a
resolution was passed by a large majority stating that it was
desirable that students examined by tne Royal College of
Physioians of London and the Royal College of Surgeons of
England conjointly, and found duly qualified, should, in virtue
of such examination, have a degree in medicine or surgery con¬
ferred on them.

G. P. (Norwich).—All we can say is that as yet no one
knows. A loouin—provided his emoluments (l.e., salary, board
•and lodging) do not amount to £5 a week—would most pro¬
bably be considered a workman, and the principal consequently
liable for accident, although the engagement was a temporary
one. As compensation can be obtained for so small a sum,
it is certainly wise to insure with a sound offioe. But we agree
it is hard lines. Unfortunately, ignorance of law is no excuse.

Omicbon.—W e cannot bring ourselves to believe that the facts
are as stated, and certainly could not take the responsibility of
advising on them unless very good evidence of the occurrence
were forthcoming. The hospital has a high name and the
staff consists of gentlemen of reputation, so we should advise
you to verify the patient's statement very carefully before com¬
mitting yourself. If anything further oomes to light, we should
be glad to hear.

A Layman. —Your communication came to hand as we were “ at
press "—too late to be dealt with In present Issue.

JfceeitmiB of the SonelieB, %uXxcetB t &c.

Wednesday, Jui.y 17th

Medical Graduates' Coli.eoe and Polyclinic (22 Chenies
W.C.).—4 p.m.: Mr. J. Berry: Clinique. (Surgical.)

North-East London Post-Graduate College (Prince of

Wales’s General Hospital, Tottenham, N.).—Cliniques :—2.30
p.m.: Skin (Dr. Meacben), Eye (Mr. Brooks), Medical Out¬
patient (Dr. Whipham).

Thursday, July 18th.

Medical Graduates' College and Polyclinic (22 Chenies
Street, W.C.).—4 p.m. : Mr. Hutchinson : Clinique. (Surgical).

North-East London Post-Graduatb College (Prince of

Wales's General Hospital, Tottenham, N.).—2.30 p.m.: Gynaeco¬
logical Operations (l)r. Giles). Cliniques :—Medical Out-patient
(Dr. Whiting), Surgical Out-patient (Mr. Carson). 3 p.m.:
Medical In patient (Dr. Chappel).

Hospital for 8ice Children (Great Ormond Street, W.C.)—
4 p.m. : Lecture :—Mr. Lane : Fractures.

Friday, July 19th.

Society tor the Study of Disease in Children (11 Chandos
Street, Cavendish Square, W.).—5 p.m.: Annual General Meet¬
ing.

North-East London Post-Graduate College (Prince of
Wales's General Hospital, Tottenham, N.Y—9.30 a.m.: Clinique:
—Surgical Out-patient (Mr. H. Evans). 2.30 p.m.; Surgical
Operations (Mr. Edmunds). Cliniques:—Medical Out-patient
(Dr. Aiild), Eye (Mr. Brooks). 3 p.m.: Medical In-patient (Dr.
Leslie).

BaraitncB.

Bmdford Poor Lnw Union.—Resident Assistant Medical Officer.
Salary, £100 per annnm, with rations, apartments, and wash¬
ing. Applications to George M. Crowther, Clerk to the
Gunrdians, Union Offices, Manor Row, Bradford.

Cancer Hospital (Free).—Two Assistant Anesthetists. Applications
to Fred, W. Howell, Sec. (See advt.)

Liverpool Infirmary for Children.—House Surgeon. 8 alary, £100
er annum, with board and lodging. Applications to Arnold
. Cleaver. Hon. Sec., Liverpool Children's Infirmary,
Mvrtle 8 treet. Liverpool.

Middlesex Hospital, W. (Cancer Department).—Medical Officer
and Registrar. Salary, £100 per annum, with board and
residence. Applications to F. Clare Melhado, Secretary-
Superintendent.

Rotherham Hospital and Dispensary.—Senior House Surgeon.
Salary 110 per annum, with rooms, commons, and washing.
Applications to the Secretary, H Kelson, Masonio Buildings,
High Street, Rotherham.

Royal Halifax Infirmary.—Second House 8 urgeon. Salary, £100
per annum, with residenoe, board, and washing. Applica¬
tions to Oates Webster. Secretary, Royal Halifax Infirmary.

Royal Albert Hospital, Devonport.—Resident Medical Officer.

’ Salary, £100 per annum, with npartments, board, fuel and

lights, and laundry. Applications to the Chairman of the
Selection Committee.

Stockport Union.—Stepping Hill Hospital.—Resident Assistant
Medical Officer. Salary, £130 per annnm, with famished
apartments, rations, etc. Applications to Charles F. John¬
son, Clerk to the Guardians, Union Offices, Stookport.

Taunton and Somerset Hospital.—Honse Surgeon. Salary, £100
per annum, with board, lodging, and laundry. Applications
to Reginald A. Goodman, Secretary, 3 Hammet Street,
Taunton.

The Ho-pita 1 for Sick Children.—House Ihyalctau, House Surgeon,
Assistant Casualty Officer. Dales and particulars of Stewart
Johnson, Sec. ( 8 ee advt.)

West Ham Union.—Medical Superintendent of Infirmary. Salary,
£700 per annum, with unfurnished house, light, and coal.
Applications to Alfred Hall, Aoting Clerk, Board Room,
Union Rond, Levtonstone, N.E.

West Bromwich District Hospital.—Senior House Surgeon.
Salary, £110 per annum, with board, residenoe and laundry.
Applications to T. Foley Bacbe, Esq., Churchill House, West
Bromwich.

SppominuntB.

Beattt, W. J., L.R.C.P.Edin., L.F.P. 8 . Glasg., by the Home
Secretary H.M. Referee and Judges' Assessor under the
Workmen's Compensation Act (1906) for County Court Cir¬
cuit 15.

Bennett, T., M.B., R.S.Glasg., Certifying Surgeon under the
Factory and Workshop Act for the Knaresborough District
of the county of York.

Coates, F. A., L R.C.P.I.ond., M.R.C.S., Certifying Surgeon
under the Factory and Workshop Act for the Whitchurch
District of the county of Hants.

Corbett, Catharine L., M.B., Ch.B.Vict., Junior Assistant
Medical Officer at West Ham Union Infirmary.

Fawcett, W. H„ M.D.Brux., M.R.C.P., F.R.C.S.Edin.,
D.P.H.Lond, Assistant Physician to the Royal Victoria
Hospital, Bournemouth.

Good, Arnold Saxty, L.R.C.P.Lond., M.R.C.S., District Medical
Offioer bv the Torrington (Devon) Board of Guardians.

Goodwtn, Henry, L.R.C.P. and 8 ., L.M.Edin., Medioal Offioer
for the Bovey Tracey District by the Newton Abbot (Devon)
Board of Guardians.

Hates, H. W. McCaullt, M.R.C.P.Edin., L.R.C. 8 .Edin.,
L.F.P.S.Glasg., Chief Medical Officer of the South Indian
Railway, India.

Johnson, J., L.R.C.P. and S.Edin., L.F.P. 8 .Glasg., Certifying
Surgeon under the Factory and Workshop Aot for the
Blackpool District of the oounty of Lancaster.

Mitchell, E. J. 1).. M.A., M.B., B C., has been appointed Ca<usltjr
Officer at St. John's Hospital for Diseases of the Skin, Leicester
Square.

Moroan, James Arthur, L.R.C.P.Lond., M.R.C.S., L.S.A., Medi¬
cal Officer of Health for the Llanwrtyd (Breconshire) Urban
District.

Nelson, W. E., M.R.C. 8 ., L.R.C.P.Lond., Certifying Surgeon
under the Factory and Workshop Aot for the Henley-in-Arden
District of the county of Warwiok.

Richards. Thomas Edward, M.B., C.M.Edin., Medioal Officer
and Publio Vaccinator for the Ystradgynlais District by the
Ystradgynlais (Breconshire) Board of Guardians.

#irth0.

Keeling. —On July 12th, at Market Bos worth. Nuneaton, the wife of
Hugh N. Keeling, M.R.C.S , L.R.C.P., of a daughter.

Loudon. —On July 5th, at Linwood, Hamilton, Lanarkshire, the
wife of J. Livingstone Loudon, M.D., D.P.H., of a son.

Newneam. —On July 10th, at 3, Lansdown Plaoe, Victoria Square,
Clifton, the wife of W. H. C. Newnham, M.A., M.B.,

M.B.C.S., of a daughter.

Worthington. —On July 10th, at Hurst House, Chesterfield, the
wife of Sidney Worthington, M.D., of a daughter.

JHarriagiB.

Bentham—Hall.— On July 9th, at the Parish Church, Wedding-
ton, Selins Points (Lins), youngest daughter of the late Rev.
Bracebridge Hall, to the Rev. Walter Reid Bentham,
youngest son of S. Bentham, M.R.C.S., L.S.A., of Hampstead.

Brownlie—Walker. —On July 11th, at the Parish Church,
Saltbum-by-tbe-Sea, Alexander Brownlie, M.D., of Red car, to
Mabel, youngest daughter of William Walker, of 8 altburn.
Yorkshire.

Glanville—Bell —On July 11th, at Hampstead Parish Church,
William M. G Glanville, M.B., B.Ch.Oxon., of Hampatead,
to Muriel, eldest daughter of Edward Bell, of Hampstead.

Patmore—Scott. —On July 13th, at St. James's Church, Picca¬
dilly, London, John Deighton, son of Dr. T. D. Patmore, to
Ethel Elisabeth, daughter of James H. Scott, of Kenwyn,
Leigham Court Road, Streatham.

Payne—Wise.— On July 9th, at 8 t. Chad's, Shrewsbury. Otto
Vaughan Payne. M.B., B.O., of Northwood, Alton, Hants
second son of the late W. G. Payne, F.R.C. 8 ., to Eleanor
Beatrice, younger daughter of the late D. R. Wise, 0 f
Murivance, Shrewsbury.

Beaths.

Bentham. —On July 10th, at Manchester, suddenly, of cerebral
haemorrhage, Samuel Bentham, M.R.C.S., L.S.A., o£ Tbe
Limes. S. Hampstead, aged 84 years.

Osoood. —On July 10th, at 165, Woodstock Road, Oxford. Haxnil-
ton Osgood, M.D., of Boston, U.S.A., in his 69th year.

Digitized

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The Medical Press and Circular.

“SALUS POPULI SUPREMA LEX.*

Vol. CXXXV. WEDNESDAY, JULY 24, 1907. No. 4

Notes and Comments.

At Liverpool quite recently was
Tie Other Side held the fourth annual meeting of
of the the British University Students'
Laatero. Congress, at which the dumb
animal that is accustomed to
being led to the slaughter of examination found
both voice and audience. In the report furnished
us we do not find how many students were present
or were represented, but from an appended
account of an Athletic Gymkhana which followed
the more serious proceedings, we gather that a
great many of the students were of the fair sex.
The latter entertainment seems to have been a
blithesome affair, the names of ladies and gentle¬
men being bracketed together in any number of
events, but no doubt this light-heartedness was
due to the elation of having in the morning dis¬
posed by unanimous resolution of some of the
great problems of medical education which cause
their pastors and masters so much heart-burning.
But whether strictly representative or not, and
even if one sex were present in undue proportion,
it cannot but be interesting and instructive to
hear what is thought in student-circles with regard
to the course their examinations should pursue.
The motion that will have most interest for medical
men is one proposed by Mr. E. Darwin Wilmot, of
Edinburgh, to the effect that the present lack of
uniformity’ in medical examinations in the British
Universities is detrimental to the progress of
medical education ; that it is desirable to establish
uniformity, both in the grouping of subjects for
•examination and in the standard of knowledge
required ; and also that a State Examining Board
.should be appointed to control examinations.

The object of this proposal,
Medical Social- according to the supporters, was
4 aai aad Medical to get rid of anomalies in teaching,
Imperialism. and also to allow students to pass
freely from one University to
another at any point in their career when they
wished to avail themselves of any specially coveted
teaching. Mr. Wilmot stated that the system of
examination by the State is working satisfactorily
on the Continent, and he wanted all the Colonial
universities also standardised, till they came into
conformity with English universities; indeed,
" he would like to see the whole Empire united
in one big medical school.” Now although State
examination is the natural corollary of State
registration of medical practitioners, and the
“ one-portal ” system is the ideal, the curious
combination of medical socialism and medical
imperialism suggested by this resolution—which
was passed by^the Students’ Congress—seems to

have the defects of both its qualities. If there is
one good feature about university training it is
that it turns out men of a certain stamp, and the
competition to turn out those of the best and most
successful stamp is highly advantageous. On
the other hand, though it is doubtless a good thing
for the young Britisher to know something of the
Colonies, it is hardly likely that the bonds with
the Mother Country would be cemented by turning
the Empire into one vast medical school. More¬
over, though it is a capital training for him to
exercise his originality, the general experience of
older people is that the student is eminently im¬
proved by a little healthy discipline, and if he
could migrate swallow-like from one university’
to another as the fit took him, the salutary rigour
of control would be in danger of becoming emascu¬
lated. If a student goes to a good medical school or
university and partakes of its esprit de corps, he
is likely to be better prepared for the battle of
life than by leading a nomad existence in places
he found pleasant.

Now that the Home Secretary
Medical has published the full rules and
Referees and orders for the working of the
the Home Office. Workmen’s Compensation Act,

1906, as affecting the medical
aspects of the points that arise under it, we are
glad to be able to say that these regulations are
less unfavourable than we understood them likely
to be. With regard to fees to medical referees, it
certainly is a sign of grace to be noted and to be
thankful for that the fees for consultation have
been fixed at what may be termed market-rates,
that is to say, two guineas for a referee’s opinion
in an ordinary case, and a guinea for any supple¬
mentary report with regard to the same accident.
For this sum the referee must be prepared to go
any distance within two miles of his house, and
for further distances he is to be given certain
allowances which do not err in the direction of
generosity, namely, five shillings a mile beyond
two and up to ten, and a shilling a mile beyond
ten. As, however, a county court district or sub¬
district is not a very large area, we imagine that
hardship under these regulations is not very
probable. The bad feature, as we conceive it, is
that in the usual way the registrar of the County
Court is to be the authority to decide whether
a referee should be employed. Difficult situations
of many kinds are likely to arise in connection
with placing patronage of this kind in the hands of
minor officials, and we see many elements of
trouble in the arrangement. Moreover, red-tape
checks and hindrances of many kinds are provided

e

7 $ Tux Medical Pum.

LEADING ARTICLES.

July 24, 1907

to waste time, multiply clerical work, and
provoke tempers.

The official mind is a curious
The example of how the maximum of

Official training can produce the height of

Mind. ineptitude, and it certainly is one
of the blessings of the British con¬
stitution that it puts the civil service directly
under Parliament, and therefore more or less in
touch with the nation. The object to aim at in
working a Compensation Act involving a large
number of small claims should be two, namely,
that the genuinely-injured workman should get
his money with the least possible trouble and,
secondly, that the malingerer should speedily find
it was no good trying to get any at all. The
more obstructive the machinery for carrying out
the act, the more trouble and expense will the
genuine workman have—expense which will
speedily obliterate the few pounds he may be
entitled to—and the more chance will rogues
have of getting a week or two’s wages to which
they are not entitled. In the vast bulk of cases
under the new Act the sole questions will be the
medical ones: Is the workman disabled ? And
how long is he disabled for ? An authoritative
referee who was readily available could decide the
points quickly enough in most instances, but, as it
is, the registrar is only likely, in view of the fee
payable, to refer to him after much delay, during
which the honest will suffer and the wicked
triumph. We shall be glad to hear how the new
administration pans out in different parts of the
country ; the working of the last two acts was
admittedly a clumsy failure.

Ex America semper aliquid novi.

Whooping- The extravagances of wealth have
Cough nowhere been so ostentatious as in
Parties. America, a country in which
mountainous fortunes and sportive
imagination are wont to riot.
The smaller fry take their tone from the wealthier
classes and frequently ape their oddities while
they do not possess their wealth. The “ freak ”
dinners that were lately the rage in the more vulgar
coterie of millionaires have, it is reported, their
counterpart at Pittsburg in what may be termed
pathological parties. It seems that in that city of
steel an epidemic of whooping-cough is about at the
moment, and as the sufferers are able to go about,
and yet are tabooed by their friends, a certain
lady who with her son is suffering from the
disease, gave a “ whooping-cough fete ” lately to
her fellow-patients. By way of entertainment, a
competition was organised for those who whooped
the loudest and the longest, and similarly, con¬
solation prizes were offered for those who had the
feeblest paroxysms. We should hope that the
better public opinion in America would join with
us in reprobating so disgusting an outrage on
good taste.

On July 12th, at a meeting of the Central District
Committee of Stirlingshire County Council, the Medical
Officer made a statement with reference to the serious
epidemic of enteric fever in the villages of Plean
and Cowie. There had up to the present been seventy-
six cases and seven deaths, and in his opinion the
outbreak was due to infected milk from a farm. The
frequent rains of the past few weeks had had a salutary
effect by laying the dust between the rows of houses
and keeping down flies in the houses and ashpits.
The fever was now abating.

LEADING ARTICLES.

HOSPITAL FUNDS AND LOCAL HOSPITAL
PRACTICE.

The question of the allocation and conditions
of tenure of hospital appointments is clearly
one of vital importance to the medical profession.
If lay bodies assert their right to control and
regulate the terms of medical staff appointments
it seems a self-evident proposition that they
should make sure of their ground before proceeding
to take any active steps in the matter. The
hospital funds occupy the position of trustees
in charge of a distributing agency, but to that
function they have added other claims of
a remarkable nature as regards hospital
administration. While few persons would ques¬
tion the desirability of having some sort of re¬
sponsible control of the financial and administra¬
tive management of medical charity, it is, never¬
theless, an entirely different thing when a Fund
threatens the existence of a given hospital by
denying a grant upon grounds that are arbitrary
and unascertainable. The policy of the Sunday
and the King Edward VII. Funds is in the hands of
a group of non-representative men who have their
own peculiar views upon the way sums of money
should be granted and of what should be the
professional status and qualifications of members
of medical staffs. Take the question of amalga¬
mation of hospitals. Three orthopaedic hospitals,
as we have previously insisted, were forced
to amalgamate in spite of the disadvantageous
sale of one enormously valuable site in Oxford
Street The Funds have permitted the charter
of the amalgamated institutions to exclude
Scotch and Irish diplomates from their medical
staffs, in spite of the fact that two [of the joining
hospitals were open to gentlemen who had gained
their theoretical surgical knowledge outside
London. In this particular matter we hold that
the Funds which urged amalgamation and did
not provide against the disqualification men¬
tioned, departed from the high standards
of justice and broad-mindedness that should
characterise great public bodies of the kind.
We venture to say that such an ) indignity
would not have been imposed upon Scotch
and Irish diplomates had the public, the medical
staffs, general practitioners and the hospitals
themselves been properly represented on the
management of the Funds. It is difficult to
understand the frame of mind that can lead 4 n
executive of amiable philanthropists to imagine
themselves gifted by a sort of divine right to
control a vast number of tangled lay and pro¬
fessional interests. It was only at the last moment
that Parliament woke up to the facts of the
situation and modified the autocratic powers
that were sought in the King’s Fund Charter
Bill. That the sphere of the Fund’s activities is to
be considerably extended seems clear from the
action of the King Edward Fund with regard to
the Hampstead Hospital. That institution afforded
an admirable example of a first-rate hospital

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July 24,1907.

CURRENT TOPICS.

The Medical Press. 79

officered by local medical men. It was popular
amongst its supporters, no less than amongst
its patients and medical men in the neighbour¬
hood. The King Edward Fund, however, formed
a theory that the local practitioner should be
replaced by consultants and that to permit this
the hospital should be amalgamated with
the North-West London Hospital. With regard
to the amalgamation proposal from the financial
aspect we have nothing to say at present, but
the proposed exclusion of local practitioners
from the hospital they have, so to speak, created,
demands the careful attention of the whole
medical profession. If the experience gained
in hospital be of educational value, as it un¬
doubtedly is, why should the Hampstead in¬
habitants who support the hospital consent to
having that advantage taken away from their
own private medical attendants ? In the pro¬
vinces it is the rule rather than the exception
for members of hospital staffs to engage in general
practice. That plan works well enough, and we
have never heard it seriously asserted that the
public would gain by making consulting practice a
sine qua non for tenure of such appointments.
Why Hampstead cannot be trusted to furnish
a sufficient number of local practitioners fitted
to attend to its sick poor is not clear. If the
King Edward Fund is to alter that state of things,
which so far has worked admirably, surely the
medical profession, no less than the public, are
entitled to have a full and adequate explanation
of why the proposal is made. It may be that the
King Edward Fund has an admirable and con¬
vincing case to present, but owing to its auto¬
cratic methods, no such statement has been or
is likely to be issued. Indeed, as we have pointed
out on various occasions, the inherent flaw of
the King Edward Fund is its want of representa¬
tive control. Under its present irresponsible admini¬
stration its acts and motives must necessarily
from time to time be called into public question,
but just as often there will be no public answer,
and the reputation of the Fund will in the long
run be likely to suffer. In the case of Hampstead
a great deal of feeling has been imported into the
dispute, and however much the motives of the
Fund may be above suspicion, it can hardly be
gainsaid that a feeling of resentment will linger
in the minds of a great many of the inhabitants
who feel that their medical attendants have been
slighted, and that an attempt has been made
by the Fund to hand over their institution for
the benefit of another hospital and of a body of
consultants hailing from another district. A further
aspect of the case is the hostility likely to be
aroused amongst the Hampstead practitioners
by what they naturally regard as an unwarrant¬
able attack upon their existing rights. It would
require a strong body indeed to go on exciting
hostility in so many classes of the community.
At any rate it would be well for the King Edward
Fund to lay down in black and white the principles
on which its grants are to be made, and whether
in the future its voice is to be equally autocratic
in deciding the fate of small hospitals by the

withholding of grants and the enforcing of amal¬
gamation schemes. It is not too late, even now,
for the Funds to amend their constitution and to-
invite to their councils representatives of the
small hospitals and of the medical profession
generally. It should be noted by our readers
that the questions involved are of universal-
application and that which is taking place in
London to-day may have to be encountered
in any part of the United Kingdom to-morrow.
It will be of some interest to watch the progress
of events at Hampstead, and to note what part,
if any, is taken by the Medical Defence and other
professional organisations whose duty it is to
safeguard the interests of the medical practi¬
tioners.

CURRENT TOPICS.

Am alg am ation of the Obstetrical and
Gynaecological Societies.

Since our last issue, containing a paragraph
headed, “ For London or the United Kingdom ? ” wd
have received further and more exact information
with regard to the circumstances under which the
amalgamation of the Obstetrical Society and the
British Gynaecological Society into a section of the
Royal Society of Medicine took place. It will be
remembered that we were struck with what ap¬
peared to be the disproportionate representation of
some parts of the United Kingdom on the pro¬
posed Council which is to be elected in October.
At first sight the figures certainly invited criticism,
but we are gratified to learn that a satisfactory
explanation of the disparity will be forthcoming in
due time, and that an entirely different complexion
will be placed on the matter than that which
appears at first sight. We are not at liberty at
present to treat the subject as fully as we should
wish, but we hope soon to be able to deal with it
at greater length. The union of these two societies
under the banner of the Royal Society of Medicine
is an event of such happy omen that it would be a
matter of profound regret were any cloud to over¬
shadow the new order of things.

An Englishman’s Breakfast.

Your average Englishman is proud of many
things which, deep down in his heart, he regards
as distinctive of his breed. In every detail of his
life he^worships virility, and he looks with calm
distrust upon lack of lustiness in art, science,
literature, commerce, politics, sport, or religion..
Good brains he can hardly dissociate from good
beef and beer, not to say plum-pudding and other
solid fare. Above all, breakfast is to him the
test-meal of the good old insular stomach, which
is always in its place when wanted, a silent, un¬
obtrusive friend that complains not, in spite of many
a buffet and a whole lifetime of ill-usage. Yet
Dr. Emil Reich says that the Englishman loads
his stomach at breakfast with chops and bacon
and eggs and other provender that he cannot
digest, and the English are therefore assumed to
be rapidly degenerating in mind and body in
consequence of this morning gluttony. The
weak link in this Teutonic chain is the assumption

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CURRENT TOPICS.

July 24,1907 .

that our countryman, as a rule, cannot digest a
heavy breakfast If one thing more than another
constitutes the birthright of all ages of Englishmen
down to the days of good King Edward VII., it
is the gusto with which he disposes of a huge
breakfast and the solid unconsciousness of that
precedent condition which blesses the later
labours of his strenuous day. The Teutonic
appetite that whets itself on a species of bastard
bread and a cup of coffee, to the sound of melan¬
choly music is to the Englishman an object of con¬
templative and never-ceasing pity. When the
English breakfast becomes a thing of the past,
then, indeed, may we cry aloud because of the
degeneracy of our race.

Drilling in Schools.

Signs are not wanting that the hand of sanitary
science is making itself felt in the regulation of
schools. For instance, one of the great achieve¬
ments of modem times has been the recognition
of the fact that it is no use to thrust compulsory
education upon starving children. One small
matter seems to have hitherto escaped the notice
of school authorities, namely, the undesirability of
drilling children in school-rooms. The scientific
facts of the situation are clear and simple. Bacteria
being heavier than air, sink sooner or later to
the floor of a room. From the necessary conditions
of environment a school-room becomes charged
from top to bottom with multitudes of bacteria of
a manifold nature. If the children have to scrape
and stamp the floor in various drills and other
evolutions, the bacteria will be stirred up in clouds
to the detriment of all concerned. The cleaner
and the better-ventilated the room, of course, the
less the danger. The plain fact of the matter
that stares us in the face, and should be brought
no less directly to the notice of all school authori¬
ties, is that school drill should take place in the
.open air or in a freely-ventilated drill shed.

Mr. McKenna and School Hygiene.

We hope that Mr. McKenna who is reputed to
be a capable administrator and sound Parliamen¬
tarian, is not seeking to put himself out of touch
with medical opinion now that he has gone to the
Education Board, nor that he is, as appears in
several directions, opposed to the pushing forward
of school hygiene. No doubt there is little to be
got out of it politically, because all comers of the
House of Commons are equally set on school
hygiene being pushed forward, though un¬
fortunately, no one is so much in earnest as to
give the others no peace till universal medical
inspection and regulation are accomplished facts.
Still, Mr. McKenna has come fresh to a series of
problems which not only have troubled men’s
minds for years, but about which they have
long been made up, and he is displaying a feeble
reluctance to lead or be led. To the Times last
week, Sir Lauder Brunton wrote an important
letter pointing out that whereas Mr. McKenna
has been shielding himself from the reproach of
inertia behind the International Congress on School
Hygiene which is to assemble in London this

summer, and while he is yet talking of all that the
Education Board are doing or are going to do for
it, actually all that has been done officially is to
appoint three semi-official delegates, pay three
guineas for their tickets, and lend two unused
lecture-rooms. Now it is time to assure Mr.
McKenna that medical men and we believe the
whole country, have made up their minds and that
they do not propose to look admiringly at the
Education Board or at a politician who cares for
none of these things. The religious difficulty
may be insoluble ; the school-hygiene problem is
solved. It now only awaits masterful and ener¬
getic administration to have the whole matter
speeding happily on the right track. We believe
that any dallying with it will cause more unpopu¬
larity to the Government than all the religious
squabbles put together.

Plague in India.

The figures quoted in the House by Mr. Secre¬
tary Morley, of the mortality from plague in India,
should rouse even the most callous to a sense of
the responsibility of England in the government
of the dependencies. From the appearance of
plague in the year 1896 to May 31st last, there
were 5,402,245 deaths from that disease. During
the six months ending June 30th, the number of
deaths was 1,060,067, being more than had taken
place during any entire year hitherto. In fact,
since the first appearance of the disease, it has
increased in almost steady progression year by
year, the only marked exception being in 1906,
when the total number of deaths was just a third
of a million. The present year, however, as we
have seen, threatens to be by far the worst yet.
Tn all seriousness we say that the plague in India
is the gravest problem before the country at
the present time. Almost a million of our fellow-
subjects are dying each year of an entirely pre¬
ventable disease, and the steps taken to deal with
it are of little more than a perfunctory character.
Public opinion shows no interest in the subject,
and hardly a daily paper has commented on the
appalling figures. It is hardly matter for wonder
that there is unrest in India, when disease is
allowed to walk unchecked through the land.
“ The white man’s burden ” must be realised as
something more than a topic for jingo songs and
armchair complacency. It is a real and pressing
fact which must be fairly faced. We look with
anxious expectation for the full account of the
policy of the Government, which Mr. Morley has
promised to put before the House of Commons
at an early date.

Halifax Hospital Controversy Ended.

A pithy moral may be pointed from the con¬
troversy that has been going on for some time past
between the Halifax Board of Guardians and the
British Medical Association. Some little while
since, on the resignation of their then medical
officer, the guardians advertised the vacant post
at a salary of 1 100 per annum, or a drop of £40
on that of the last occupant A campaign was

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July 24. 1907-

PERSONAL.

Tkz Medical Puss. 81

then started by the Association, and several can¬
didates were induced to withdraw their applica¬
tions, and the Halifax vacancy was posted in a
medical black list. After the failure to secure an
officer at £100, the guardians advertised the post
again at /120. An applicant was appointed, but
the Board failed to acquaint her of the opposition
of the Association, and they, moreover, induced
her to sign a document agreeing to fulfil her duties
under a penalty. In spite of these precautions,
further negotiations went on between the local
medical men and the guardians, with the result
that the new officer is to start at a salary of /125.
This incident proves the necessity of watchful
vigilance on the part of some central body as
to the terms of State, Poor Law and other
public appointments. It also emphasises the
value of concerted action, of publicity, and of the
absolute necessity of loyalty on the part of in¬
dividual members of the medical profession to
the principle of collective protection and self-
preservation, let journalists and guardians call it
trades-unionism or what they will.

-An Advance in Police-court Psychologry.

The humaner administration of criminal justice
is becoming by slow degrees more and more appa¬
rent as the world grows older. It will be a long
time, however, before the mental responsibility
or otherwise of an accused person will be sub¬
mitted to any skilled and impartial arbitration.
Here and there a prisoner is acquitted on the
score of insanity, or of suffering from what is
commonly known as kleptomania. From the
account of many police cases, on the other hand,
it is perfectly obvious to the medical reader that
the accused must have been suffering from mania
with delusions or from general paralysis. We
have often urged the necessity of some central
authoritative body of mental experts, to whom
appeal could be made in all doubtful cases, and
who should exercise a further general supervision
•over all trials in which the evidence suggests the
desirability of special enquiry. On the Brentford
bench last week, the magistrate discharged a
prisoner charged with theft on the report of the
police surgeon that she was suffering from minor
epilepsy and that during an attack she had not
the slightest knowledge of what she was doing.
The magistrate enquired if that state of affairs
w'as not very unusual, but fortunately did not
adopt the usual legal attitude with regard to the
plea of mental irresponsibility, namely, that of
assuming an explanation which is not understand¬
able by sane standards is, therefore, false. It
is to be hoped that the Brentwood decision
may be taken as an encouraging sign of the times.

PERSONAL.

The King has been pleased to appoint Sir Thomas
McCall Anderson, M.D., F.F.P.S., to be one of Hi3
Majesty’s Honorary Physicians in Scotland, in the
room of Sir Thomas R. Fraser, M.D.Edin., LL.D.

Sir Richard Douglas Powell, K.C.V.O., has been
promoted from being Physician-Extraordinary to the

King to be Physician-in-Ordinary, in the place of the
late Sir William Broadbent.

Dr. Bertrand Dawson, Physician to the London
Hospital, has been appointed Physician-Extraordinary
to the King.

Dr. A. E. Boycott, M.A., B.Sc.Oxon., has been
appointed Gordon Lecturer on Pathology in the
Medical School of Guy’s Hospital.

The address in Medicine at the meeting of the
British Medical Association will be delivered on July
31st by Dr. W. Hale White, of Guy’s Hospital, who
will advance “A Plea for Accuracy of Thought in
Medicine.”

The address in Surgery has been allotted to Mr.
H. T. Butlin, of St. Bartholomew’s Hospital, who
will deal with “The Contagion of Cancer in Human
Beings, Auto-inoculation.”

A popular lecture on Weather, Climate, and
Health will be given by Sir John William Moore,
of Dublin.

Dr. Arnold Davies, B.A. (Lond.), a member of
the Livingstone Medical Missionary College, Edin¬
burgh, has been appointed by the London Missionary
Society to succeed Dr. N. C. Bentall. in India.

In the Edinburgh Royal Maternity and Simpson
Memorial Hospital last week the Committee in charge
of the complimentary recognition of Sir A. R. Simpson,
M.D., LL.D., met the Board of Directors, and asked
their acceptance of a gift of money towards the
endowment of a bed.

Dr. Henry Davy, President of the British Medical
Association for 1907-8, will be inducted on the 30th
inst., and will deliver his presidential adtiress on
the evening of the same day, which has been fixed
for the opening of the 75th annual meeting of the
Association at Exeter.

On July 13th a deputation representing the Dublin
Civil Service Medical Aid Association waited upon
Dr. J. J. Murphy, at his residence, to present him
with an address and purse of sovereigns, as a mark
of the appreciation and regard entertained by that
body towards him as medical officer.

Dr. August Dupre, the well-known chemist and
authority on explosives died on July 16th at his
residence, Mount Edgcumbe, Surrey, in the 72nd
year of his age. He had been consulting adviser to the
Explosives Departmert of the Home Office since 1893.

Professor Chrobak. of Vienna, has resigned his
appointment as Director of the Lying-in Wards and
the Gynsecological Clinic in that city.

Mr. R. E. Wright has been awarded the Medical
Travelling Scholarship of the University of Dublin.

Dr. H. M. Woodcock has been awarded the Royal
Society’s studentship in biology to help him to carry out
his researches into the life-history of the hamatozoa
of birds at the I.ister Institute.

Mr. G. O. Whittaker presided at the North Midland
Branch of the British Dental Association’s recent

annual meeting. -

Professor Grancher, one of the most famous of
French physicians, has died at Paris.

Professor Alexander Macphaii., of St. Mungo's
College, Glasgow, has been appointed Lecturer on
Anatomy at Charing Cross Medical School.

Professor Radner is to preside at the International
Congress of Hygiene to be held at Berlin in September*

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82 The Medical Pke'8.

CLINICAL LECTURE.

July 24, 1907.

A Clinical Lecture

ON

“DISORDERS OF SLEEP/' ( a )

By PURVES STEWART, M.D„ FJRC.P.,

Physician to Westminster Hospital, and to the Royal Orthopaedic Hospital j Assistant-Physician to
the West End Hospital (or Nervous Diseases.

[specially reported for this journal.]

Most of us spend about one-third of our life
in sleep, but in spite of this, the physiology of
sleep is not yet completely understood. Let us
recall for a moment the chief phenomena of
ordinary healthy sleep. First, there is a diminu¬
tion, then a loss of conscious recognition of
ordinary stimuli, stimuli which would ordinarily
attract our attention, whether those stimuli
be derived from the outer world, or from within
our own organism. There is also the characteristic
but indescribable sense of well-being with which
we are all familiar, just at the moment of dropping
off. Consciousness becomes blunted, voluntary
movements become languid, and ultimately cease,
and the muscles of the limbs relax. Mean¬
while, there develops a double ptosis, respiration
is slowed and becomes deeper, the pulse is slowed,
the cutaneous vessels slightly dilate, and the
body temperature falls a little. Many processes
of metabolism, especially digestion and pertain
secretions, are retarded. Various explanations
have been offered for these phenomena. But
at the outset we should recognise that sleep is
not merely a function of the brain, it implicates
many organs of the body. It is generally ad¬
mitted that during sleep the brain is anaemic.
If we take an animal or a patient who has been
trephined and observe through the trephine
hole during sleep, we see that the volume of the
brain is diminished, that it is pale, and that the
cortical vessels are contracted. This vascular
constriction is not confined to the cortical vessels,
for if we succeed in examining the retina with the
ophthalmoscope while the person is asleep, we
find in the retinal vessels a similar constriction,
so that we may conclude there is, during sleep,
anaemia of the whole brain. We are all familiar
with the difficulty of doing severe mental work
after a heavy meal, and we know the drowsiness
at such times, and the tendency to fall asleep.
This is probably due to temporary abdominal
hyperaemia, causing a compensatory cerebral
anaemia. The activity of certain nerve cells,
especially those of the cortex, is temporarily
diminished. Some observers a few years ago
suggested that this was due to retraction of the
dendrites of the different nerve cells, whereby
those cells became temporarily insulated, that
there was a sort of amoeboid movement of retrac¬
tion. But the evidence in support of this theory
is by no means convincing. In fact, modem
histological observations show that the nerve
cells are not anatomically independent. Other
observers attribute the phenomena of sleep
to poisoning of the nerve cells by the accumulation ,
of C0 2 , or to some toxic waste products of j
metabolism, which act as narcotics. This may
be so to some extent, but it has been shown that
neither C0 2 poisoning nor other intoxication

(a) Delivered at the Polyclinic, Chcnies Street, London, February
19 th, 1907.

, are necessary to sleep. On the contrary, we
i usually sleep to avoid intoxication and to prevent
exhaustion. Healthy sleep is not necessarily a
poisoning of the nerve elements. There is a
periodicity whereby the healthy person, whether
he is fatigued or not, has a recurrent appetite
for sleep. Sleep has a constructive, anabolic,
invigorating effect on the whole body. This is,
doubtless, partly due to physical rest, partly to
the interruption in the production of toxines
arising from muscular contractions, and partly
to the absence of stimuli which, during waking
hours, excite nervous katabolism.

Some writers have assigned a special importance
to a particular region of the brain in connection
with the function of sleep, namely, the floor of
the third ventricle and the Sylvian aqueduct,
pointing out, in support of this theory, the w'ell-
known ptosis and divergent strabismus, both of
which might be due to a temporary paresis of
the ocular nuclei. And they recall the fact that
cases of tumour of that region are particularly-
likely to have early and persistent drowsiness.
But some of these cases can be well explained in a
different way; sometimes as due to cerebral
anaemia. Why ? A tumour at the base of
the brain may mechanically compress and
narrow the arteries which form the circle of
Willis. This has been several times demon¬
strated in cases of tumours of the base and of the
third ventricle. Some time ago I had under
care a woman, aet. 26, with a cystic growth of
the pituitary body and the floor of the third
ventricle. Her only symptom was paroxysms
of overpowering sleep, which increased, passed
into coma and stertor, and she died. She never
had any paralysis, nor optic neuritis.

Another help to natural sleep is the absence
of violent external stimuli, such'as loud sounds
or sudden flashes of dazzling light; therefore
silence and darkness conduce to sleep. A pleasing
monotony of gently reiterated stimuli has a
similar soothing effect, such as the sound of waves
beating on the shore, or the steady red glow of a
fire on a winter’s afternoon, or the restful tones
of the preacher’s voice in church. These things-
cannot be ascribed to cerebral anaemia, nor
to exhaustion, nor to any toxic action.
There are different degrees of normal sleep,
estimated according to the strength of the stimuli
necessary to awaken the sleeper to a consciousness
of his surroundings. The lightest is mere drowsi¬
ness, in which, although the person is not directing
his conscious attention to surrounding objects,
he can still be aroused by slight stimuli, such as
ordinary conversation or a light touch. The
next is sleep with dreams, when the sleeper is
unconscious of his surroundings but the psychical
centres are still active, though uncontrolled.
And under the influence of dreams, while the
cortical motor centres are still active, he may-

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July 24. 1907.

CLINICAL LECTURE.

The Medical Press. 83

perform motor actions, constituting the well-
known somnambulism. But this, in health, is
rare, because ordinarily the cortical motor cells
are dull at the same time as are the sensory cells.
Still more pronounced is the sleep which is deep
and dreamless. This, under pathological con¬
ditions, merges into what we call stupor, and
ultimately into coma. The chief distinction
between sleep and coma is, that a sleeping person
can be aroused, whereas a comatose person
cannot.

Let us now pass to the consideration of some
■disorders of sleep. There may be pathological
drowsiness, the commonest instance of which,
perhaps, is that of the anaemic young woman.
This may be partly toxic, from loaded intestines
or possibly from decaying teeth, or other sources ;
but it is mainly vascular. The heart in these
cases has but little energy, and the vessels through¬
out the body are flabby and deficient in tone,
and therefore in the erect posture the vessels of
the brain are badly filled. If the patient sits
down during the day, she feels drowsy ; but when
she lies down at night the conditions are altered ;
the brain becomes hyperaemic—still from want
of vascular tone—and she accordingly lies awake.
Therefore in treating the anaemia we often ad¬
minister digitalis, combining it with iron, and
bromide of potassium. Then the day drowsiness
disappears, and the patient is able to sleep at
night. Mvxoedematous patients are habitually
sleepy and stupid, probably from toxaemia ; so
are many idiots and cretins. And after a severe
fit it is not uncommon for an epileptic to fall
into a deep sleep. No doubt this sleep is largely
due to the toxines produced by the nervous
system and by the muscles during the fit. The
drowsiness produced by a combination of ex¬
haustion and extreme cold, as in the Arctic regions,
is very striking ; and it is probably largely the
result of deficient circulation, and unless the heart
be vigorously stimulated, the sleep is liable to
pass on to coma and death. The sleep induced
by gazing into a bright fire on a winter’s afternoon
is something different; it is probably a mild
variety of hypnotic sleep. The continuous red
glow acts on the optic nerve by a summation of
stimuli ; it is not merely the temperature, because
in the same temperature if the fire be not seen,
drowsiness is not so likely to occur. The church
drowsiness is also probably explicable on the
“ summation of stimuli ” idea. There are several
elements : the soothing monotony of the preacher’s
voice, the sitting posture of the listener, who,
of course, has the additional excuse of cerebral
anaemia, and there is the common habit of closing
the eyes to avoid visual distractions. This does
not apply to “ revival ” services, where the con¬
ditions are very different.

There is also the drowsiness of impending
diabetic and uraemic coma, both toxic in origin.
Also there is the remarkable “ sleeping sickness,”
which is endemic in certain parts of Africa, and
is associated with trypanosomes in the blood,
glands, and cerebro-spinal fluid. The drowsiness
is no doubt due to some toxine produced by the
parasite. In the later stages there is perivascular
cerebral infiltration around the cerebral vessels,
a variety of chronic meningo-encephalitis.

Then there is narcolepsy, in which the patient
suddenly falls asleep in the middle of whatever
lie may be doing. These cases are usually
hysterical.

The hypnotic state is another condition which
is analagous, in some respects, to ordinary sleep,
but time does not allow us to discuss it here.
Suffice it to say that the phenomena of hypnosis
may be produced by continuous monotonous
stimuli—visual, auditory, or other, aided by
suggestion.

Nightmares are horrifying dreams, which pro¬
duce so much distress that they sometimes wake
the person up. They are generally toxic in
origin. The commonest cause of nightmare is
gastro-intestinal fermentation; we know what
the proverbial lobster supper is capable of. They
will occur again and again in a child, and it is
curious that the character of the nightmare
in the child is generally the same each time. In
children gastro-intestinal fermentation is a very
important factor. Still more frequently we find
that the child has got adenoids, which interfere
with respiration, and produce a degree of carbonic
acid poisoning which acts as a narcotic. Atten¬
tion to the gastric condition or to the adenoids
generally corrects the night-terrors.

Patients with tropical abscess of the liver are
particularly liable to horrible dreams, so much
so, that they may be afraid to go to sleep ; big
sturdy soldiers fear to fall off to sleep. Doubtless
the cause here also is toxic.

Nightmares are also fairly frequent in those
who have aortic regurgitation. Here the cause
is probably not toxic, but vascular, due to the
irregularity in the blood supply and to pulsation
in the cortical capillaries.

Lastly, there is insomnia, or sleeplessness.
These cases may be divided into two great classes :
(1) Extrinsic ; (2) Intrinsic.

Extrinsic insomnia includes those cases in
which the sleeplessness is secondary to some
outside cause, not necessarily associated either
with the brain or with any of its blood
vessels. For example, physical pain of any sort
will keep a patient awake; so will a cough,
or vomiting, frequency of micturition, or diar¬
rhoea, or pruritus. And, of course, in these
cases we do not give a hypnotic; we treat the
primary symptom, and if we succeed, sleep
follows naturally. This group also includes
emotional insomnia. This latter is much more
often the effect of grief than of joy ; and it is
more often associated with fear or apprehension
for the future than with sorrow for the past.
When a pleasurable emotion does cause insomnia,
it is generally the anticipation of some happiness,
and one in the near future. A man will not lie awake
because someone is going to leave him a fortune
twenty years hence ; but he may spend a sleepless
night on the eve of his marriage. The treatment
of emotional insomnia, apart from assuaging the
patient’s sorrow—which is often beyond our
sphere—is best accomplished by giving a cerebral
sedative, such as a mixture of chloral and bromide.
The insomnia of extreme joy we are seldom called
upon to treat; but if the patient becomes too
excited, we can give cerebral sedatives here also.

But we are often consulted about the other
kind of insomnia, the intrinsic. This may be
due to vascular, or to toxic, or to nervous faults,
or to a combination of all three.

First, as to vascular insomnia. The brain may
be hyperaemic; this renders sleep impossible.
Hyperaemic insomnia may be of the high-tension
type, or of the low-tension type. In high-tension
insomnia the patient is often the suhiect of general

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84 The Medical Pum.

CONICAL LECTURE.

July 24 . iqo7 -

arterial sclerosis, or of renal disease, and the
hyper-tension is readily demonstrated by the
Riva-Rocei sphygmo-manometer The best remedy
for such cases, as Broadbent has so long
urged, is to give a mercurial aperient, such as
blue pill, or calomel, two or three times a week.
Of course, we must also lay down general directions
as to diet, &c., and regulate the mode of life.
Hypersemic low-tension insomnia occurs in
anaemic and neurasthenic patients, as we have
already seen. And it is characterised by the fact
that when the patient sits upright in a chair she
feels drowsy, whereas when she lies in bed at
night the brain is over-filled with blood, and
consequently she cannot get to sleep. In these
cases the best remedy is a cardio-vascular tonic,
such as digitalis, and moderate doses of bromide
of potassium. Hyperaemic insomnia, whether
of the high or low tension form, is generally
associated with cold feet; and if the patient’s
feet can be got warm the cerebral hypera'mia
tends to become alleviated. A cup of hot soup
or hot milk will cause temporary abdominal
hyperaemia, and thus relieve the cerebral con¬
gestion.

Insomnia may be one of the distressing features
of chronic heart failure. As the patient is drop¬
ping off to sleep, he suddenly starts up with
a feeling of suffocation, gasping for breath.
This form is probably due to deficient circulation
in the medulla oblongata. We treat it by cardiac
tonics, possibly combined with one of the non¬
depressant pure hypnotics, or even, in selected
cases, with morphia, which we must administer
cautiously and combined with atropine.

Next, there is toxic insomnia, and this is one
of the commonest varieties met with in practice.
Many of these cases are associated with gastric
or intestinal fermentation, and especially with
dilatation of the stomach. The symptoms are
very characteristic. The patient fails asleep, but
after an hour or two—the period varying according
to the amount of dilatation present, he wakes up,
perhaps after a horrible dream ; he has profuse
sweating, or some gastric uneasiness, and he
will have a “ sinking feeling ” in the abdomen,
with a craving for food. If he eats a biscuit, or
something of the sort, his stomach contents
become diluted for a time and he feels relieved.
And this may mislead the patient into thinking
that his insomnia is due to exhaustion from want
of food, which is far from the fact. During his
waking hours the patient is usually depressed,
even hypochondriacal, he may be almost melan¬
cholic. When we have such a history wc should
carefully examine the patient’s abdomen, and if
we find the physical signs of dilated stomach we
must treat the patient accordingly : put him on
dry diet, free from starchy foods, excluding
green vegetables, and attend generally to the
intestinal functions. Meanwhile, we should ad¬
minister gastro-intestinal antiseptics, such as
carbolic acid, creasote, or 3 Napthol, or sulpho-
carbolate of soda. To give hypnotics in such
a case, without correcting the gastric condition,
is worse than useless.

I must now refer to the sleeplessness produced
by chronic excess in the use of alcohol. This
sleeplessness sometimes culminates in delirium
tremens. There is also the insomnia of acute
fevers, and that also is toxic. In the insomnia
both from fevers and delirium tremens, sleep can
often be best induced by putting the patient

into a cold pack, or by wet sponging. Tobacco
smoking in excess may cause insomnia, partly
by a toxic action on the nerve cells, and partly
by its influence on the circulation. Strong tea
and strong coffee sometimes act in a similar way.

There is also a primary or nervous insomnia,
and that is generally due to over-fatigue, especially
mental. We see it in busy professional and
business men. But in most cases of insomnia
there are several factors. There is not only
the toxines of exhaustion and of hasty, ill-digested
meals, but also a succession of powerful mental
stimuli all day long, causing a persistent cerebral
hyperaemia.

As to treatment, in cases of primary insomnia,
besides correcting anything in the way of gastro¬
intestinal fermentation or any vascular fault, we
should make it a golden rule, I think, to send
every case away for a complete holiday. And
instances of pure insomnia are proper cases for
the employment of pure hypnotics, which have
a direct sedative action on the psycho-sensory
cortex. The names of these hypnotics are legion.
Amongst the most reliable is, perhaps, the old-
fashioned paraldehyde. It has a somewhat
nauseous taste, but I do not regard that as any
drawback, because it will prevent a habit being
formed. We do not often hear of people contracting
the paraldehyde habit. Other reliable hypnotics
are chloral, sulphonal, and veronal. Never give
a patient carte blanche to take the drug himself;
self-drugging with hypnotics is highly dangerous
in the layman, and still more so in the medical
man. who should never prescribe for himself.
He should rather go to his bitterest professional
rival.

There are other drugs, even more powerful
than those I have mentioned, for example, hyoscine
and morphia. They should be resorted to only
in cases of obstinate insomnia. In extreme cases
of excited mania or melancholia we are justified
in giving gr. of hyoscine hypodermically, or
we may give morphia $ gr. with gr. of
atropine. It is very important for every mental
case to have sleep. Persistent insomnia in cases
of insanity is of serious omen, and all modern
alienists insist on sleep-charts being kept. Severe
insomnia extending over a month in a case of
insanity makes the prognosis as to recovery very
gloomy indeed.

Note. —A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture
for next week will be by J. Bland-Sutton, F.R.C.S.,
Surgeon to the Middlesex Hospital and Senior Surgeon
to the Chelsea Hospital for Women. Subject : “ The
Value and Fate of Belated Ovaries."

The Lord Mayor and Corporation of Cardiff, in order
to commemorate the recent visit of Their Majesties
and H.R.H. The Princess Victoria, intend to present
40,000 specially designed boxes containing milk
chocolate to the school children of that city, and
have entrusted the execution of this large order to
Messrs. J. S. Fry and Sons, Ltd., of Bristol and
London, Makers to H.M. the King.

Cambridge Lemonade. —Messrs. Chivers and Sons,
Ltd., of Histon, Cambridge, have sent us a sample
of their “ Cambridge ” Lemonade, which is already
well | known for its refreshing qualities. The con¬
venient form in which it is made up—namely, that of
a powder—enables it to be used largely for travelling
and pic-nics, as well as for ordinary domestic use.
The name of Chivers is a guarantee as to quality.

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July 24, 1907.

ORIGINAL PAPERS.

The Medical Peem. 85

ORIGINAL PAPERS.

THE GENERAL PRACTITIONER.

III.—HIS PRACTICAL NEEDS.

By J. LIONEL TAYLER, M .R.C.S., L.R.C.P.Lond.

These are, I think, four—(1) an efficient liter¬
ature that is representative of his requirements;
(2) leisure to study and to rest with less fear of
interruption ; (3) incentives for the fostering of
research desires; (4) freedom from excessive

competition.

(1) An Efficient Literature. —This point I have
already alluded to in my last paper, and here, I
hope, it only needs emphasising. Every worker in
any form of activity needs a representative, trust¬
worthy literature composed of good reliable text
books, that have a reference value to such worker,
and periodicals, also reliable, dealing with more
transient aspects of his employment. These are
exactly what the general practitioner lacks because
he is still looked upon as a subordinate when he
is an independent investigator whose results ought
to be related to other medical investigators.

That general medical literature does not attract
and is of little use to the ordinary medical man
is proved by the little reading on medical subjects
which he undertakes. I remember being the guest
of a doctor who prided himself on his efficiency
after some forty years of practice, and I think in
the main his pride was justified, who though he
had distinguished himself at college, and had
succeeded both financially and by reputation, had
not added, as far as I could discover, one single
text-book on any branch of medicine to his
book-shelves since his student days, nor did he
belong to a medical library. This is perhaps ex¬
ceptional, though I am sure it is less so than is
apt to be thought, but it is certain that new
books are very seldom added to the medical nucleus
that is acquired in student days, and yet if books
were really a help, they would unquestionably
be bought if only to compete more favourably
■with other medical men. This lack of reading is
not true to anything like the same extent, of the con¬
sultant and the specialist, hence books must serve
their ends better than they do the ordinary man's.

The reason is obvious : A practitioner who sees
a patient once, twice, or even several times, but
in each case for a special defined reason, and
receives his fee for each consultation is on a dis¬
tinctly different footing from the one who may be
called in for any cause, who is frequently on terms
of intimacy with the family, and may have all
kinds of questions asked him. A book dealing
solely with defined diseases satisfies the former,
but for the latter it is all but useless.

Such questions as the advisability of marriage
for a delicate but not diseased woman or man ;
advice on girls’ or boys’ education in relation to
their health ; on choice of a house, the soil it
should rest on, its situation, drainage and sanit¬
ation ; heredity ; diet and food adulterations ;
exercise and clothing which are all quite legitimate
ones, are not adequately treated in any book,
so far as I am aware, that is in existence, and are
frequently not alluded to. Then there are certairi
issues that a doctor is quite justly expected to
give an authoritative opinion on, such as hydro¬
pathy, homeopathy, vivisection, vaccination, hyp¬
notism, faith healing, Christian Science, patent
medicines, and he may turn in vain to any one,

two, or three works of reference for brief, reliable
interesting statements on these subjects. Again
bodily temporary or permanent conditions which
are not due to disease—and frequently depend
upon some error in diet, exercise or vocational
habit—such as constipation, flatulence, headache,
sleeplessness, but are nevertheless very' difficult
to treat, are mostly unconsidered. Occasionally
one is asked such a question as this, and in the
future it will be a frequent one: “Will you please
examine me, and tell me if I am healthy ? ” and
to this may be added the still harder point: “and
how am I to keep so ? ” Though insurance books
are some help they are really of much less use than
would be thought as all the old assumptions of
size, weight, height, etc., have broken down, and
we simply do not know if a given man is naturally
small like a Japanese, heavy like a Welshman, or
light like an Irishman, or is unhealthily under¬
sized, heavy, or light. And it is needless to point
out that our advice should depend on our diag¬
nosis.

A literature corresponding to the general prac¬
titioner’s needs is therefore the first essential,
and I am convinced that if it existed it would
be widely appreciated.

(2) Leisure to Study. —The exactions of patients
who trouble doctors at all hours of the day and
night over quite slight matters must be met.
As a student I was once called at three in the
morning because a patient wanted a thickened
but, he admitted, painless toe-nail cut, and though
I have never since had quite so flagrant an example
of unreasonableness to contend with, yet, like all
other medical men, I have time and again been
troubled late in the day or at night with the silliest
of trivialities. It is quite useless to attempt to
do solid reading under the circumstances, as one
is always waiting for the call bell, and so a novel
that can be picked up and thrown down again
accounts for far too much of the leisure at our
disposal. Many men do their best work "in their
carriage while visiting, reading the weekly medical
journal and getting their new ideas largely from
such source alone. Others rely on chats with
brother practitioners. But in all cases the result
is far from satisfactory as most recognise.

The only solution to this difficulty of constant
interruption is that which many qualified men
have already adopted, namely, of graduating the
fee to the lateness of the hour when one’s advice
is sought, and except during fixed consulting
hours, charging one fee before twelve, one and a
half between twelve and six, and two fees after
this.

Such a rule would apply to all classes alike, it
creates no invidious distinctions and it gives the
patient the option of sending if the need is great,
while it appears to be at the same time an effective
deterrent to unreasonable demands. Something
of this nature is required to prevent medical
men’s leisure being wasted.

Of course some arrangement should be made
also in reference to obstetrical cases. Beyond
a certain number of visits extra fees should be
charged for those that the patient is herself re¬
sponsible for. There is at these times all the
difference between the genuinely anxious and the
fussy patient and the latter should be made to
realise that the trouble that she causes is a costly
matter for herself.

If practitioners would combine by some such
scheme it would in the end be beneficial not only

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86 The Medical Puss.

ORIGINAL PAPERS.

for the profession at large, but for the general
public’s own interests, as a higher level of capacity
would be possible for medical men to attain to.

(3) Incentives to Study .—There are few more
curious anomalies than the position of the medical
man in regard to medical research. In every other
occupation a man has at least the possibility of
reward for original investigations. In medicine
alone the worker may not profit by the creation
of improvements in his calling and yet the person
who is not medical may.

It must of course be admitted that the medical
position is a peculiar one. Everything must
be done to prevent health being considered from
the commercial aspect. Advertising is for this
reason wholly discreditable. Also to make a
profit from the sale of drugs or instruments is
equally unsatisfactory. Yet it must be evident
to every person who thinks over the matter at all
that to deprive a medical man of all remuneration
for his labour must tend to make him less interested
in the original aspects of his pursuit and this is an
evil of incalculable magnitude.

Further, by removing the true pioneer from
his rightful position and not keeping the place
vacant, but allowing the little trained chemist
and the untrained quack to compete for what is
denied to the medical practitioner must, and as a
matter of fact does, result in the exploitation of
worthless products by adventurers on its worse
side and on its better by the production of new
drugs that may be of value—but since they cannot
be tested therapeutically by chemists, however
efficient—are for a long period unsupported by
clinical testimony as to their special actions. It
is neither to the interest of the patient (who is
treated by a medical man who has little incentive
to develop his skill and who is imposed upon by
untrue advertisements of patent medicines) nor
to that of the doctor that this state of things
should continue.

To obviate this surely it would be possible to
have new remedies tested by specially appointed
Government experts, whose own stipends must
be unalterable ones, and an award granted to the
discoverer for his legitimate labours, which though
not large should at least compensate him for his
effort. This sum, if it were fixed either in the
form of a small unalterable annuity, or by payment
of a given amount of money that would be re¬
garded as complete compensation for the discovery,
would enable the new product or contrivance to
become at once public property, while the dis¬
coverer’s financial interest in it would at the same
time cease. If, further, no other means of patent¬
ing any new drug or instrument were legal and the
advertising or selling of medical things by un¬
qualified persons was made criminal, a fresh stim¬
ulus would be given to the chemist and the
medical man in their respective occupations, while
the removal from social life of the advertising
quack who influences so prejudicially many
thousands of people would be an unquestionable
gain to humanity.

There is of course nothing new in this proposal,
but surely some such recognition of service is
desirable. Obviously until labour in this direction
is made in some degree remunerative it is im¬
possible for any man who has to earn his living,
to spend much effort in a direction where he cannot
expect the least return. To thus crush out in¬
centive by giving it no outlet is neither wise
national nor individual policy and until such indi¬

J ply 24, 1907.

vidual incentives are in existence medicine can
never take its true position in relation to other
scientific studies.

(4) Excessive Competition. —Lastly, it is a fact,
regret it to what extent we may, that owing to
growing competition the various members of the
medical profession are becoming increasingly
hostile to each other.

Some means of checking this tendency must be
found. A minimum fee should, I think, be fixed
by the General Medical Council, and doubtless
simpler quieter modes of living would accomplish
much.

In conclusion, it is along lines such as these
that the development of medicine must take place.
We must come together on a broader and more
friendly basis ; we must have more leisure and be
treated more considerately by the general public;
we must have incentives to study and not see the
quack reaping in districts that are rightfully our
own; and our literature must recognise and
cater for the needs of the general practitioner.
Finally by removing the stigma of inferiority from
the ordinary medical man by giving him a share
in the control of medical institutions and by realis¬
ing that he has at his command information that
can be obtained from no other source it is reason¬
able to hope that a newer and larger horizon will
be revealed to us.

POOR-LAW AND SANITARY
ADMINISTRATION IN IRELAND. («)

By SIR CHARLES A. CAMERON, M.D.

F.R.C.P.I., D.P.H.Cantab.

Chief Medloal Offloer of Health for Dublin.

The Sanitary Acts are administered in Ireland
by the following bodies:—1st, the Local Govern¬
ment Board, the supreme public health authority
of the country; 2nd, the county boroughs:
3rd, the urban district councils ; 4th, the rural
district councils.

The Local Government Board has certain
powers vested in it by statute, which enables it
to supervise the boards of guardians who have
charge of the pauper poor, sick or well. The
Board must approve of the appointment and
dismissal of officers of the guardians ; its auditor
examines their accounts and makes surcharges
if payments of money have been illegally made.
If the Board considers that the guardians have
neglected their duties, it may supersede them by
the appointment of vice-guardians. The Board
has much the same power in reference to the
boroughs and urban and rural district councils.
It must approve of the appointment and dis¬
missal of sanitary officers, and of their salaries
and increases of salaries. This practically secures
fixity of tenure to the medical officers of health,
who are appointed by the sanitary authorities,
and in which respect they are in a more secure
position than the medical officers of health in
England and Scotland.

The Local Government Board contributes to
the salaries of the sanitary officers of the local
authorities. Dublin received last year more
than £2,000 on account of the salaries of the
medical superintendent officer of health and the
sanitary sub-officers. For some years up to
1902 the Local Government Board paid one

(a) Bead at the Conference of the Boyal Sanitary Institute,
Dublin, June 17th, 1007.

Digitized by G00gk

July 21, 1907.

ORIGINAL PAPERS. Th* Medical Fust 87

half of the salaries of the sanitary officers. In
that year an Act of Parliament was passed,
which fixed the contribution for that year as
the maximum sum that in future could be given.
As a result of this Act, the Local Government
Board cannot contribute to the increase of
salaries or to the salaries of new appointments,
if by so doing its contribution would exceed the
grant of 1902.

The borough councils are empowered to appoint
medical superintendent officers of health, executive
sanitary officers, and sanitary sub-officers
(another name for inspector of nuisances, or
sanitary' inspector). They can establish hospitals
and work them, or contribute to their main¬
tenance, or do both. Dublin has a smallpox
hospital in connection with its Sanitary Depart¬
ment. It has no Corporation general or fever
hospital, but it contributes between five and
six thousand pounds annually to hospitals under
private management. In addition, the Public
Health Committee are empowered to pay for
the maintenance of fever patients in the fever
hospitals, or in the fever wards of the general
hospitals. All the powers which Dublin and
other county boroughs possess in reference to
the appointment of sanitary officers and contri¬
butions to hospitals are also enjoyed by the urban
and rural district councils.

The Irish Public Health Act of 1875 consti'
tuted all the poor-law medical officers ex-officio
medical officers of health. They were paid by
the boards of guardians, but when their districts
were situated in towns having sanitary authori¬
ties, their salaries were fixed, though not paid,
by those authorities. This anomaly ceased on
the passage of the Irish Local Government Act,
which transferred the payment of the salaries of
the medical officers of health from the boards of
guardians to the governing bodies of the counties
and boroughs, and of the newly-created rural
district councils. This Act transferred all the
sanitary functions of the boards of guardians to
a newly-created set of authorities, termed rural
district councils, whose functions are practically
the same as the sanitary authorities of the towns.
They are practically composed of the boards of
guardians, but they have sometimes different
chairmen and clerks. They pay the salaries
of the ex-officio medical officers of health, sanitary
sub-officers, &c.

It is now generally conceded that it was a
mistake to have converted nolens volens the
dispensary' physicians into medical officers of
health. Many of them disliked the new functions,
especially as, with very few exceptions, their
salaries were very small, often £10 a year. In
1900 a Commission was appointed by the Local
Government Board to inquire into the causes
of the high death-rate of Dublin. One of the
recommendations was that an assistant medical
officer of health should be appointed, and the
sixteen ex-officio medical officers of health relieved
of their functions. No authority in Ireland has
the power to abolish the ex-officio health officers.
It has been suggested that in the next proposed
Dublin Improvement Act a clause should be
inserted to discontinue their services. I doubt
very much that Parliament would pass such a
clause, for as a rule sections of general Acts
are not in any important manner repealed by
local Acts. In a general sanitary Act for Ireland,

the ex-officio health officers might, of course, be
dealt with.

One great difficulty in depriving the dispensary
physicians of their sanitary functions is the
question of compensation. If they were com¬
pensated by retiring allowances, then for many
years to come the local authorities would have
to pay a double set of medical officers of health.
Most innovations and improvements are, how¬
ever, attended with expense ; and the abolition
of the ex-officio health officers, and their replace¬
ment by whole-time officers, would (so far, at
least, as rural districts are concerned) be worth
the expense involved by it. So far as the large
towns are concerned, the district medical officers
of health perform, on the whole, very good
sanitary work. In the rural districts they are
handicapped very largely. They have not
efficient sanitary sub-officers. The rural district
councillors are practically the boards of guardians,
who elect and pay them as dispensary physicians
or medical officers of the workhouses. The
health officers, whenever they make sanitary
reports, are not unlikely to give offence to some
one or other of the rural district councillors.
This is particularly the case as regards the
hygiene of the dairy and farmyard. A con¬
siderable proportion of the milk supplied to the
towns comes from the country. The sanitary
sub-officer who is generally also the relieving
officer, and who has a salary of only a few pounds
a year, can hardly be expected to give much
attention to the hygiene of the dairy and cow¬
sheds. He is not qualified by the possession of a
certificate of competency to act as a health
officer granted by such bodies as The Royal
Sanitary Institute. I think it may safely be
assumed that in the greater number of the rural
districts in Ireland the sanitary laws are practi¬
cally a dead letter.

It would be most desirable that the Depart¬
ment of Agriculture and Technical Education
should take over from the sanitary authorities
the supervision of all places in which milk is
produced. For the administration of the Disease
of Animals Act and the Orders relating to dairies
and cowsheds, it has a staff of nearly sixty
veterinary' surgeons. By an increase of this
staff and the appointment of inspectors not
veterinary surgeons, but having some knowledge
of rural sanitation, the health of dairy stock of
the country and the purity of the milk would be
far better attended to than they are at present.

Whether or not the ex-officio medical officers of
health should cease to exist, the county council
ought to be empowered to appoint medical officers
of health and sanitary sub-officers. If the officers’
functions ceased, the sanitary staff of the county
would have to be larger than if there were no
district medical officers. In England and Scot¬
land, as well as in Ireland, there are district
medical officers of health; but that did not
prevent the establishment of county officers
with powers to act in every district, and to review
the proceedings of the local authorities. I would
be glad if this Conference would pass a resolution
urging the Government to introduce a Bill for
the appointment of County Medical Officers of
Health. _

Dr. F. H. Scott, who wishes to continue his re¬
searches into the metabolic processes of nerve-cells
has had the accrued income of the Gunning Fund
placed at his disposal for the purpose.

Google

Diqiti

88 The Medical Pstss.

ORIGINAL PAPERS.

July 24. 1907.

TWENTY-THREE YEARS OF
GYNAECOLOGICAL PROGRESS. («)

By W. D. SPANTON, F.R.C.S.Eng.,

Consulting Burgeon, North Staffordshire Infirmary, Ac.

To attempt a general survey of the work accomplished
by our society during the past twenty-three years
would be quite impossible in the time at my disposal.
It becomes a duty, nevertheless, to recall some of the
more important features of it, which afford a con¬
vincing proof of its usefulness and of the value of the
results it has accomplished.

To begin with, I have to revert to the early days of
recognised gynaecology in this country, when strong
convictions and abundant moral courage were vitally
necessary. These attributes fortunately some of our
pioneers possessed, and enabled them to lay the foun¬
dation for the scientific study of British gynaecology
as a distinct and important branch of special surgery.

The Foundation Meeting was held on December 27th,
1884 ; and I find, on looking through the first list of
officers of the Society, only one of the vice-presidents
is still with us, the veteran Dr. C. H. Routh, though
of the original Council we have still one-half remaining
among our Fellows. The objects were expressed to be
“ to promote and encourage the science of gynaeco¬
logy,” and Dr. R. Barnes then said he was “ sure its
existence would be abundantly justified by honest
and useful work.” This prophecy has, we know, now
been abundantly fulfilled.

The first specimen shown by Dr. Wallace was a
typical one of degeneration in multiple uterine myo¬
mata, where hysterectomy had been performed ; and
it seems to strike the key-note of one of the most
important tunes which our society has had to sing—
that of early surgical interference in all such cases.
But the most advanced surgeons on the same occasion
concurred in the speaker’s remarks that " to extir¬
pate a tumour simply because it was a tumour, which
gave little or no trouble, and which in all probability
would finally disappear, implied taking a responsi¬
bility on the part of the surgeon which he ought to
decline.” This view, I am glad to say, has been reite¬
rated in an emphatic manner at one of our recent
meetings. No one subject has been so fully dealt
with as that of uterine tumours; and valuable in¬
vestigations have been recorded, throwing light on
their pathology and treatment; but I do not find
anyone bold {enough to enter upon their causation.
That seems as much a mystery as ever, and might
form a good topic for the new Royal Society of Medi¬
cine.

We find in the very early days (1884) some dis¬
cussions on the Listerian mode of treatment in laparo¬
tomies and kindred operations ; and a divergence of
views was even then beginning to manifest itself in
vigorous language. At that period numerous cases
were brought forward of ovarian and parovarian
tumours of all kinds, and uterine appendages removed
for a multiplicity of conditions. It was about this
time an outcry arose against what some persons
deemed the too frequent and indiscriminate opera¬
tions of this class ; and although, in looking back, it
is evident enough that the evils were greatly exag¬
gerated, a more conservative policy was the direct
result, so that good came of it.

One condition, however often referred to—that of
diseases of the Fallopian tubes—was in its early stage
of evolution, for we find frequent reference to the
difficulties encountered by the best operators of that
day, notably Lawson Tait and Dr. Bantock ; the same
difficulties as are encountered still, but with more
accurately defined knowledge how to deal with them,
derived from the experience of operators in the past.
The treatment of pelvic abscess by abdominal section
has been frequently dealt with, being first brought
prominently forward by Dr. Richard T. Smith and
Mayo Robson. Associated with this, a discussion on
“ Puerperal Septicaemia ” elicited some emphatic

(«) A Valedictory Presidential Address read before the British
Gynaecological Society, July 11th, 1907.

remarks from Lawson Tait and Robert Barnes, that
“ whenever pus formed and collected in the abdomen
and pelvis, the indication was strong to make an
incision into the abdomen and give it exit.”

The subject of Porro’s operation (spoken of as
amputation of the uterus), brought forward by Dr.
Godson, drew attention to its advantages, under
specified conditions, over that of Caesarian Section.

That all-important disease, cancer of the uterus, has
received a large share of attention from this society,
and the consensus of opinion is that, like cancer else¬
where, if it can be thoroughly removed early enough
a cure will follow ; and although, in advanced cases,
no remedy has yet been found which will effect a cure,
much may be done by removal of the diseased tissues
in various ways, to prolong and make more com¬
fortable the patient’s remaining life. Early hysterec¬
tomy, all agree, offers the best chance for the patient.
The treatment of uterine tumours by electrolysis, as
advocated by Apostoli, found favour with a minority
only, and was strongly condemned by others—chiefly
those who had never tried it. That it has its uses,
few will deny ; though it seems to have fallen almost
into disuse now. Another important aspect of myoma
in connection with pregnancy has been before us,
which illustrates forcibly the close association of
obstetrics and gynaecology. As in most things, there
are two sides to the question, and it is well to hear
both before arriving at any definite conclusion as to
the right course to adopt in every such case.

We find scattered among the records many subjects
of general interest, which, having a special bearing
on gynaecology, have been discussed from that stand¬
point. Among them, the dangers of the use of mor¬
phia, conveying a very suggestive note of warning.

The treatment of uterine prolapse has been fully
dealt with, and the ventral methods compared with
the vaginal freely discussed. When the causes are
so diverse, the treatment must necessarily be very
varied too ; and it becomes quite impossible to do
more than indicate what may be considered the best
mode of treatment for well-defined conditions—no
universal rule is possible.

Of displacements of the uterus, with reference to
mechanical support, much has been said ; but it
would seem that opinions as to the best method remain
as varied as ever. I fear that, until men and women
are made of some more rigid material than living
flesh and blood, there always must be a difference of
opinion regarding the treatment of conditions which
cannot, in their very nature, be fixed quantities.
As we proceed, we find such matters as cholecystotomy
and nephrolithotomy described. These were, to a
large extent, novelties then ; the beginning of great
things for those branches of abdominal surgery which
have now arrived at the stage of having specialists of
their own. The very wide subject of dysmenorrhaea
has, at various times, been freely discussed, and, each
time it comes up, some new light is able to be thrown
upon it. Social matters of interest have been dealt
with from time to time—notably the Midwives Bill
introduced in 1890, since in a modified form passed
into law, conducing without doubt to the safety of
parturient women who were formerly in the hands of
ignorant persons.

During our last short session, many interesting
subjects have been discussed, most of them having a
practical bearing on everyday gynaecological work
rather than of an academic character. Among them
may be mentioned membranous dysmenorrhoea. a
subject of importance to the general practitioner, and
about which much has yet to be learned.

We are indebted to Professor Jacobs, of Brussels, for
bringing before us the subject of the radical treat¬
ment of prolapsus uteri, more especially by means of
an extensive operation he described. This led to a
valuable discussion, and the views of many Fellows
who took part in it were freely expressed, and will be
found recorded in the valuable volume (the last,
unfortunately) of our Transactions.

The important subject of the surgical treatment of
inflammatory diseases of the uterine appendages was

July 24. 1007.

CLINICAL RECORDS.

Thb Medical Pres-:. Sq

once more brought forward by Dr. A. E. Giles—another
reminder of vexed controversies which a few years
ago would have provoked acrimonious debate. It is
one of those matters which time and experience have
helped to make clear, and enabled certain rules for
guidance in treatment to be laid down, which must
prove helpful to less experienced practitioners. Re¬
ference was very suitably made to the exhaustive work
in this department carried out by Dr. Cullingworth ;
and there is no doubt that he, and Lawson Tait, were
those chiefly instrumental in showing the necessity
for surgical action in cases of this class. Now that
they are able to be better differentiated, and the con¬
ditions more accurately defined, what was once de¬
cried as an empirical, is now fully accepted as a scien¬
tific mode of treatment. For this result we have
who’lv to thank the gynaecologists.

Another interesting paper brought before us. rather
surgical than gynaecological, by Mr. Stanmore Bishop,
was that of movable kidney. The influence of this
condition on a woman’s life was entered into, and led
to some varied views. Some would look on it rather
as a symptom or an effect than a cause ; and a fear was
expressed lest surgery should take the place of other
measures. For my own part I am firmly convinced
that a mobile kidney is often a sole cause of some of
the most troublesome ailments in women, especially on
the left side, where it sometimes simulates very closely
the symptoms of gastric ulcer—on the right side, its
frequent association with appendicitis is also easy of
explanation. But to ascribe, as has been done by
some authors, such remote troubles as insanity to a
mobile kidney, seems to me beyond the ken of modern
gynaecologists, at any rate.

At our last meeting, we had the advantage of having
brought before us, by one so eminently qualified to
speak as Mr. Mayo Robson, the question of the treat¬
ment of general peritonitis. This is, indeed, an im¬
portant one for all surgeons, and needs all the light
that can be brought to bear upon it by skilled minds.
On this occasion, as usual, diverse views were ex¬
pressed ; but one and all agreed that the modern
treatment of this condition, by which every effort is
made to assist nature rather than to thwart her efforts,
has been a great advance. To open the abdomen
early ; whenever possible, to remove the cause, and
then trust to natural processes to complete the work
is what we now aim at. Those who attempt too much,
equally with others who stand by and do too little,
usually come short of success. It was especially fitting
in a practical society like ours, that this subject should
have recrudesced, and led to a discussion which is
certain to result in good.

It would be a grave dereliction of duty on my part
if I were to omit some reference to the indefatigable
and valuable labours of some of our Fellows, who
have, by their energy and their influence, overcome the
difficulties which were inherent to the union of our
society with the new Royal Society of Medicine. To
Dr. Macnaughton-Jones, Mr. B. Jessett, Dr. Slimon,
and Dr. Beckett-Overy especially, our warmest thanks
are due ; and I feel sure that, in years to come, when
the Obstetrical and Gynaecological Section of the
Royal Society of Medicine is thoroughly established,
everyone will look back with the utmost satisfaction,
and with grateful feelings, to those who have been
instrumental in its accomplishment.

One achievement on which the Society has good
reason to congratulate itself, is the series of valuable
Transactions which have been published, and will
remain as a monument of practical gynaecological
literature. It is not too much to say that the success
which has attended the society is, in no small measure,
10 be attributed to the full and admirable manner in
which its work has been recorded, and correlated with
that of other countries

Sir .Thomas Browne wrote that " as the work of
Creation was above Nature, so is its adversary anni¬
hilation, without which the world hath not its end,
bat its mutation." So of our society. Its birth is
now to us “ a sleep and a forgetting,” and “ the soul
that rises with us, our life’s star,” will find its apo¬

theosis in the higher life which lies before us in our new
sphere.

Now, to our old Society, we have to bid ** Farewell.”
‘‘extinctus amabitur idem.”

CLINICAL RECORDS.

CASE OF FIBRO-MYOMA OF THE VAGINA.

By J. H. SWANTON. M.D.„ M.Ch., M.R.C.P.Lond.

PliyjleUn for Disemset of Women, Remington General Hospital, etc.

The patient, C.G., from whom this growth was
removed, was aet. 40, a widow, whose occupation
was that of cook.

She came to hospital complaining of pain in her
back and lower part of abdomen, frequency of mic¬
turition, and painful defnecation. The only previous
illness was described as inflammation of the bowels.
Menstruation commenced at 14 years of age, regularly
appeared every 28 days, and lasted seven days with
scanty loss. She had pain occasionally before each
period. The patient had been pregnant five times,
her eldest child was set. 18, and she had four mis¬
carriages. the last having occurred five years ago,
after a pregnancy of three months. She nursed her
child for nine months.

Her present illness began three months ago with
pain in her back, caused by standing. There was
a red vaginal discharge which came on every fourteen
days. There was dysuria without frequency of
micturition. She had been getting thinner recently.
The patient was thin and had an anxious expression
with agitated manner. The superficial reflexes were
increased. The abdominal muscles were rigid. There
was a red vaginal discharge with a faint odour. The
urethra was drawn upwards; the uterus was enlarged,
and its consistence increased; the fundus was retro-
deviated and not freely movable. Both external and
internal piles were found.

In September, 1906, she returned, complaining
of backache. The uterus was now movable, A
nodule was found in the vaginal vault at the junction
of the anterior and posterior left quadrants. The
mucosa could be removed freely over it. The uterus
was anteverted and a suitable pessary inserted. In
October, 1906, the tumour was found to have become
enlarged and the surrounding tissues were less sharply
defined. In February, 1907, the nodule had not
altered much, but the surrounding infiltration was
greater. On conjoined manipulation the uterus
was found to be painful, In March, 1907. the patient
was admitted, when the uterus was curetted and the
vaginal tumour removed at the same time, owing to its
increased growth. An incision was made into the
mucosa and the tumour found to be attached to the
muscular wall by a pedicle, which was cut through
after ligaturing and the growth then removed. The
wound w r as sutured with iodised catgut and healed
without complication.

The tumour measured three-quarters of an inch
in its longest axis and one-third in the shortest. The
surface was irregularly lobulated, of pearly white colour,
with subcapsular areas of haemorrhage. On section
a capsule was found externally enclosing a mottled
central portion made of irregularly-arranged whitish
tissue in strands surrounding areas of grey tissue ;
also a looser tissue of the same kind on one side imme¬
diately under the capsule. After serial staining of
one set of sections with hematoxylin and eosin and
another with Van Giesson's fluid microscopical ex¬
amination showed that the fibres of the capsule were
loosely arranged with polymorphonuclear cells scattered
between, and in other portions some extravasations
of blood were seen.

The central portion consisted of white fibrous tissue
arranged in whorls and unstriped muscular tissue
irregularly interspersed. The arterioles in the central
portion showed hypertrophy of the middle coat, as
observed by Mr. Stanmore Bishop, and described in a
communication read before the British Gynaecological
Society and recorded in the XVII. Volume of its
Transactions.

zed byLiOOQle

go The Medical Puss.

OPERATING THEATRES.

July 24,1907.

The patient was discharged in seven days after the
operation and convalesced in a satisfactory manner.

In connection with the etiology of these growths
Comil and Ranvier have associated them with syphilis,
but in this particular instance sufficient evidence was
not forthcoming.

Fibro-myomata of the vagina are rare. Machen-
hauer has collected reports of seventy cases, and
stated they were found in women between forty and
fifty years of age. They varied in size from a cherry
to that of a f etal head, and are found in the upper
part of the anterior wall, being chiefly sessile. The
surface may occasionally ulcerate.

CASE OF CYST OF THE CLITORIS.

The patient from whom this cyst was removed
was a dancer, aet. 20, who complained of a painful
swelling on her vulva early in May, 1907. Her men¬
struation, which began at fourteen, appeared regularly
every twenty-eight days, lasted four, and was scanty.
There was a thick yellow inter-menstrual discharge.
She had been married for two years, and was pregnant
a year ago, but aborted after two months. Since then
her menstruation has been irregular, being more
frequent and of longer duration.

The onset of this growth was dated from an injury
received while dancing, what she described as the
“ cobbler” dance, three months previously.

The swelling gradually increased in size, but after
manipulation three days previously it became rapidly
larger, more painful, and accompanied with dysuria.
The patient gave a history of alcoholism. The tumour
became smaller during menstruation.

On examination the clitoris was found to be the
seat of a fluctuating tender, dusky, tumour about
three-quarters of an inch across. The bifurcation
of the anterior extremity of the left labium minus
was widely separated owing to the size of the cyst. As
the symptoms were urgent the tumour was tapped,
giving exit to a quantity of coagulated blood mixed
with a thick oleaginous fluid followed by a thin greyish
fluid with a faint odour. The patient experienced
such relief that further treatment was refused. In
ten days afterwards, however, she was admitted into
hospital owing to a return of pain and swelling. The
growth had extended under the anterior commissure
and vestibule to the right side. The tumour was
removed by making a triangular incision reaching
from the suspensory ligament to a point about an inch
outside each labium minus, and another across the
vestibule. The cyst was dissected out without
rupture. Haemorrhage was free, but easily controlled
by deep mattress sutures of catgut, the skin being
united by continuous catgut sutures.

The growth consisted of a thick walled oval cyst
about i£ inches in length and J inch across. There
was a small opening anteriorily from which purulent
fluid exuded. The wall was three-sixteenths of an inch
in its thickest portion, and diminished down to a
membrane anteriorly. The contents consisted of pus
and fatty debris, but no cholesterin was found. The
anterior two-thirds of the inner surface of the cyst
wall was haemorrhagic. The inner surface generally
was rugose with traces of septa, more marked in the
posterior third. On microscopical examination the
walls were made up of laminated layers of connective
tissue with numerous vascular spaces ; more internally
the tissue was necrotic with numerous polymorphonu¬
clear leucocytes and lymphocytes. There was no trace
of a distinct lining membrane. The differential
diagnosis must be made between a dermoid cyst, fatty
tumour, sebaceous cyst and chronic abscess. The
attachment of the cyst to the skin, the known date
of onset, and its position were against a dermoid cyst.
The absence of lobulation and the firm consistence
would distinguish it from a lipoma. The diagnosis
between a sebaceous cyst and a chronic abscess was
not so easily disposed of, but the history and struc¬
ture of wall were in favour of its being a sebaceous
cyst in which suppuration had recently taken place.

The patient was discharged convalescent on the
sixth day after the operation.

OPERATING THEATRES.

GREAT NORTHERN HOSPITAL.

Double'Osteotomy of theJFemur for Knock-
Knee. —Mr. Arthur Edmunds operated on a female
child, aet. 5, who was suffering from an extreme degree
of knock-knee. The child was a thin, ill-nourished
little girl, who had obviously been the subject of severe
rickets, but, with the exception of the deformity of
the femora, the mal-nutrition presented no other de¬
formities. When the child lay down with the internal
condyles of the femora in apposition, the internal
malleoli were separated by about seven inches. The
deformity in knock-knee, Mr. Edmunds pointed out,
may be mamlv due to a curvature at the lower end
of the femur, or it may be due also to a curve at the
upper end of the tibia. It was very rare to find the
curve in the tibia alone. By flexing the leg at the
knee-jomt, it was always possible to make out the
share played by each bone in the production of the
deformity. If the femur is alone affected the internal
condyles and the malleoli can be made to touch simul¬
taneously when the knees are flexed. For example, if
a child be placed on a table so that the knees hang
over the edge, the deformity completely disappears.
In early stages of knock-knee, while the bones are yet
soft, a simple splint will usually suffice to completely
cure the deformity ; but when the bones have become
more firmly ossified—that is to say, when a child is
set. about 5—this mode of treatment is not sufficient,
and osteotomy has to be performed. Osteotomy,
however, although it seems at first sight such a trivial
operation, is very frequently a severe strain on the
constitution of these weakly children, and after pro¬
longed immobilisation in plaster of Paris, the legs are
often found so weak and wasted that it is a very long
time before the child is able to walk. In the present
case the child on admission was so poorly nourished
that it was not thought advisable to perform an
osteotomy, until she had been sent away to the country
for several months. Her condition on re-admission to
the hospital was very much improved and operation
was accordingly undertaken. Many types of osteo¬
tomy have, Mr. Edmunds said, been introduced, but
the linear osteotomy on the lines laid down by McEwen
was perhaps the best. An incision about three-
quarters of an inch long, above and in front of the
adductor tubercle, was made down to the bone and
the osteotome introduced, twisted to 90°, separating
during its rotation the periosteum from the bone.
The bone was then divided, its various portions heirg
dealt with systematically, and any remaining spicules
fractured ; the leg could then be brought into good
position. The wound was closed with a few sutures-
The opposite leg was then treated in exactly a similar
manner, and both legs dressed and bandaged to hall
box-splints. It was felt desirable to avoid the pro¬
longed plaster of Paris treatment, and as soon as the
wounds were healed systematic daily massage would be
commenced. Massage in fracture not only. Mr.
Edmunds said, prevents the adhesions forming between
muscles and articular surfaces of bones, but also main¬
tains the nutrition of the limb and enormously accele¬
rates bony union.

In the present case, at the end of three weeks|
although both femora had been completely divided,
no movement could be detected between the
fragments and the child was able to stand alone. The
splints were removed, and the child was encouraged to
move the legs in bed. After another fortnight’s rest
the girl was allowed to get up and run about. She
was kept in the ward for some time longer in order to
make quite certain that the union was stable, and

July 24, 1907.

TRANSACTIONS OF SOCIETIES.

was then discharged six weeks after the operation.
Mr. Edmunds pointed out that by treating cases in this
way. that is to say by early massage, firm union is
obtained much more readily, and the period of con¬
valescence materially shortened.

TRANSACTIONS OF SOCIETIES.

THE BRITISH GYNECOLOGICAL SOCIETY.

Meeting held Thursday, July iith, 1907.

Mr. W. D. Spanton, F.R.C.S., President, in the Chair.

SPECIMENS.

Dr. J. H. Swanton showed a fibro-myoma of the
vagina; an account of this case will be found on page
89 of the present issue.

Dr. Macnaughton-Jones said such tumours oc¬
curred comparatively infrequently. Up to the last
time that he had occasion to collect statistics of fibro-
myomata of the vagina there had been about 260 cases.
Dr. John Phillips brought forward the records of 29
cases which he had collected, up to the beginning of
the year 1905. One of the most important points of
interest about such tumours was as to whether they
degenerated and became malignant. There were
certain cases on record in which those tumours had
become sarcomatous. Sometimes they assumed a
myxomatous character, but as a rule they did not
produce any remarkable symptoms. The age of onset
did not correspond with that of malignant disease
generally, for they occurred between 30 and 50. They
were seen far more frequently in the anterior wall than
in the posterior wall. They frequently had a pedicle
and sometimes were found as multiple sessile tumours.
He believed they seldom became malignant.

Professor Taylor said he had met with four in¬
stances of fibro-myoma of the vagina, all of them
having occurred in the anterior wall, and all were
sessile. In one case the growth was recurrent. He
operated on four different occasions, removing the
growth from the same situation, and finally cauterising
the base. In that case he expected to find the tumour
was sarcomatous, but he had the satisfaction of know¬
ing that the last operation had maintained its efficacy
longer than any before. Three years had elapsed
since the operation, and he found that the histological
characters of the tumour were those of simple myoma.

Dr. Macan said it would be an interesting question
in the pathology of these growths if we could distin¬
guish between abnormal growths of fibroid tissue in
the abdominal wall in the ovaries, uterus, and vagina.

The President said he did not remember having
had a case of the kind. It seemed that everything
now centred around the possibility of malignancy-
supervening in what had always been regarded as
simple growths, and this was the line of investigation
for the future.

Dr. Swanton, in reply, said none of the speakers
had touched on the association of syphilis with such
tumours. Comil and Ranvier found several cases of
the kind were associated with a syphilitic history.

He next showed a specimen of Glandular Cystic
Adeno-carcinoma of Ovaries and Vermiform Appendix
an account of which will appear in our next issue.

The President said he regarded this as being an
instance of the type to which he had already referred,
namely, of suggesting innocency at first and then sub¬
sequently a rather rapid development of malignancy.
He had been especially struck by the extreme malig¬
nancy of these growths.

Dr. Giles said one point which particularly con-
eerned him was the question of diagnosis, which in
this case',was that of fibroids. Carcinoma of the ovary
was a condition which was not often diagnosed directly,
especially where there was no free fluid present in the
abdomen. The presence of free fluid and cachexia
w the patient would suggest that it had a malignant
element. He had met with four cases of carcinoma
of the ovary not associated with any fluid in the ab¬

Thk Medical Press. 91

domen and all were associated with uterine fibroids.
In some, the fibroids were comparatively small, but in
all operation was undertaken for fibroids, the pre¬
sence of an ovarian tumour not having been suspected
in any one of them. That was perhaps easily under¬
stood, inasmuch as those tumours had a comparatively
solid consistence, and when there were multiple fibroids
the irregularities might equally indicate them with
ovarian growths in addition. Where fluid was pre¬
sent, he thought the prognosis was in most cases
bad. In other cases carcinoma of the ovary might
be attended with a good prognosis. One of the four
cases to which he had just alluded had since died of
recurrence, but the other three patients were alive and
well at the present time, the periods which had so far
elapsed since the operation varying from two to tbr*e
yea.\-«. Therefore he considered that if the growth was
not attended with free fluid, which meant that the
growth had not perforated its capsule, the prognosis
might betfairly good.

Dr. Macnaughton-Jones said he exhibited the
largest carcinoma of one ovary he had ever seen.
There was a fibro-adenoma of the other ovary. At
the time the patient was reduced in weight to about
5st. She lived six months afterwards and then died
of recurrence of the carcinoma in the bowel. Some
years afterwards he showed to the Society carcinoma
of both ovaries with large carcinomatous masses and
fibre-myomata 01 tne uterus co-existing« He quite
agreed that the seriousness of those cases depended
upon the escape of carcinomatous fluid. In one of the
cases to which he had referred the tumour was solid,
and the others were of a cystic character, and the prog¬
nosis largely depended upon perforation with escape
of some of the fluid into the peritoneal cavity. But on
the other hand, he considered that, as a rule, cases of
malignant growth of the ovary would be found to
terminate fatally.

Dr. Macan pointed out how often malignant diseases
of the ovary were bilateral. All would agree that the
occurrence of ascites with any tumour of the ovary
pointed to an unfavourable prognosis, and this was
especially so when tumours were found on both sides.
He had recently the opportunity of looking at the very
valuable work of Professor Winter’s on diagnosis, and
that authority laid great stress on the fact that in
malignant disease of the ovaries one was apt to find
that both ovaries were affected more or less, though
not necessarily to an equal degree.

Dr E. A. Neatdy said he w.sh“d to know whether
carcinoma of the ovary occurred frequently as a primary
condition. Mr. Bland-Sutton, Dr. Cuthbert Lockyer,
and others had recently pointed out how often they
occurred secondarily to either some intestinal or some
mammary growth. A few months ago he removed a
large ovarian carcinoma, and at the same time he found
a nodule in the small intestine which he took to be
carcinoma, but which he did not consider advisable
to remove. He warned the friends that she would
probably have to come back for operation later on,
and when she returned some months later she was then
®o wi-.ak that she died before operation could bt
undertaken. Post-mortem it was found that the
growth in the small intestine was columnar-celled
carcinoma, very much resembling in character that
which was found in the ovary. He would be glad to
hear what the experience of members had been in
that regard, as to the frequency of such growths of a
secondary nature in the ovary.

Dr. Swanton, in reply, said there was no evidence
at that time of operation of perforation of the capsule
of the cyst, although it might possibly have occurred
at a previous date. He diagnosed fibroid growth
because the uterus was increased in size and, moreover,
was adherent to the mass behind in the pouch of
Douglas. His own experience had also been that
bilateral malignant disease of the ovarian tissue was
more 'iequeni than unilateral disease of that region.
He thought his case must have been one of primary
carcinoma, because there was no evidence in the
abdomen of any other growths beyond that which was
shown under the microscope, which occurred in the

Q2 Tpe Medical Press. TRANSACTIONS OF SOCIETIES.

Tf'LY 24. 1907.

vermiform appendix. It seemed to him the cystic
condition had existed some time previously, and only
recently malignant degeneration had come on. The
statistics of the frequency of primary ovarian carcinoma
showed it co be rather more common lhan secondary
carc'r.oma.

A MYOMA OF UNUSUAL INTEREST.

Dr. H. Macnaughton-Jones showed a large myoma
removed from a patient, set. 32, unmarried. There
had been, comparatively speaking, few symptoms, the
only one of importance being menorrhagia and con¬
sequent anaemia. On exposure of this tumour he had
found it quite encapsuled with peritoneum. This was
subsequently explained by Dr. Cuthbert Lockyer’s
report on ft, as he says : “ The growth arose in the
right side of the body and cervix, and has burrowed
beneath the peritoneum of the floor of the pelvis."
Another peculiar histological feature was the presence
of a sacular cavity or long cul-de-sac, which he thought
was the dilated and thinned out uterine body which
had degenerated. On subsequent examination this
was found to have collapsed and the uterus was seen
to be incorporated with the tumour. Dr. Lockyer
regards this cul-de-sac as a dilated lymphatic, and has
found this deceptive resemblance to a uterine cavity
on previous occasions. Both ovaries were removed,
having degenerated, and lutein haematomatous cysts
being present.

Professor J. W. Taylor asked whether Dr. Mac¬
naughton-Jones did not think the cavity could be
accounted for by the separation of the layers of the
eritoneum. Sometimes when a fibroid grew into the
road ligament on one side of the uterus he had found
the peritoneum separated and the growth more or less
encapsulated, a triangular space was formed either
above or below the tumour.

The President thought that whenever we met with
a case of myoma of the uterus there was always some
interesting point which was worth discussing. The
interesting points about the present one appeared to
be the complete capsule, and the small cavity which
was formed. He was inclined to agree with the
suggestion that it was a simple matter for some in¬
flammatory material to have separated the two layers
of peritoneum and formed a sort of false sac.

Dr. Macnaughton-Jones, in reply, said Dr. Cuth¬
bert Lockyer’s opinion was that the cavity was a
lymphatic sac.

Dr. Swanton read notes of a case of Cyst of Clitoris,
which will be found on page qo.

The President thought such cases must be exceed¬
ingly rare, although cysts occurred in various parts of
the vagina, and often proved troublesome. From the
description it did not seem to present any indications
of malignant outgrowth.

Professor Taylor thought the situation of the growth
was unusual. As far as one could judge, it seemed to
be of a sebaceous character. He had met with a
sebaceous cyst very much like that, but not occurring
in the clitoris ; it was in the labium minus of one side.
He regarded the specimen as a suppurating sebaceous
cyst.

Dr. Macan said that cysts of that character in the
clitoris were veiy rare. He could not remember any
cases recorded in literature. Professor Taylor’s ex¬
planation of the present case seemed to be the most
likely, that it probably arose from sebaceous glands.
But in the absence of microscopical details he did not
see how the matter could be decided.

Dr. Swanton, in reply, said his difficulty in giving
further information about the cyst arose from the fact
that such a length of time elapsed between the first
appearance of the growth and the time at which the
operation was performed. The evidence indicated
that it was a sebaceous cyst which had suppurated.

THE PRESIDENT’S VALEDICTORY ADDRESS.

The President announced that he had received 1
letters of apology for absence from several of the j
Fellows.

Professor J. W. Taylor said he had much pleasure in '
proposing that the best thanks of the Society be

accorded to the President for his Valedictory Address.
He hoped it would not be regarded by the President as
one of the least of the many honours he had possessed
that it was under his presidency that the Society made
a great step forward by the junction with its sister
organisation, the Obstetrical Society of London in the
new Royal Society of Medicine.

Dr. H. Macnaughton-Jones had much pleasure in
seconding the vote of thanks proposed by Professor
Taylor, and would refer to the Minutes of the Council
of the Society as to its origin. Those Minutes were
interesting from an historical aspect and recorded that:
“ Several members of the profession specially prac¬
tising gynecology considering the time was ripe for the
formation of a Gynecological Society, seeing the
question had been omitted for some years past, agreed
to meet together to consult and see if such was feasible,
and, accordingly, on Monday, December 22nd, 1884,
the following met at 27 George Street, Hanover
Square : Dr. Meadows, Dr. Robert Barnes, Dr. Aveling,
Dr. Bantock, Dr. Hey wood Smith, Dr. Fancourt
Barnes, Dr. Edis. Dr. Meadows took the chair, and
after some remarks from him. Dr. Heywood Smith
read letters which had been received from several who
had been in favour of the pro ect, and it was agreed to
call a meeting of medical men for Saturday, Decem¬
ber 27th, 1884, at the rooms of the Medical Society by
means of the following circular, of which he would only
read one Clause : “ Owing to the extraordinary neglect
of gynecology in the general hospitals and their con¬
spicuously inadequate provision of beds for the treat¬
ment of diseases of women, special hospitals entirely
devoted to gynecological work have been established.''
There had been 201 meetings of the Society, and 213 or
215 meetings of its council. He wished to mention
the names of Dr. Meadows, Dr. Bantock, Dr. Fancourt
Barnes, Lawson Tait, Dr. Charles Routh, Dr. Macan,
Greig Smith, Dr. Edis, and Dr. Bedford Fenwick,
because they were the names of the men who in the
early years of the society had borne the burden and
heat of the day. But he also thought that anyone
who spoke at the last meeting of the society should
acknowledge fully the debt which the society owed to
its provincial Fellows. (Hear, hear.) Wherever one
might look, in England, abroad, or in the Colonies,
we found provincial Fellows of this Society among
the most distinguished. One of them was present
that evening, a gentleman who not only had been
President of the Society, but for whom the Fellows
entertained great respect, Professor Taylor. The
Society was not the first medical body to admit
women to their meetings. Perhaps he might be allowed
to say it was the only blot on the escutcheon of the
Society that they did not welcome women before they
did. But he felt certain that the action of the Obstet¬
rical Society of London in the matter was taken largely
because they knew the Gynaecological Society in¬
tended doing it. They were glad and proud that it
was a provincial Fellow of Mr. Spanton’s standing
and eminence who occupied the chair of the Society'
at its dissolution.

The resolution was then carried by acclamation.

The President expressed his deep obligation to
Professor Taylor and Dr. Macnaughton-Jones for the
words in which they had respectively proposed and
seconded the resolution, and to the meeting for passing
it.

Dr. Heywood Smith said they would not be able
to separate happily unless they passed a special vote
of thanks to one who had really borne the brunt of
the whole difficult negotiations which led to the
amalgamation, namely, Dr. Macnaughton-Jones. They
were justified in congratulating themselves on the
work which the Society had done.

Dr. Richard Smith seconded the vote of thanks to
Dr. Macnaughton-Jones and those who had been
associated with him in the work with great pleasure,
for the negotiations had an harmonious ending. He
was present on one occasion when Mr. Erichsen said
at University College that he thought they had arrived
at finality in surgery. But what would he have
thought now ? They all rejoiced in the progress which

July 34, 1907.

CORRESPONDENCE.

The Medical Pm». 93

had been made, and trusted that the future might be
even more productive than the past.

The resolution was then put and carried by acclama¬
tion.

Dr. Macnaughton-Jones, in acknowledging the
vote of thanks, said that it would be more suitable
that he should thank the Society for all the help which
had been given to him rather than that it should
thank him for what he had done to bring about amal¬
gamation. The first President of the Section would
be the present President of the Obstetrical Society of
London for the time being, Dr. Herbert Spencer. The
Fellows of the Obstetrical Society who would form
part of the Council would be Dr. Henry Russell
Andrews, Dr. Henry Briggs, Dr. Champneys, Dr.
Cullingworth, Dr. Dakin, Dr. G. Eastes, Dr. Fairbairn,
Dr. Gow, Dr. Handheld Jones, Dr. Herman, Dr. Kerr,
Dr. Lewers, Dr. Cuthbert Lockyer, Dr. John Phillips,
Dr. Amand Routh, Mrs. Mary Scharlieb. Dr. Herbert
Williamson, Dr. Thomas Wilson, with Dr. Robert
Boxall as one of the Secretaries. As was understood,
each Fellow of the present Society would be a Member
of the new Section of the Royal Society of Medicine.
It would be seen that the laws which were drawn up
were founded upon the general principle of the new
Royal Society of Medicine, which was a thoroughly
democratic principle.

Dr. Macan proposed : “ That we desire to record
our appreciation of the courtesy and cordiality with
which the Obstetrical Society of London has united
with our Society in their arrangements for amalga¬
mation.” He believed it was clear that the members
of the Obstetrical Society had treated the Fellows of
the Gynaecological Society with the greatest con¬
sideration and an appreciation of that attitude should
be put upon record.

Dr. Slimon seconded the resolution, and it was
carried unanimously.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Pari*. July 21st. 1907 .

Extra-Uterine Pregnancy.

The diagnosis of extra-uterine pregnancy constitutes,
in certain cases, one of the most difficult problems of
obstetrics. It must be made in the first and second
periods of the pregnancy.

During the first months, there exists no certain sign
that the woman is pregnant, and the presence of
ectopic pregnancy can only be suspected from the
history of the case, symptoms of probability, bloody
discharge, pain, the presence of a tumour lying against
the uterus which has not the volume of the age of the
gestation and whose cavity is empty. However,
nothing can be affirmed, and the pregnancy might be
confounded with : A uterine fibroma, hydro-salpingitis,
hemato-salpynx, retro-uterine ha-matocele, retro-ver¬
sion of the gravid uterus, abortion.

A fibroma is intimately connected with the uterus of
which it is a direct prolongation ; it is not sensitive to
pressure and palpation. Metrorrhagia is abundant
and painless ; its development is slow ; the cervix is
not spongy to the touch. In certain cases, the diag¬
nosis is impossible.

In the different forms of salpingitis, the distinction
is equally difficult. In the research of the causes, it
may be possible to establish the existence of an anterior
genital infection : Gonorrhoea, abortion, tuberculosis,
syphilis. The pain is seated in one of the iliac fossa?
or in both, extends down the thighs and is relieved by
rest. The menses are painful with more or less violent
colic ; they are irregular and frequently haemorrhagic.

To the touch, the os appears healthy or is the seat
of metritis ; the body of the uterus is increased and
painful, while the posterior and lateral culs-de-sac are
filled by the inflamed organs. On the other hand, women

suffering from salpingitis present a special facies ; they
are pale, emaciated, dyspeptic, and neurasthenic.

In the majority of the cases of haematocele, the
rupture of an extra-uterine pregnancy is the cause ;
sudden and intense pain in the abdomen, signs of in¬
ternal haemorrhage, tendency to syncope ; later, the
presence of a more or less voluminous tumour, at first
fluctuating, afterwards becoming hard and resisting ;
the cervix is pushed forward and applied behind the
symphisis of the pubis.

In retro-version of the gravid uterus, the os pre¬
sents the normal sponginess, and bi-manual examination
proves that the uterus alone is increased in volume,
and if the tumour can be reduced there is no doubt
possible as to the existence of a normal pregnancy.

During the last months of ectopic pregnancy, the
diagnosis becomes singularly easy. The fcetal cyst
becomes more evident and can be easily felt on one
of the sides of the median line. By auscultation the
movements of the foetus can be perceived as well as
the bruit dc souffle and the heart beats. Where the
foetus is dead the difficulties of diagnosis are increased.
In such case, diverse questions put to patient may
throw light on the nature of the tumour ; if there
existed symptoms of abortive labour, if membranes
were expelled, if the breasts had increased in volume,
if the volume of the abdomen had diminished, &c.
In practising several successive examinations, the
attendant will be able to satisfy himself if the tumour
is in way of regression, if there exists osseous crepi¬
tation, a sign of great importance when established.

The prognosis is almost always fatal for the child
and very grave for the mother.

As to treatment, extra-uterine pregnancy should be
considered, said Woerth, as a malignant tumour, and
requires extirpation as soon as it is diagnosed, while
other authors advise expectancy where the pregnancy
has reached beyond five months, and that the feetus is
alive. But the patient should be constantly watched
so that an operation could be made at the first signal.

Where the foetus is dead, and if there are no bad
symptoms, the operation may be deferred until the
haemorrhage is less abundant by reason of the decrease
of the cysto-placental circulation.

Acute Rheumatism and the Thyroid Gland.

There seems to be a correlation between the thyroid
gland and the articular inflammation of rheumatism.
M. Vincent reports several cases of acute articular
rheumatism, where the thyroid gland was increased in
volume and very painful to pressure. Sometimes, on
the other hand, the gland is hardly perceptible to in¬
spection or palpation, but in those cases the rheu¬
matic fever runs an ordinary course. In other
patients, after a temporary reaction of the thyroid
gland, it diminishes considerably in volume, while the
articular symptoms persist. Improvement is slow, and
the malady leaves the patient in a state of anaemia and
prostration.

GERMANY.

Berlin. July aist. 19o7. .

At the Medizinische Gesellschaft, Hr. Westenhoeffer
showed lymphatic tumours of the stomach and in¬
testines from a patient who had died from leucaemia.
The tumours were in part ulcerated, from which fatal
haemorrhage had taken place.

Hr. Ernst Mai reported on Escarine lately recom¬
mended by G. Klemperer for haemorrhage from the
stomach. Ten cases had been treated by it in the
Moabit Hospital. In all of them the bleeding stopped
at once, so that the day after no blood was found even
in the stools, although milk and eggs had been given
on the first day, whilst the former custom in the de¬
partment had been not to give patients with bleeding
from gastric ulcer any food by the mouth for the first
three days.

Out of the ten cases the bleeding returned in one
only, and the case proved fatal. The autopsy showed
carcinoma. Escarine was a mixture of the finest
aluminium powder in glycerine. It was prepared for
sale in tablet form, in tubes with six tablets each, of
2.5 grm. each, of which four to five tablets were given

Digitized by GoOgle

94 The Medical Prim.

CORRESPONDENCE,

July 24. 1907.

stirred in water. This dose was given two days con¬
secutively. It was cheaper than the continued use
of bismuth powder. He had given the remedy to
rabbits and dogs in which an abrasion of the mucous
membrane had been caused by a wound, and on the
animals being killed the mixture was found to be well
spread over the wounded surface.

Hr. Ewald, although he had given large doses of
bismuth for long periods, had never seen any symptoms
of poisoning from it. He had also tried escarine and
had seen good results from it; it did not always do
good however; thus in one case he had given it for
three consecutive days, but the bleeding steadily re¬
turned in spite of it, and only ceased after gastro¬
enterostomy.

Hr. Niemann read a paper on
The Practical Results of the Feeding of Infants
with Buttermilk.

He first of all emphasized the fact that only per¬
fectly fresh buttermilk made in large establishments
came into consideration. As an addition, 15 grm. of
wheatmeal and 60 grm. of sugar were added to each
litre of buttermilk. These were shredded in under
continuous stirring, the mixture was boiled for a short
time, and then kept cool ; 120 infants were fed with
it, 102 with a good result. Very little children, aDd
those above aet. 8 months, were not suited for this
form of feeding.

Twenty-six healthy children, who had not thriven
well on a diet partly of cow’s milk, did excellently on
this. Of 71 children with intestinal catarrh, 63 bore
the buttermilk diet well; but it must not be given
too early, not until the third day, when the acute
symptoms had subsided. The combination acted well
especially in children who were much run down after
intestinal catarrh or were otherwise atrophic. If a
greater proportion of fat was desired, cream could be
added. By means of a large series of curves the in¬
fluence of buttermilk on the increase of weight was
shown, and, in conclusion, he observed that any early
repugnance was soon overcome, and no vomiting took
place, but the bowels required regular watching ;
the stools were mostly alkaline, but acid in about
28 per cent. Not unfrequently, on commencing with
the buttermilk diet, a slight increase of temperature
was observed ; if this remained or got higher the diet
had to be changed.

Hr. Cassel believed that with healthy children the
buttermilk diet could be given from the first; it was
also well adapted for mixed feeding ; its proper domain,
however, was in intestinal catarrh after the acute
stage had subsided, and in atrophic children. The
difficulty to the general introduction of buttermilk
feeding lay in its very precise technique, and the great
watchfulness required. Soxhlet’s feeding sugar might
be given in place of sugar. It was best to begin with
small doses and increase them very gradually. The
stool reaction was of no importance, but if vomiting
occurred, if the stools were frequent and squirty, if
the abdomen was distended and tender, the diet must
be changed at once. If at first there was repugnance
to the food it might be overcome by giving it by the
spoon and cold. There was sometimes a difficulty in
weaning from buttermilk ; this was assisted by an
addition of cream or 3 to 5 per cent, of ramogea.
then passing on to half-milk or two-thirds milk. It
was not correct that rickets came on more frequently
with buttermilk feeding than otherwise. Its chief
advantage lay in its poorness in fats and in its purity.

Hr. Jaffa remarked that buttermilk feeding had its
distinct indications; it was suited for all children
who could not bear fats ; on the other hand its rich¬
ness in sugar prevented its being well borne by all
children.

AUSTRIA.

, Vienna, July 2fat, 1907.

Simulated Monoplegia.

Erben showed a case of monoplegia, which gave
rise to a long controversy on the physiology and
anatomy of the limbs. Erben wished to prove to the

members by his mode of examination that paralysis
was not real, but Tandler disputed the case.

Tandler said, if a man were laid prone, and his knee
bent up to a right angle on the leg, and then allowed
to fall, it would descend in the normal direction by
the action of the quadriceps, viz., rectus, vastus, exter-
nus, and internus, and crureus. If the lower part of
the leg be bent past this right angle towards the body
when in the same position, the leg would fall towards
the body in paralysis, but he doubted if the first
experiment was due to the contraction of the quad¬
riceps. If a perfectly healthy man be tried in this
way over the right angle the leg will violently assume
the stretched position. For part of the first move¬
ment he admitted that the tonus of the quadriceps
governed the movement in the healthy subject, but
in the dead body there was none.

At this point Reiner presented a case of bilateral
quadriceps paralysis, the result of polio-mvelitis seven
years ago. Tandler’s phenomena were clearly de¬
monstrated. The peculiarity of both muscles being
similarly affected was a source of surprise, as the cells
in both of the anterior cornua must have suffered.
It was also proved by this case that the quadriceps could
be dispensed with in standing erect, which the patient
could do admirably ; but when he attempted to walk
the defect was instantly observed, by the tension of
the plantar muscles and the stamping character in
motion. In coming down stairs he substituted the
action of the quadriceps by swinging round the descend-
ing foot with the point of the foot outstretched ta
reach the lower step, while the opposite side swung
round to perform the next step, which resembled
talipes equinus in extension.

With this patient, Erben performed his method,
which Tandler objected to, all proving how paralysis
can be simulated; after which Tandler admitted that
Erben had some foundation for his proof, but had.
changed his position since demonstrating his own case.

Thrombosis Arteria Vertebral is.

Algyogyi presented a case with symptoms he would
place before the members for their judgment : Right
eyelids and pupil narrower than left, reaction prompt,
right bulbus more sunken, movement to both sides
free, no double vision, slight nystagmus in lateral
vision, fundus in both normal, sensory and motor
function of trigeminus normal, slight insufficiency of
the muscles of the lips on right side, pronounced in
laughing; uvula tense, with smell, taste, and hearing
intact.

There was decided hoarseness in consequence of
paralysis of the right vocal cord ; but no real cause
could be discovered. Motility in limbs free, but slight
adynamia of the right arm and hand was present.

Sensibility on right side normal, particularly in the
region of the trigeminus, but the left in this part was
markedly dull; Faradic pain, and temperature quite
lost. This defect extended below the fourth cervical
vertebra, and extended round the trunk. There was
no ataxy or Romberg symptom present. The thoracic
organs, with the exception of the second aortic tone,
perfectly normal, and the same might be said of the
abdomen.

Pulse 85, right patellar reflex too high, plantar
reflex absent on left side but normal on right. Abdo¬
minal reflex increased on right ; radius right increased.
Reflex of palate and pharynx gone, while that of
conjunctiva and cornea was present.

Weight before illness, 82, kilos; now 78. Urine
gave 5.2 per cent, of sugar ; other constituents normal,
but w’th specific diet the sugar fell to 0.1 per cent.

From these symptoms the medulla oblongata would
be accused as the centre, and probably the right half,
which might be acute or apoplectic bulbar paralysis.
From the symptoms it would seem that the vascular
system is at fault somewhere, and as hiemorrhage into
the oblongata is a rare occurrence and usually associated
with violent symptoms, loss of conscience and a speedy
termination, which were absent in this case, we must
fall back on the more progressive lesion of a partial
thrombus in the vertebral artery.

zed by GoOgle

July 24, 1907.

CORRESPONDENCE.

Th» Medical Press. Q 5

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

Centenary of the Edinburgh Royal Asylum.—
The hundredth anniversary of the foundation of
Morningside Asylum was commemorated on July 12th
by a garden-party held in the Institution, which was
attended by some fifteen hundred guests. Happily
the weather was propitious, and the function passed off
successfully. The whole of the grounds and most of
the buildings were available for the purposes of the
function, and the quaint sixteenth century architec¬
ture of Old Craig House, once the residence of John
Hill Burton, the Scottish historian, was viewed with
special interest. A mass of the buildings and grounds
enabled the guests to find their way unaided to points
of special interest, including Criaglockhart Hill, which
is 500 ft. above sea level and commands a magnificent
view of the town and surrounding country. The
awakening of Edinburgh to the need for some means
of caring for the insane is associated with the death
of the Poet Fergusson in 1774. Fergusson was one
from whom Burns drew some of his inspiration ; he
became insane and died amid squalid surroundings in
the old city Bedlam. The sad circumstances attending
his death aroused the compassion of some of the more
public-minded citizens, foremost among whom was
Dr. Andrew Duncan, Senior, one of the leading philan¬
thropists of the day, and one to whom Edinburgh owes
more charities than the Royal Asylum. He circulated
a pamphlet proposing the establishment of a lunatic
asylum, being at the time President of the College of
Physicians, but, though some support was secured
for the project, immediate succour was not attained.
Later, a Parliamentary grant of £2,000, drawn from
the estates forfeited by Jacobites in the ’15 and ’45
(“ one good result of rebellion,” the History of the
Asylum has it) was obtained, and a Royal Charter was
granted in April, 1807. The asylum was actually
opened for patients on July 19th, 1813, and the
structure thus initiated served until 1837. Accommo¬
dation was offered only to those who had means, and
in that year the claims of the indigent insane were at
last recognized as so strong that the institution was
extended to meet the case of those who could pay
nothing, or little, for admission. In 1877, the whole
institution was reorganised. Dr. Clouston, who
succeeded Dr. Skae in 1873, took a leading part in
this. He visited the chief asylums in America and
on the Continent, and the reconstruction was carried
out along the lines suggested by this visit. West
House was almost entirely rebuilt and the East House
was temporarily enlarged pending the completion of
the buildings on the Craig House estate, purchased
about that time. Old Craig House was retained in
its original form as an old mansion house, while the
new buildings were scattered about the grounds in the
form of villa residences. During the past 90 years,
£370,000 has been spent on land and buildings ; of this
amount £284,100 has been paid off. The income from
private patients has risen from £12,000 to £38,000,
and the staff now numbers 269 persons. Since its re¬
construction the asylum has taken a creditable place
among the public institutions of Edinburgh, and has
maintained a reputation as being in the van of medical
science.

Royal Visit to Edinburgh. —Their Royal High¬
nesses the Prince and Princess of Wales paid a visit to
Edinburgh last week in order to fulfil several public
engagements. On July nth, they made a brief tour
of inspection of the Royal Infirmary, where they were
received by the Lord Provost, Colonel Warburton
(Superintendent), Mr. Caw (Treasurer), and Miss Gill
(Superintendent of Nurses). In the outer hall the
Board of Managers, and in the inner hall members of
the medical and surgical staffs, including Drs. Green¬
field, Bramwell, Bruce, Russell, Grelland, Graham
Brown, Fleming, Ritchie, and Rainy, and Messrs.
Annandale, Chiene.^Macgillwray, George Mackay,

Cathcart, Paterson, and Guy were presented to
the Prince and Princess. The Royal Party then pro¬
ceeded to the Diamond Jubilee Pavilion, and visited
Ward 35, in which gynaecological cases are treated.
Dr. Barbour, the physician-in-charge, and Drs.
Fordyce and Haullan, assistant physicians, were pre¬
sent and accompanied their Royal Highnesses round
the ward. The Prince of Wales, in conversation with
Colonel Warburton, asked many questions regarding
the expenditure of the institution, and treatment and
feeding of the patients, and indicated that for econo¬
mical management the Infirmary compared favour¬
ably with other institutions of which he had personal
knowledge. After going through the wards and operat¬
ing theatre the Royal party visited the lower corridor
in order to see the dedicatory memorial tablet, with
the appearance of which they expressed gratification.
The visit was a comparatively short one, lasting only
some thirty minutes, and at its close the Prince and
Princess expressed themselves as highly satisfied with
the brightness and airiness of the Infirmary, and much
impressed by its extent.

Compliment to Sir A. R. Simpson. —On July 15th,
a complimentary ceremony took place in the Edin¬
burgh Royal Maternity Hospital, the Committee who
had undertaken the duty of making some recognition
of Sir A. R. Simpson’s long and distinguished career,
meeting the Board of Directors there, and asking their
acceptance of a gift of money towards the endowment
of a bed. Mr. Nicholson, on handing over the cheque,
said that the Committee thought the object they had
in view of showing their appreciation of Sir Alex.
Simpson, could best be attained by endowing a bed
in the institution in which he had always taken so
lively an interest, and which bore the name of his
uncle, Sir James Young Simpson. The Chairman of
the Board thanked the Committee and said he con¬
sidered it a high honour to the hospital to have such
a permanent memorial of Sir Alexander Simpson.

LETTERS TO THE EDITOR.

ENGLAND AND GERMANY—A CONTRAST.
To the Editor of The Medical Press and Circular.

Sir,—Y our correspondent " M. O. H.” in his
letter of July 10th, asks whether English local govern¬
ment, judged by results, is a failure? No one who
knows enough about German methods can fail to
answer this query in the affirmative. Germany,
under a scientifically-guided bureaucracy, is making
immense strides. Her people, as a whole, stand
on a higher plane of civilisation than ours. They are
better educated, and have more self-respect. Ragged
vagabonds, unemployables arc as difficult to discover
as the class of 'Arry and ’Arnett. I have never met
anyone who has ever encountered a drunken woman
in Germany. The people are profoundly discontented
with their Government in the region of higher politics,
but understand and recognise the necessity of obedi¬
ence and co-operation in matters affecting social
progress. They are, for example, all vaccinated
and re-vaccinated, so that small-pox is virtually
extinct, and they are ready to obey any evidently
beneficial police order, however trivial, down to
the cropping of their children’s hair. School children
for years have all been systematically inspected
medically, and sorted and dealt with in accordance
with physical and mental standards. The three
years' military service leaves a highly beneficial mark
on the bulk of the young manhood, and almost
completely prevents the manufacture of the hooligan
class. The condition of the homes of the working
men and poor everywhere, including the big towns
where the housing problem is acute, is. on the whole,
very superior to that common in England. This
fact was dwelt upon in the remarkable report of the
Birmingham brass-workers after their full enquiry
in Berlin. In England sanitary laws are almost
everywhere imperfectly administered for the reason
which "M.O.H." points out, namely, that the mass
of citizens are too selfish and indifferent to take a

3 itized by

jOOgle

96 The Medical Pum.

OBITUARY.

July 24, 1907.

due share in local Government. W Local governing
bodies are everywhere too largely made up of ignorant
or selfish men, and these, through lack of local public
opinion, neglect the laws it is their duty to administer.
An essay would be needed to expose fully the con¬
trast between the two peoples in every social phase.
Germany has in the Fatherland almost ten millions
more people than the total population of European
blood in the whole British Empire, and is increas¬
ing at the rate of nearly a million a year. Unless
the teaching of history is worthless, the expansion
of this mighty race should convey a warning and a
lesson to patriotic Englishmen and the statesmen by
whom they are guided and led.

I am, Sir, yours truly,

A Student of Sociology.

July 19th, 1907.

QUACK DENTISTS AND A ROYAL COMMISSION.
To the Editor of The Medical Press and Circular.

Sir, —I notice that the quack dentists affect great
indignation at the suggestion that a Royal Commission
on Quackery should include them in its scope. The
dental speciality is a legally recognised branch of the
medical profession, and under the same administration
—the Medical Council—and could not be left out of the
enquiry. One would have thought that unqualified
men, if they had any justification for their position,
would have welcomed investigation, and even personal
cross-examination as to their methods by leading
counsel. They will be liable to be subpoenaed and
compelled to give evidence. If, as there need be no
doubt, a Commission should be in due course ap¬
pointed, we shall then, at least, have a full public
exposure of what is now dark in this direction.

I am, sir, yours truly,

A Hospital Dentist.

July 18th, 1907.

OBITUARY.

DR. ALFRED LLOYD OWEN, M.D., OF SOUTHSEA.

We greatly regret to record the death of Dr. Lloyd
Owen, of Southsea, on the 4th inst., which sad and
unexpected event has deprived a large circle of friends
of a greatly valued adviser, and his professional
brethren also of a wise, experienced, and much-
esteemed colleague.

Lloyd Owen was born at Portsmouth in August,
1845, and he was the third son of Mr. Jeremiah Owen,
who then held a high and important position in the
Royal Dockyard. He was educated at Christ’s Hos¬
pital and on leaving the school he went to Trinity
College, Dublin, and there passed through a dis¬
tinguished career as a student. In 1866, he obtained
the degrees of B.A. and M.B.Dublin, and also the
diploma of M.R.C.S.Eng. After a short absence he
returned to Trinity College, and took the degree of
M.D. He was appointed house surgeon to the Royal
Free Hospital, London, in 1867. In 1869 he married
the daughter of the late Dr. William Gibnev, surgeon
of the 15th Hussars, and soon after entered into partner¬
ship with the late Mr. Husband, of York, the senior
surgeon of York County Hospital, and treasurer of
the British Medical Association. He did not remain,
however, long in Yorkshire, for in 1870 he commenced
practice in Southsea—formerly only a suburb of
Portsmouth, but at this period it had become a fashion¬
able resort which was largely due to the skill and
enterprise of Dr. Lloyd Owen’s uncle, Mr. Thomas
Owen, who for several years was Mayor of Portsmouth,
and occupied a leading position in the neighbourhood.

By his natural ability, unflagging industry, and
extreme courtesy, Dr. Lloyd Owen soon obtained a
high professional reputation and an extensive prac¬
tice. He held the appointment of surgeon on the
stall of the Royal Portsmouth Hospital for 35 years
with great distinction, and on his retirement in 1906
he received the warm and hearty thanks of the Com¬
mittee of Management, and was elected consulting
surgeon to the hospital. During this long period his

services were greatly appreciated by the suffering poor,
and he did much to help forward the progress and
development of the Institution. For many years he
also held the important post of Admiralty surgeon at
Portsmouth.

As a surgeon, Lloyd Owen’s career was very success¬
ful. He was an excellent practitioner, painstaking in
the discharge of every duty, and enjoyed to a remark¬
able extent public confidence and esteem. Of his
qualities of head and heart no one could speak too
highly. The writer of these few lines had for years
many opportunities of estimating his character.
Personally, he was a true and faithful friend, with a
transparent integrity and courtesy visible in every
action. A striking example of his kindness of heart
was exhibited during his last illness by his anxiety to
secure a grant of money from the surgical aid fund of
the hospital to help a poor girl, whose limb he had
removed, in obtaining an artificial limb.

In his home life he was a devoted husband and
father, and now the deep sympathy of all who knew'
him is with his widow and her family in their sudden
and irreparable loss and sorrow.

Dr. Lioyd leaves behind him five sons and one
daughter. ’ Two of his sons are officers in the Royal
Navy, and two are serving in the Army.

The funeral took place at Southsea on the 8th inst.
with universal expressions of regret, and around his
grave there was a great gathering of old friends and
colleagues, who were present to pay a last tribute to
one whose memory will ever be associated with the
warmest and kindest recollections.

J. W. C.

DR. JAMES DUNSMURE, OF EDINBURGH.

Much regret, as well as surprise, was felt in Edin¬
burgh on hearing the sad news of the unexpected death
of Dr. Dunsmure, which took place on July 15th.
Some weeks ago he underwent an operation, and
apparently rallied from it, but on the 15th, he had a
relapse and died very suddenly from heart failure.
Dr. Dunsmure came of a medical stock, his father,
like himself, having been one of the best-known
practitioners in Edinburgh. He was educated at
Edinburgh, and studied in Berlin and Vienna, and
on his return home succeeded to his father’s practice
and to many of the appointments his father held.
Then he became medical adviser to the Governors of
Trinity Hospital, the Alexander Mortification, John
Watson’s Institution, the Trades Maiden Hospital,
and the N.B. Railway Company. Like his father, he
was a President of the Royal College of Surgeons of
Edinburgh, and took a keen interest in the Quarter
Centenary celebration of a few years back. During
his term as President, he had the honorary degree of
LI..D. conferred on him by the University of Glasgow.
He was a keen sportsman, and delighted in shooting,
fishing, and golf; along with three friends he made a
point of playing a weekly foursome at Musselburgh
Dr. Dunsmure was of a somewhat retiring disposition,
but was a kind-hearted genial man, and had few equals
either as companion or host. He was a widower, and
is survived by his onlv daughter.

J. S. F.

FRANCIS HYDE FORSHALL, M.R.C.P.Ed.,
M.R.C.S., L.R.C.P.

We regret to announce the death of Dr. Francis
Hyde Forshall, which occurred on July 6th, at
Highgate, in his seventy-fourth year. Dr. Forshall
was the youngest son of the late Rev. Josiah Forshall,
F.R.S., formerly Secretary and Keeper of the Manu¬
scripts at the "British Museum. He was educated
at Tonbridge School, Edinburgh University, and St.
Bartholomew’s Hospital. When he was qualified
as L.R.C.P., he joined the Medical Department of
the Army, in which he remained about seven years,
seeing service in India and Canada. After leaving
the Army he studied in Paris for a time, and then
wert to Highgate, where he entered into partnership
with the late Dr. Harrison. He held several public
appointments during his active life, including the

itized by G00gk

July 24, 1907.

NEW BOOKS AND NEW EDITIONS.

The Mvdical Pmm. 97

Police Surgency to the Y Division and the medical
officership of the Highgate and Muswell Hill Dis¬
pensary. Dr.%Forshall retired from practice sixteen
years ago, and was then presented with some very
beautiful silver {of the George II. period, valued at
£300, and an illuminated address.

REVIEWS OF BOOKS.

PHYSICAI/DIAGNOSIS. (a)

This volume forms an excellent handbook of
physical diagnosis. In spite of the many admirable
works in existence dealing with that subject, the author
may be congratulated on having added to the number
another having various praiseworthy and peculiar
features. The accuracy of the matter is maintained
at a high and consistent level. The work being con¬
fined to some 450 pages, the author has wisely con¬
tented himself with dealing fully with more important
sections, such as the application of systematic methods
of physical examination to the thorax, heart and
pericardium, and the abdomen. Many points are in
this Iway necessarily either omitted or dealt with
briefly. For instance, we find no mention of exophthal¬
mos. nor of exophthalmic “ goitre ” beyond a casual
reference to the visible pulsation often present in
that condition. On the whole, however, Dr. Anders
may be congratulated on the brilliant way in which he
has performed his task, although the American methods
of spelling will jar the susceptibilities of educated
English readers. There are many excellent diagrams
and other illustrations, but most noteworthy of all is
the fine series of plates illustrating the Rontgen-ray
diagnosis of various thoracic and abdominal conditions.
One illustrating the intestinal contents is specially
interesting.

DISEASES OF THE EYE. (&)
t The author, in his book, has set himself the task
of writing a concise description of the commoner eye
diseases, designed solely to meet the needs of the phy¬
sician engaged in general practice, rather than a
complete treatise on eye disease. Remembering that
a “ little knowledge is dangerous,” Dr. Theobald does
not encourage his readers to trust to such methods as
ophthalmology, retinoscopy, or perimetry as an aid
to diagnosis, unless they have opportunities of con¬
siderable practice in perfecting themselves in these
arts. Such methods of examination as oblique
illumination and the perimeter are well described and
in the case of the latter sufficiently fully for ordinary
purposes. We like the way Dr. Theobald lays down
his treatment of the various diseases. Instead of
enumerating several remedies which might cure, and
leaving it to the inexperienced reader to take his
choice, he lays down one or two courses which his ex¬
perience has taught him to be usually efficient. The
appendix contains a useful list of prescriptions with
a short note as to the indications of each, which will
be welcome to many; and although there is nothing
original in the book, nothing, in fact, that cannot be
found in existing authorities, the author has been, on
the whole, successful in being simple and precise in
his descriptions of prevalent diseases and their treat¬
ment.

NEW BOOKS AND NEW EDITIONS.

Tax following have been received for review ainoe the publi¬
cation of our last monthly list:—

Sidney Appleton (London).

The Principles and Practice of Dermatology. By Wm. A. Pusey,
A.M., M.D. Illustrated. Pp. 1,021. Price 26s. net.

(а) “ Physical Diagnosis.” With case examples of the inductive
method. By Howard Anders, M.D., Professor of Physical Diagnosis.
Philadelphia : Sydney Appleton. 1907 .

( б ) *' Prevalent Diseases of the Eye.” By Samuel Theobald, MJ).,
Professor of Ophthalmology and Otology in the Johns Hopkins Uni-
«nity, U.S.A. Pp. 520 , 219 illustrations, and 10 coloured plates.
Philadelphia :^W. B. Saunders Company. _ 1906 .

*° S ? So * 8 and Danixlbsohx. Ltd. (London).

The Haslemere Museum Gasette. Conducted by Jonathan
Hutchinson, P.B.C.S., LL.D., P.R.S., assisted by E. W.
Swanton. Vol. I., 1906 and 1907. Pp. 622. Prioe 7s. net.
Baillierb, Tindall AND Oox (London).

The Offloe of Midwife (in England and Wales). By 8 tanley B.
Atkinson, M.A.. LL.M., M.B., eto. Pp. 123. Prioe 2a. 6 d. net.
Burgib and Colbottbnb, Ltd. (Leamington 8 pa).

Royal Leamington Spa: Ita Springs, Baths, and Qeneral
Attractions. By John Murray Moore. M.D., M.B.C. 8 ., etc.
Pp. 34. Price 3d.

Cassell and Co., Ltd. (London).

Blllharzlosls. By Frank Cole Madden, M.D., F.B.C. 8 . Pp. 78.
Price 3s. 6 d. net.

Gout: Its Pathology Forms, Diagnosis, and Treatment. By
Arthur P. Luff, M.D., B.Sc., F.R.C.P. Third Edition. Pp.
290. Prioe 10s. 6 d. net.

The Clabendox Pbess (Oxford).

Surgical Instruments in Greek and Roman Times. By John
Stewart Milne, M.A., M.B. Illustrated. Pp. 187.

James Clabee axd Co. (London)

Health in the Home Life. By Honnor Morten. Pp. 170. Price

Frowde, Henri, Oxford University Press, and Hoddeb axd
Stoughton, 20, Warwick Square, London, E.C.

The Oxford Medical Publications. (In the Choice of Authors
and Subjects the Publishers have had the Advantage through¬
out of the Advice and Aaaistanoe of William Osier, M.D.,
F.B.S., Regius Professor of Medicine in the University of
Oxford).

Practical Anaesthetics. By H. Edmund O. Boyle, M.R.C.S.,

L. R.C.P., Assistant Anesthetist to St. Bartholomew's Hos¬
pital. Pp. 178. Price 5s. not.

The Treatment of Disease in Children. By O. A. Sutherland,

M. D., F.R.C.P., Physician to Paddington Oreen Children's
Hospital, to the North-West London Hospital, and to the City
Orthopedic Hospital. Pp. 311. Price 5s. net.

Surgicaf Emergencies. By Percy Sargent, M.A., M.B., B.C.
Cantab., F.R.C.S., Surgeon to Out-patients, St. Thomas's
Hospital. Pp. 256. Price 5s. net.

Medical Lectures and Aphorisms. By Samuel Gee, M.D.,
F.R.C.P., Honorary Physician to H.R.H. the Prince of
Wales and Consulting Physician to St. Bartholomew's Hos-

£ ital. Second Edition. Pp. 307. Prioe 5s. net.

eases of the Larynx. By Harold Barwell, M.B.Lond.,
F.R.C.S.Eng, Surgeon for Diseases of Throat, St. George's
Hospital. Pp. 266. Price 5s. net.

Functional Nervous Disorders in Childhood. By Leonard O.
Guthrie, M.A., M.D., F.R.C.P., Senior Physician to Padding¬
ton Green Children's Hospital; Physician to the Hospital for
Epilepsy and Paralysis, Hsida Vale. Pp. 300. Price 7s. 6 d.
net.

Cancer of the Womb : Its Symptoms, Diagnosis, Prognosis and
Treatment. By Frederick John McCann, M.D.Edin., F.R.C.S.
Eng., M.R.C.P.Lond., Physician to In-patients, Samaritan
Free Hospital for Women, London; Lecturer on Gyntecologv,
Medical Graduates' College and Polyclinic, London. Pp. 17^2.
Price 20s. net.

Heart Disease and Thoracic Aneurysm. By F. J. Poynton,
M.D., F.R.C.P. Pp. 310. Prioe 5s. net.

Auscultation and Percussion. By Samuel Gee, M.D., Fifth
Edition. Pp. 325. Price 5s. net.

Clinical Lectures and Addressee on Surgery. By C. B. Lock-
wood. Pp. 276. Price 5s. net.

The Operations of General Practice. By Edred M. Corner, M.A.,
M.B., etc., and H. Irving Pinches, M.A., M.B., etc. Pp. 296.
Price 15e. net.

Hexbt J. Olaisheb (London).

On Acute Pneumonia: Its Signs, Symptoms and Treatment.
By Seymour Taylor, M.D., F.R.C.P., Physician to the West
London Hospital, etc. Pp. 64 Price 1*. net.

William Hodoe and Co. (Glasgow).

County Council of Dumbarton: Sixteenth Annual Report

S Tear 19C6) to the County Counoil and District Committees
y John C. M'Vail, M.D., D.P.H., eto. Pp. 103.

County Council of Stirling: Sixteenth Annual Report (Tear
1906) to the County Council and District Committees. By
John C. M’Vail, M.D., D.P.H., etc. Pp. 160.

Lewib, H. K. (London).

What to Do in Cases of Poisoning. By William Murrell, M.D.,
F.B.C.P. Tenth Edition. Pp. 280. Prioe 3s. 6 d.

Post Graduate Clinical Studies for the General Practitioner.
By H. Harold Scott, M.B., M.R.C.S., eto. First Series.
Pp. 166 and 35 diagrams. Price 8 s.

J. B. Lippincott and Co. (London).

International Clinics: A quarterly of Illustrated Clinical
Lectures, etc. Edited by W. T. Longcope, M.D. Vol. II.
8 eventh Series, 1907. Pp. 312.

Obstetrical Societt op London.

Transactions of the Obstetrical Society of London. Vol. XLIX.,
for 1907. Part II., for March, April and May. Pp. 205. Prioe
5s.

Youno J. Pkxtlaxd (Edinburgh).

The Edinburgh Medical Journal. Edited by Alexis Thomson,
M.D., F.R.C.S.Edin., and Harvey Littlejohn, M.B., F.R.C.S.
Edin. New Series. Vol. XXI. Pp 576.

Manual of Surgery. By Alexis Thomson, F.R.C.S.Edin., and
Alexander Miles, F.R.C.S.Edin. Vol. II. (Regional 8 urgery).
Second Edition, revised, enlarged and illustrated. Pp. 816.
Price 10s. 8 d. net.

John Weight and Co. (Bristol).

The Clinical Use of Prisms. By Ernest E. Maddox. M.D.,
F.R C.S.Edin. Fifth Edition, revised and enlarged. Pp. 205.
Price 5s. 6 d. net.

A Pharmiooepia for Diseases of the Skin. Edited by James
Startln. Sixth Edition. Pp. 64. Prioe 2s. 6 d., net.

Through Jamaica with a Kodak. By Alfred Leader. Illus¬
trated. Pp. 208. Price 6 s. net.

itized by G00gle

98 The Mxdical Pmss.

WEEKLY SUMMARY.

July 24. 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT SURGICAL LITERATURE.

Tbe Rflle of the Various Elements In the Develop*
ment and Regeneration of Bone. —Sir Wm. MacEwen
(Brit. Med. Journ., June 22nd, 1907) undertook this
inquiry by direct experiment. The subject is dealt
with under two heads : (a) To test the potentiality
of periosteum as a factor in the reproduction of bone.
It was found that (1) when a complete cylinder, con¬
stituting a portion of the shaft of a long bone, was
removed while the periosteum was preserved intact,
that ten weeks later an osseous defect was found
constituting a gap in the continuity of the shaft;

(2) periosteum freed from osseous plaques when re¬
moved and transplanted was not followed by repro¬
duction of bone, but by the absorption of periosteum;

(3) silver rings were placed on bone deprived of perios¬

teum, with the result that in each case the rings
became covered by bone, (b) The regeneration of
bone, from proliferation of osseous tissue. (4) Direct
experiment, showing that a long bone deprived of its
periosteum continues to grow ; (5) so also do flat
bones of the skull; (6) bone may be made to grow in
the midst of lacerated muscles by the mechanical
distribution of osteoblast; (7) shavings of nude bone
placed between muscles in a gap in the continuity of
the shaft showed in seven weeks, not only that they
grow, but that they also proliferate to a very marked
extent; (8) there is direct evidence to show that
transplanted living bone actually grows and prolife¬
rates, instead of forming, like blood-clot, a passive
framework for the granulation tissue to penetrate,
which framework will then become absorbed ; (9) to
test the osteogenetic power of bone cells constituting
the shaft of a long bone, they were grown inside of a
glass tube. S.

The Use of Massage and Movement in the Treatment
of Fractures. —Cathcart ( Scottish Med. and Surg.
Journ., July, 1907), from personal experience, has
come to the following conclusions on this subject
(1) Absolute immobility of the broken ends of bone
is not essential to bony union. (2) Extravasated
blood in joints, and among muscles and synovial
sheaths, leads to adhesions in its neighbourhood, apart
from the bruising and laceration of soft parts which
accompanies fracture. (3) Massage, in the form of
stroking and gentle kneading, and with it occasional
movements are beneficial in the treatment of fractures,
as they aid the actual union of bones, help in the
absorption of effused blood and serum, restrain if not
prevent the formation of adhesions among the soft
parts, and maintain the nutrition of the muscles.
They therefore simultaneously hasten union and pre¬
pare the limb to return to functional use almost as soon
as the bones are united. (4) Splints, extensions, &c.,
are more to prevent mal-union, than non-union. (5)
The manipulation necessary for the massage and move¬
ment treatment of fractures can be successfully carried
out by anyone who will take the trouble to under¬
stand the object of manipulation and is sufficiently
gentle to handle the part without causing pain. In
recent fractures, massage diminishes swelling, allays
muscular spasm, and soothes pain. When there is
much pain and spasm of the muscles passing over the
broken bone a small hypodermic of morphia or hot
fomentations are of advantage. The limb is well
dried and dusted with some fine powder to facilitate
rubbing. Gentle stroking of the limb should be begun
on the proximal side of the injury, the amount of
pressure to be used must be guided by the sensations
of the patient, as the patient must not be caused any
pain. Even when a general anaesthetic is required,
preliminary massage should be employed to reduce
effusion before splints are applied. As regards move¬
ments, active movements wul help to prevent stiffness,

and passive movements will help to maintain nutrition.
Gentle passive movements should be used first. Both
forms of movement require to be used with care so
as to avoid displacement of the broken ends of bones;
and pain and serious discomfort to the patient must
always be avoided. There is one form of active
movement to which the author calls especial attention,
that is in the reduction of displacement due to mus
cular contraction. Apparently voluntary efforts in¬
sure relaxation of the displacing muscles together with
contraction of those that are helpful in reducing the
deformity. Discussing splints, the author considers
that they are useful (1) to prevent deformity, and
while pain on movement lasts ; (2) to give support
to the seat of fracture and adjacent parts. He con¬
siders that the long splint for treatment of fracture of
the shaft of the femur will seldom now be needed,
since we no longer wish to fix the hip and knee-joint,
except in restless children and delirious adults, and
since we can quite well prevent rotation outwards of
the lower fragment by sand-bags. There are cases in
which continuous extension by weights or an elastic
cord are indispensable to obtain the best possible
apposition of broken ends of bones. But the extension
should not be continued too long—not after ten days
to three weeks. The author discusses the treatment
in reference to various common fractures, including
fracture of the olecranon and patella. S.

Notes of an Experience of Stovain as a Spinal
Analgesia in 100 Cases. —Pringle (Brit. Med. Journ.
July 6th, 1907), who has been employing thismethod of
producing anaesthesia for operations in Glasgow,
used Bier’s preparation of stovain with epirenane, as
put up by Billon, of Paris, in 98 of his cases; two
patients got Chaput’s preparation. The injection is
made with the patient sitting up and the shoulders
arched. There is seldom any pain in connection with
the injection, which is best made in the first lumbar
space. It is essential to get a free run of cerebro¬
spinal fluid when the trocar is withdrawn. After tbe
stovain (from .04 to .06 eg.) is injected, the pressure of
the cerebro-spinal fluid is, in the majority of patients,
sufficiently great to force the syringe plunger back
into the barrel, and this is allowed to occur several
times to ensure a good mixture of the solution with the
fluid. The effects are produced in from five to
fifteen minutes. Usually muscular paralysis of the
lower limbs is complete before sensation is abolished.
Analgesia has, on an average, reached the level of the
tenth dorsal nerve. In one case it was complete up
to the clavicle on both sides without any respiratory
difficulty being induced. The highest incision under
stovain was for umbilical hernia. Very few patients
manifested any discomfort during the period they were
under the influence of the drug. There was a little
retching or vomiting in the case of a few’, and four
patients had syncopal attacks ; but in no case was
there any anxiety about the condition. The ages of
the patients varied from 13 years to 80 years. Iu
two cases unilateral analgesia only occurred. Tbe 100
operation cases included amputations of the thigh
(2), hernias (31), appendicitis (12), wiring fractures (6),
suprapubic prostatectomy (3), inguinal colostomy (2),
pyonephrosis (1), &c. Among these 100 patients there
were 22 cases of failure to induce analgesia sufficient
to allow the operation to be completed. The after¬
effects of stovain have not been troublesome at all.
Headaches have been complained of by some patients,
and one or two have vomited a little after operation;
but in neither case were these symptoms as severe
as is often seen after ether and chloroform. A good
number of patients complain greatly of pain in the
wound for the first hour^or two after theoperation,

by Google

D

JPLY 24. 1907.

more so than after a general anaesthetic. In conclu¬
sion. the author has no doubt that in stovain we have
a very excellent anaesthetic for the region comprising
the lower limbs, and the lower part of the abdomen,
even though it may be a little uncertain in its action.

s«

Symptomatic Varicocele in Malignant Tumours of
the Kidney.— P. Hochenbegg ( Zeitschr. fur Klin.
Med. Bd. 62) says symptomatic varicocele can be
distinguished from idiopathic varicocele in the following
way : Let-the patient lie down, at once the idiopathic
varicocele disappears, only the relaxed condition of the
scrotum remaining, but in the case of the symptomatic
or secondary varicocele, this will become perhaps
more tense on the patient assuming the horizon¬
tal position, or will in any case only slightly diminish
in size. Symptomatic varicocele usually appears
at an advanced age, and comes on more or less'suddenly;
it is produced under various conditions ; the tumour
may invade the renal vein and occlude the opening of
the spermatic vein. This condition is, of course,
only possible on the left side. The growth may
infect the lymphatic glands, in which the spermatic
and renal veins become imbedded and compressed.
The spermatic vein may become occluded by the
weight of the tumour ; it is in such cases that the
varicocele becomes tenser when the patient lies down.
The kidney may be dragged downwards by the weight
of the tumour and the veins become kinked ; this
occurs more frequently on the left side than on the
right. The presence of a varicocele, due to either
of the two last-mentioned causes, does not alter the
prognosis, but if its presence is due to either of the
two first-mentioned causes, then the case is inoperable.
If posture and manipulation of the tumour is without
effect on the variocele the prognosis is not good.
Of sixteen cases of malignant tumour of the kidney
observed by the writer, symptomatic varicocele was
present in six of these patients. G.

An Improved Preparation for Intra-Mnacnlar Injections
of Mercnry. —F. J. Lambkin {Lancet, July 6th, 1907) calls
attention to a new preparation of the insoluble salts of
mercury he has used with great success lately, the
vehicle used for the suspension of the mercury being
pure palmatin, which has the great advantage of being
a soluble constituent of the organism, in place of the
insoluble substances formerly used. The success
which has followed on combining this preparation
with camphorated creasote, as an analgesic, begins a
newjera in the treatment of syphilis by intra-muscular
injections of insoluble salts of mercury, for, in the
first instance, one great objection to the treatment,
i.e. , the introduction of insoluble foreign bodies
into the circulation—is done away with, and, in the
second place, pain has been practically abolished,
even in the case of calomel, so that this drug can
now be used fearlessly in every case in which the
surgeon thinks its use is indicated. G.

The Treatment of Lnpns. —Dr. Drew ( Lancet ,
July 13th, 1907) describes a method of treating lupus.
The lupus patch to be treated is frozen with ethyl
chloride till it is snow white ; over this frozen surface
crude hydrochloric acid is rubbed in thoroughly, and
with some degree of force. This thorough surface
cauterisation should be carried out about once a week
as long as it is necessary, that is, until only deeper
nodules remain (lupus fibroma). The remaining
nodules are cured by puncture cauterisation. The
advantages of this method are : (1) It is simple,
cheap, rapidly effective, and gives good cosmetic
results ; (2) It can be carried out at home without
hospital treatment, and this is specially important
for patients with limited means; (3) Complicated
apparatus is not necessary, therefore the method can
be applied by any practitioner.; (4) The method can
be applied in all forms of lupus and in all situations,
with the exception, perhaps, of the eye. Favourable
results are obtained by repeated cauterisation, especi¬
ally of lupus of the nasal cavity ; (5) As a preliminary
for later Finsen treatment one gains time and gets
favourable results. G.

The Mkpicat P»ess. 99

j Punctured Fractures of the Base of the Skull.—

I R. L. Knaggs, in a paper (Lancet, June 1st, 1907)
on this subject, draws attention to the frequency
with which such injuries as punctured fractures
of the base of the skull are overlooked ; two or three
days often pass during which the patient goes
about as usual, then brain symptoms appear
sometimes quite suddenly, and the patient may
die in the course of a few' hours. It is well to re¬
member the paths by which a foreign body may
reach the base of the skull. The most usual one
is through the orbit; the orbit is not necessarily
entered from the front, but may be crossed from
below upwards, or reached from inside the. zygo¬
matic arch, and the position of the skin wound may
be such that it w'ill arouse no suspicion that the brain
has been injured. Another path is through the mouth,
pharynx or nose ; this latter is very rare. Another
not uncommon route passes through inside the zygo¬
matic arch, the external wound is usually in the
cheek and the lower jaw may be damaged. Lastly,
the convex portion of the posterior segment of the
skull may be wounded directly. It is also well to
remember that often such wounds are regarded by
patients as trivial, and they may only seek advice
with the onset of brain symptoms. In cases where
the foreign body inflicting the wound is long, slender,
and brittle, a "portion may readily be left behind,
and retained in the skull. Lastly, it is well to re¬
member that even if the immediate danger of death
from cerebral haemorrhage or injury is escaped there
is a tendency to later septic complications, which
may be deferred for several days. At the base of
the skull the majority of the venous sinuses are
situated ; it is unfortunate that the converging walls
of the outer part of the orbits tend to direct a weapon
towards this dangerous area. G.

Obstruction of the Central Retinal Vein. —Verhoeff,
Boston (Ophthalmic Review, December, 1906) in
dealing with the pathological findings of six cases
of his owm and twelve reported cases diagnosed oph-
thalmoscopically as thrombus of the central vein,
brings evidence to show that the most frequent cause
of the clinical picture is an endo-phlebitis proliferans.
Out of the cases reviewed, in only two was the central
vein thrombosed, and these were septic cases. A
coagulum due to the fixing agent may resemble a
thrombus, but in the majority of the cases the evidence
was insufficient to show that it was due to thrombus,
but rather indicated that it was due to an endo-
phlebitis proliferans. The obstructing mass showed
no blood remains, such as blood pigment, and the
adventitia around the obstruction showed no signs
of inflammation, but the mass consisted either entirely
of connective tissue or partly of proliferated endo¬
thelial cells. The anatomical examination of all the
cases save one showed the presence of glaucoma. In
one of Verhoeff’s cases acute glaucoma set in three
weeks after the onset of the symptoms of obstruction
of retinal vein. The eye had to be enucleated for
pain and showed, on examination, an absence of a
thrombus, and the presence of complete occlusion
of the vein due to an endo-phlebitis proliferans. There
was no cupping of the disc, but the glaucoma seemed
to have been due to excess of albumen in the vitreous,
derived from the retinal veins and capillaries. This
excess of albumen was shown by the vitreous being
found coagulated by the action of the formalin, when
the eye was divided. Conclusion.—Complete ob¬
struction of the central vein, with classical ophthal¬
moscopic picture of thrombosis of this vessel, may be
produced by endo-phlebitis proliferans without thorn-
bosis. The’ proliferation may involve the sub-endo¬
thelial tissue alone, or the obstruction may be com¬
pleted by a more active endothelial proliferation
into the lumen. All of the cases anatomically ex¬
amined in which obstruction of the central retinal
vein has been attributed to non-septic thrombosis
can be explained by, and ill all probability were due
to. endo-phlebitis proliferans alone. In certain cases
obstruction of the central retinal vein may early
give rise to acute glaucoma. M.

WEEKLY SUMMARY.

100 Thx Medical Puss.

MEDICAL NEWS IN BRIEF.

July 24, 1907.

Medical News in Brief,

Liverpool School of Tropical Medicine.

Sir Alfred Jones presided at a dinner given on
July 15th. at Liverpool, for the purpose of bidding
farewell to Dr. J. L. Todd (late director of the Tropical
Research Laboratories at Runcorn), who is returning
to Canada, and to bid God speed to Dr. Barrett and
Dr. Yorke, members of the Black Water Fever Ex¬
pedition, who are going out to Africa. The company
included the Bishop of Liverpool, Lord Mountmorres,
Sir Rubcrt Boyce, F.R.S., Professor Ross, C.B.,
Professor Carter, Dr. Caton, the American Consul
(Mr. Griffiths), and the Mexican Consul-General in
Liverpool. Sir Alfred Jones and Sir Rubert Boyce
spoke to the toast of farewell to Dr. Todd, the latter
remarking that the doctor was the finest example
of an Imperial student. Coming from Canada,
he had been willing to work in every part of our
Empire, and, while giving his time and talents, he
had also contributed something like /200 per annum
to the Tropical School, and, more particularly, to
found the institution at Runcorn, where the best
scientific work had been done. He *Sir Rubert)
hoped that that institution would be firmly united
to the Liverpool School of Tropical Medicine. He
would also like to see another expedition sent out
in connection with sleeping sickness, for having,
they believed, found the means of preventing that
disease, it was their duty to push the treatment
as much as possible. Dr. Todd said that the school
had shown very little gratitude for the work of Dr.
Dutton, who died whilst engaged in research work.
They had tried to collect sufficient to establish a
professorship in his honour, but of the /i6,ooo re¬
quired only ^4,000 had been received. The Bishop
of Liverpool proposed success to the Black Water
Fever Expedition, and paid a high tribute to the
work of the School of Tropical Medicine, which, he
said, had been wonderfully successful in enabling
European civilisation and Christianity to lay hold
of peoples who some time ago knew them not. It
was highly satisfactory that London and Liverpool
joined hands in sending out that expedition. Pro¬
fessor Ross supported the toast, which was ack¬
nowledged by Drs. Barrett and Yorke. On the motion
of the American Consul, the toast of “The Study
of Tropical Medicine” was honoured, and was re¬
sponded to by Colonel Bruce, who said that the
Mediterranean fever, which had been the dread of the
Army at Malta, had practically been blotted out.

Joint Stock Companies and the Practice et Dentistry.

Judgment has been given during the past week in
the Irish Courts in a case of very great interest and
importance to the medical and dental profession.
The case which was heard some weeks ago has been
already mentioned in these columns. In brief, it
consisted in an application by the Attorney-General
at the relation of Mr. Kevin O’Duffy, Hon. Secretary
of the Irish Dental Association, claiming an injunction
to restrain Myddleton, Limited, a Belfast company,
and its members from practising as surgeon dentists,
and the directors from permitting the company to
remain on the registry of Joint Stock Companies.

Mr. Justice Barton, in giving judgment, said in
applying to the present case the authorisation which
had been cited during the hearing, the particular form
and character of this proceeding had to be borne in
mind, as well as the peculiar nature of the rather
scanty evidence which the plaintiff had laid before the
Court. He could not say that the memorandum of
association in this case was open to legal objection.
The title of the company did not contain the word
dentist or any of its synonyms, or any allusion to

dentistry. The principal purpose of incorporation was
to carry out dental operations by means of properly
qualified persons—a purpose which is not per sc illegal.
If the company were to carry out dental operations
by means of unqualified persons, serious questions
might arise, including the question of ultra vires.
But there was no evidence in this case upon that
question of fact. The Court did not know who had
carried out the dental operations of the company.
Therefore the plaintiff claimed wider relief than the
evidence justified. The plaintiff, had, however, estab¬
lished his right to the relief claimed in restraining the
defendants from registering the company as dentists.
In conclusion, the judge said : “ I am disposed to
think that defendant’s counsel endeavoured to form
upon Jaffe’s case a larger claim of privilege for com¬
panies than the decision in that case will support.
They claim for limited companies as a result of that
case an unobstructed right to use the word, ‘ dentist,’
or its synonyms in any and every shape and in any and
every context. Jaffe’s case decided that the word
‘person,’ in Section 3 of the Dentists Act, 1878, does
not include individual persons, and that the Section
hits individuals but does not hit limited companies.
But a company, although it may be exempted from
the penalties imposed by that Section, is not, in my
opinion, thereby privileged to make false representa¬
tions which are calculated to mislead the public as to
the qualifications of the individuals whom it com¬
poses or employs. There will be an injunction to
restrain the defendant company and the directors and
members thereof from employing the defendant Alfred
Myddleton under the title of surgeon dentist or dentist,
to carry on business under the memorandum of asso¬
ciation of the said company, and from holding!forth
or representing in the register of directors and managers,
or the reports or returns pursuant to the Companies
Act to the registrar of joint stock companies, or in
their advertisements to the public, or otherwise, or
elsewhere that the defendant Alfred Myddleton is a
dentist, or that the defendant company comprises or
employs persons of the name of Myddleton who are
dentists. The plaintiff had practically succeeded, and
if he had limited his claim he would be entitled to the
whole costs of the action. The order as to costs will be
that the plaintiff shall have the costs of the action
save in so far as they may have been increased by the
relief claimed in other parts of the statement of claim.”

Society for ttaa Relief of Widow* end Orphans of Medical

Men.

At the quarterly Court of Directors of this Society,
held on July ioth, Dr. Blandford, President, in
the chair, twenty-one directors were present. The
deaths of Sir William Broadbent and Dr. Robert Barnes
were reported ; both had held the office of director.
The Secretary was directed to send letters of condolence
to Lady Broadbent and Mrs. Barnes. Two new mem¬
bers were elected. Since the last quarterly Court one
of the widows, an annuitant of the charity, had died.
Her husband paid a life subscription fee of £26 5s.,
and the widow had received in grants the sum of £490.
Six letters had been received from widows of medical
men, asking for relief, but in each instance this had to
be refused as their husbands had not been members
of the Society. The sum of ^1,300 10s. w f as voted for
the half yearly grants to the 49 widows and 20 orphans,
at present on the books of the Society. Membership
is open to any registered medical practitioner, who at
the time of his election is residing within a twenty-
mile radius of Charing Cross. Full particulars may
be obtained from the Secretary at 11 Chandos Street,
Cavendish Square, London.

Digitized by LaOOQle

July 24.1907.

PASS LISTS.

The Medical Pees*. IOI

Ulster Modlcal Society.

At the annual meeting of the Ulster Medical Society,
the President, Dr. Ganssen (Dunmuny), in the chair,
Dr. Howard Stevenson, the honorary secretary, read
the annual report of council. Dr. Fielden, honorary
treasurer, presented the statement of accounts, show¬
ing a balance in favour of the society of /30 10s. 8d.,
and Dr. Storey, honorary librarian, presented the
library report. The following were elected office¬
bearers for the ensuing session, 1907-8 : President,
Dr. John McCaw, Senior Physician to the Belfast
Hospital for Sick Children ; Vice-Presidents, Dr. A.
Fullerton and Dr. Wallace ; Treasurer, Dr. Fielden ;
Librarian, Dr. Storey ; Secretary, Dr. Howard Steven¬
son ; Editing Secretary, Dr. Rankin ; Council, Drs.
R. J. Johnstone, T. Houston, S. A. Craig, A. G. Robb,
W. St. C. Symmers, W. B. McQuitty.

North-East London Post-dradoate' College.

A vacation course will be held at the Prince of
Wales’ General Hospital, Tottenham, during the
coming September, commencing on the 9th of the
month, the arrangements for which have been adapted
to the requirements of those engaged in active practice.
They include daily cliniques in the wards, demon¬
strations in the out-patient and special departments,
classes on clinical methods. Other practical clinical
demonstrations and clinical lectures with lantern
demonstrations. The fee for the course, which will
last a fortnight, is one guinea. Further particulars
of the course may be obtained from the Dean of
the Hospital.

Royal Colktt ol Surgeons In Inland: Fellowship
Examinations.

Notice is hereby given that on and after January 1st,
1910, all examinations for the Fellowship of this
College will be conducted under the scheme of exami¬
nation now known as Grade I. No candidate after
the above date will in any circumstance be admitted
to examination for the Fellowship of this College under
the scheme now known as Grade 2, which will then
cease to be used.

Tba United Services Medical Society.

At the first meeting of the Council of this newly-
formed Society, it was decided that meetings be held
at the Royal Army Medical College at 8.30 p.m. on
the second Thursday in each month, commencing on
October 10th, 1907 ; that the annual subscription be
5s., payable in advance; and that a notification of
the formation of the society accompanied by an in¬
vitation to join be sent to all medical officers on the
active lists and to those on the retired lists whose
addresses can be discovered. Should any medical
officer on the active or retired list of the Navy, the
British and Indian Armies, or the Auxiliary and
Colonial Forces not receive an invitation, the Council
hope that, if desirous of joining the society, he will
communicate with one of the honorary secretaries,
Fleet-Surgeon W. W. Pryn, R.N., '“Tredown,” 25
Idmiston Road, West Norwood, S.E., or Lieut.-Colonel
C. H. Melville, R.A.M.C., Royal United Service In¬
stitution, Whitehall, S.W.

PASS LISTS.

University et Glasgow.

The following candidates have passed the fourth
(final) professional examination for M.B., Ch.B. The
names are arranged alphabetically.

W. W. Adamson, G. V. Anderson, A. H. Arnott,
David Arthur, B.Sc., Herbert Bertram., R. L. Binning,
William Brown, M.A., B.Sc., James Caimcross, T.
H. Campbell, R. P. Cartwright, T. G. Copestake, A. J,
Couper, A. D. Cowan, J. R. Craig, C. A. Crichlow,
Neifson Davie, H. W. Dempster, J. A. Doctor, Donald
Duncan, W._H. Duncan, Allan Dunsmuir, L. J. Dun- |

stone, A. W. Eadie, W. M. Elliott, A. Fairley, T. H.
Forrest, Thomas Forsyth, Berkeley Gale, George
Garry, James Gemmell, David Gibson, H. M. Granger,
J. V. Grant, T. P. Grant, W T . C. Gunn, Lawrence Hislop,
Archibald Hogg, A. J. Hutton, C. L. Kerr, A. T. I.
Macdonald, Neil Maclnnes, M.A., Robert Mclnroy,
J. B. Mackay, T. C. Mackenzie. A. D. M’Lachan,
D. C. Maclachan, A. N. R. M‘Neill, C. J. C. Macquarie
Carswell Marshall, J. H. Martin, Horatio Matthews,
W. S.Melville, J. C.Middleton,M.A., B.Sc., J. W. Miller,
Thomas Miller, M.A., J. R. Mitchell, Hugh Morton,
James Muir, R. C. Muir, Patrich O’Brien, D. M. Reid,
Donald Renton, M. M. Rodger, T. D. C. Ross, Alex¬
ander Scott, J. M. Smith, John Steedman, C. K.
Stevenson, M. J. Stewart, Lawrence Storey, J. A.
Struthers, J. M. Taylor, R. S. Taylor, D. A. Thompson,
M.A., H. J. Thomson, J. A. Thomson, Robert Todd,
John Turnbull, Martin Turnbull, W. B: Watson, John
Weir, F. R. Wilson, Samuel Wilson, M.A., W. M. T.
Wilson, Thomas Winning, M.A., G. Yeghia Yardumian
Matthew Young.

Women. —Jeannie Montgomery Andrews, Martha
Maclean Buchan, Margaret Gardner Forrest, Ella
Smith Hill, M.A., Annie^M’Crorie, Janet Annie Macea,
Jessie Deans Rankin,* M.A., B.Sc. ; Jane Isabel
Robertson, M.A.

The following passed with distinction in the subjects
indicated :— i

In (a) Surgery and Clinical Surgery ( b) Practice of
Medicine and Clinical Medicine—David Arthur, B.Sc.,
Hugh Morton, Matthew John Stewart.

In (a) Surgery and Clinical Surgery (6) Midwifery—
William Cooper Gunn.

In Surgery and Clinical Surgery.—Jeannie Mont¬
gomery Andrews, William Brown, M.A., B.Sc., Martha
Maclean Buchan. Thomas Hay Campbell, James
Robert Craig. Charles Adolphus Crichlow, Donald
Duncan, William Marley Elliott, Archibald Fairley,
Margaret Gardner Forrest, Samuel Nicol Galbraith,
Berkeley Gale, James Wilfred Georgeson, Henry Max¬
well Granger, Thomas Purdie Grant, James Dow Gray,
Ella Smith Hill, M.A., Archibald Hogg, Andrew James
Hutton, Thomas Miller, M.A., Daniel M'Kinlay Reid,
George Waugh Scott, John Steedman, Campbell Kay
Stevenson, Lawrence Storey, David Alexander Thom¬
son, M.A., Hugh Johnstone Thomson, Samuel Wilson,
M.A., Matthew Young.

In Practice of Medicine and Clinical Medicine—John
M'Vittie, Horatio Matthews.

In Midwifery'—Allison David M’Lachlan, Alexander
Scott.

Royal Caller* of Surgeon* of Edinburgh.

The following gentlemen, having passed the re¬
quisite examinations were, at a meeting of the College
held on the 16th inst., admitted Fellows :—Edward
Archer-Brown, M.B., M.R.C.S. Eng., L.R.C.P. Lond.,
Johannesburg ; William Bruce Bell, M.B., C.M.,

Manchester; Alexander Glover Coullie, M.B., Ch.B.,
Pencaitland ; David Elliot Dickson, M.B., C.M.,
Lochgelly; William Arnott Dickson, M.B., Ch.B.,
Lochgelly; Henry Tristram Holland, M.B., Ch.B.,
Baluchistan; William Leonard Maccormac, M.B.,
Ch.B., London, S.W. ; Archibald McKendrick, L.D.S.,

L. R.C.S.E., Kirkcaldy ; Charles Edmund Russel Ren-

dle, M.R.C.S. Eng., L.R.C.P. Lond., Plymouth ; Her¬
bert Wilkinson Riggs, M.D., C.M., Vancouver ; Geoffrey
Allen Upcott-Gill, M.R.C.S. Eng., L.R.C.P. Lond.,
London, N.W. ; and William Young, M.B., C.M.,
Major, Indian Medical Service. ,

Society of Apothecaries of Loadoa.

The following candidates, having passed the neces¬
sary examinations, have been granted the L.S.A.
Diploma of the Society, entitling them to practise
Medicine, Surgery, and Midwifery :—E. R. Bastard,

M. L. Ford, A. J. Hopper, R. J. W. McKane, G. B.
Messenger, E. E. C. Vollet, and J. S. Ward. •

, y Google

102 The Medical Press. NOTICES TO CORRESPONDENTS.

NOTICES TO
CORRESPONDENTS, ffc.

M^Corkrbpondrxtb requiring ■ reply In this column ere partlca-
lerty requested to meke use of e Dittinetive Signature or Initial, sad
to avoid the prectloe of signing themselves “ Reeder,” “ Subscriber,"
“Old Subscriber,” Ac. Much confusion will be spered by attention to
this rule.

SUBSCRIPTIONS.

Subscriptions may commence et any date, but the two volumes
each year begin on January 1st and July 1st respectively. Terms
per annum, 2la.; post free at borne or abroad. Foreign subscriptions
must be paid in advance For India, Messrs. Thacker, Spink and Co.,
of Calcutta, are our officially-appointed agents. Indian subscrip¬
tions are Rs. 15.12.

A Laiman. —We cannot publish letters from laymen when
they are evidently not inspired by public spirit, but rather
prompted by private feelings of malice or spite.

Qron.—Medical men's ordinary earnings from practice and
appointments will, of course, be chargeable on the ninepenny
basis, but it is the individual's own responsibility to see that
he gets the abatement. Unless the claim is made the surveyor,
with the usual red-tape methods of administration, will not" be
bound to call the taxpayer's attention to his rights. A special
form (whioh we are advised is not yet available) is being
printed, and will be distributed at the surveyor's pleasure, but
if it is not sent in by September no allowance will be made.
Your best plan then will be to write to your surveyor and
make his life a burden till you get a form out of him.

THE TREATMENT OF HAIRY MOLES.

S uebt writes:—“I should be glad if any of your readers
d tell me briefly what is the best treatment for hairy moles
in a girl aged 11, the moles being situated on the face, and the
parents not sufficiently well off to send her to a specialist or
even to town for hospital treatment. Have X-rays been of any
value in this condition?’’

Mr. Edward B.—The marked communication reached us as we
were “ at press,” too lale for reference In present Issue.

Codntrt Practitioner. —Possibly enemata, or suppositories of
glycerine would be found beneficial.

R. P.—There are several agencies that deal in the plncing of
resident patients with medical men. Home of them are very
shady affairs and some quite straightforward. The Assoeuciou
of Medical Men receiving Resident Patients is clearly the cne
that appeals most directly to medical men, as it is eutnely
worked by medical men, and aims merely at being self-support¬
ing. The address of the bon. secretary is 56, Outer Temple,
8trand, W.O.

PLAGUE IN INDIA.

Dr. Rutherford lost week asked the Secretary of Stare for
India what was the number of deaths from plague during June
In the Punjaub and in the whole of India; and what was the
total for the six months in the Punjaub and in India.

Mr. Morley’s reply was that the figures for Juna ware; —
Punjaub, 58,821 deaths; whole of India, 68,064. For six months
ended June:—Punj mb, 032,953; whole of India, 1,060,067.

Errata. —In the paper published in our last issue entitled
" Some Further Reflections on Cancer and Its Treatment,” by
J. A. Shaw-Maekenne, M.D.Lond., at page 62, column 2, par. 3,
line 10, " ... animal tissues and organs. I have . . .”

should read “ ... animal tissues and organs, I have . . . .”
Page 63, column 1, par. 5, line 4 from bottom, " ... foetal
secretion ... " should read " ... foetal secretin . . .”
^Subscriber (London, 8.E.) —We are glad to be able to ease your
mind by saying emphatically that the inatitutlon you are Interested
in was not referred to.

Mediccs —Thank yoa for your letter and cutting. The matter Is
an Important one and we hope to deal with It next week.

Jfceeiinfls of the Societies, ’jCectnres, &c.

WEDNESDAY, Jult 24th.

North-Eabt London Pobt-Gbaduatb Collide (Prinoo of
Wales’* General Hospital, Tottenham, N.).—Cliniques 2.30
p.m. : Skin (Dr. Meachen), Eye (Mr. Brook*), Medical Out¬
patient (Dr. Whipham).

Thursday, Jult 25th.

Medico-Pstcholooical Association of Great Britain and
Ireland (11 Chandos Street, Cavendish Square, W.).—9.30 n.m.:
Council Meeting. 11 a.m.: Annual Meeting. Election of
Officers and Council. 2 p.m.: Address:—The President (Dr. P.
W. MacDonald). Paper:—Dr. C. C. Easterbrook: The Sana¬
torium Treatment of Active Insanity by Rest in Bed in the Open
Air. 7.15 for 7.30 p.m.: Annual Dinner at the Whitehall
Rooms, Hotel Metropole.

North-East London Post-Graduate College (Prince of
Wales's General Hospital, Tottenham, N.).—2.30 p.m.: Gynwco-
logical Operations (Dr. Giles). Cliniques :—Medical Out-patient
(Dr. Whiting), 8 urgical Out-patient (Mr. Canon). 3 p.m.:
Medioal In-patient (Dr. Chappel).

Friday, Jult 26th.

Medico-Pstcholooical Association of Great Britain and
Ireland (11 Chandos Street, Cavendish Square, W .).—11 a.m.:
Discussion on Psychiatry as a Part of Publio Medicine (intro¬
duced by Dr. T. 8 . Olouston). Clinioal Demonstration and
Paper:—Dr. A. Wilson: The Psychology of Crime. Paper: —
Dr H Devine: A Coos of Katatonia in a Congenital Deaf Mute
(illustrated with lantern slides). 2 p.m.: Communication.—Dr.
W. F. Robertson and Dr. G. D. MoRae: Observations on the
Treatment of General Paralysis and Tabes Dorsalis by Vaccines
and Anti-sera. Paper:—Dr. L. C. Bruce: Clinical Observations
on Certain Cases of Mental Depression.

North-Ear London Post-Gbaduat* Collror (Prince of
Wales's General Hospital, Tottenham, N.V—9.30 a.m.: Clinique:
—Surgical Ont-patient (Mr. H. Bran*). 2.30 p.m.: Surgical

Tul v 24, 19 07.

Operation* (Mr. Edmund*).
(Dr. Auld), Eye (Mr. Brook*).
Leslie).

Clinique* ;r-Medioal Out-patient
3 p.m.: Medical In-patient (Dr.

ftaomcies.

York Dispensary.—Resident Medioal Officer. Salary, £190 a
year, with board, lodging, and attendance. Application* to
W. Draper, Esq., De Grey House, York.

The Cambridgeshire, etc., Asylum.—Second Assistant Medical
Officer. Salary, £120 per annum, with board, lodging, and
attendance in the Asylum. Applications To T. Musgrave
Francis, Clerk to the Visitors, 18 Emmanuel Street, Cam¬
bridge.

Bradford Children's Hospital.—House 8 urgeon. Salary, £100.
Applications to C. V. Woodcock, Secretary, Bradford.

Carmarthenshire Infirmary.—Resident Medical Officer. Salary,
£100 per annum, with furnished apartments, board, attend¬
ance, fire, gas, and washing. Applications to Howell
Howell, Secretary.

Salford Union.—Male Resident Medical Officer. Salary, £130
per annum, with furnished apartments and attendance.
Applications to F. Town son, Clerk to the Guardians, Union
Offices, Eccles New Road, Salford.

The Guardians of the Leeds Union.—Assistant Medical Officer.
Salary, £120 per annum, with board, washing, apartments,
and "attendance. Applications to Jas. H. Ford, Clerk to
the Guardians, Poor Law Offices, South Parade, Leeds.

Tunbridge Welts General Hospital.—I£ouse Surgeon. Salary,
£100 per annum, together with board, furnished apartments
in the Hospital, gas, firing and attendance. Applications to
the Secretary.

Hospital for Sick Children, Great Ormond 8 treet, London, W.C.
—House Physician, House Surgeon, Assistant Casualty
Officer. Stewart Johnson, Secretary. iKeeadn.)

Royal Southern Hospital, Liverpool.—Resident Pathologist and
Registrar. Salary, £100. with board and residence. Applica¬
tions to the Superintendent.

Jlppomtmenis.

Dimocx. Horace, M B., B.C.Cantab., M.R.C. 8 ., LJtt.C.P.Lond.,
Assistant House Surgeon at Addenbrooke's Hospital, Cam¬
bridge. . , .

Dowling, E. A. G., L.R.C.P., M.R.C.S., L.D.S., Leoturer n
Dental Anatomy. Physiology and Dental Histology at Uni¬
versity College. Bristol.

Eloood, Olive, M.S Lond.. Honorary Anaesthetist to the Bir¬
mingham and Midland Dental Hospital. _

Evans, William Owen, L.R.C.P., L.R.C.S., L.M.Edin., L.F.P. 8 .
Glasg , District Medical Officer and Medioal Officer to the
Workhouse by the Pontardawe (Glamorganshire) Board of
Guardians. .... „ .

Eire, J. W. H., M.D., M.S.Durh., Bacteriologist to Guy*
Hospital. .

Friend. Julius, L. 8 .A., Medical Officer to the No. 2 District by
the Leeds Board of Guardians. __ .

Hitchcock. Norman, M.B., B.S.Lond., M.R.C.S., L.R.C.P.Lond.,
Resident Medical Officer to the Brixton Dispensary.

Jones, John Arnold, M.B.. Ch.B.Vict.. F.R C.S.Edin., Honoiary
Assistant Aural Surgeon to the Manchester Eye and bar

L0CHR°ANE, al FRANX J., M.D., B.S.Glasg., Honorary Gynecologist
to the Derbyshire Royal Infirmary. _ .. . _ . .

McEwan. Peter. M.B., Ch.B., F.R.C.S.Edln., Resident Surgical
Officer at the Bradford Royal Infirmary.

Pfolet, F. Newland, F.R.C.fJ.Eng., L.D.B., Consulting Dental
Surgeon to Ouy'* Hospital. , , . .

Perbt, Fbedericx W„ L.D.S., Demon»trator in .Dental Anatomy,
Physiology and Dental Histology at Univeiaity College,

Pilun. SI H L., L.D.S., R.C.S.Eng., Dental Surgeon to Guy's

PRTt?F* P nENi».T ,T.. F.R.C.S.Eng., Medical Referee under the
Workmen's Compensation Act, 1206, for County Court Ciro^t
No 38 and to he attached more particularly to Braintree,
Chelmsford, Colchester, Dunmow, Halstead, Harwich, ana
Ma'.Jon County Courts.

jBirths.

Hudson.— 0.n July 19th, at Sarratt Hall, Sarratt, Hert*. to Dr.
and Mrs. Hudson, a daughter. . ,,_.

Newbolt.— On July 16th, at 42, Catharine Street, Liverpool, tb«
wife of George Palmerston Newbolt, F.R.C. 8 ., of a d*uffbt* .

Perigal. —On Julv 15th, at Blenholme new Barnet, Herts, tne
wife of Arthur F. Perigal, M.D., of a da ughter.

iHarmaes.

Aterb-Shacxleton.— On July 18U>, at 8 t J

Svdenham, the Rev. Fratlk Ayer*. M.A., 3 i( * r S.thri Rose.
St. Michael', and All Angels', Sydenham, to Ethel w*
third daughter of Henry SbaoklMon. M.D., We**

cJMSiw.-O. M, 17th Jt SL MVO'«£
Crewe.

Icath.

affrfson.— On July 21st, at the Hostel of
Harman Street. Hoxton, London. jf 0 °° a c anonbury

of the late John Furrance Jeaffrcon. F.B.C. 8 ., of Canon our.

Lane. London.

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The Medical Press and Circular.

"SALUS POPULI SUPREMA LEX."

Vol. CXXXV. WEDNESDAY, JULY 31, 1907. No. 5

Notes and Comments.

That fashion in treatment varies
nearly as much as fashion in
Tke Work ladies’ hats is an undeniable fact,
Care. but it may be hoped that whereas

the latter leads nowhere, the
former is showing a rational and
upward tendency. The Weir-Mitchell cure is
certainly not as popular, at all events with
patients, as it was a few years ago, and, in
searching for a successor, it may be that an
excursion in precisely the opposite direc¬
tion will be healthful and heeding. Already
in sanatoriums for consumptives, notably at
Frimley, the value of work is beginning to be
demonstrated, and there is no doubt that in asy¬
lums a great many improvable patients are a
great deal better occupied in practising mechanical
handicrafts than in lounging about watching
cricket-matches. Some very interesting experi¬
ments are reported from Vienna of the value of
work at the State Institution for Mental Diseases
at Mauer Oehling. Dr. Starlinger, the superin¬
tendent, has more than half his patients at work
of some kind—agricultural, dairy, farm, or
mechanical. Moreover, for those of a literary
turn he gives facilities for the production of a
newspaper, and a periodical largely written and
composed by the patients is published in the'
asylum. We have not had the advantage of seeing
a copy, but we can imagine it would be suffi¬
ciently entertaining to rank, let us say, with
Punch. The important point is that all this work is
of great benefit to the inmates, and the work-cure
may eventually invade our shores as successfully
as the rest-cure did ten years ago.

Sir Thomas Fraser, like Lord
Sir Thonas Brougham and Mark Twain, has
Fraser had the curious experience of
Redlvfro. seeing himself killed before his
own eyes, though he has not, we
believe, shared with Sir Harry
Parkes and a few other eminent people the exqui¬
site enjoyment of assisting at his newspaper post¬
mortem. The mistake arose in the Lord Cham¬
berlain’s office, it seems, in the same way that most
mistakes and injustices arise in government de¬
partments, namely, by junior clerks doing the
work for which their seniors are supposed to be
responsible. We should have thought that even
junior clerks would have had at their command
sources of information with regard to eminent
men which would have enabled them to verify
such important facts as to whether they were
alive or dead ; indeed, it is inconceivable that two

minutes’ conversation on the telephone with the
Scottish Office would not have brought authentic
news. For our own part, we were led by the Lord
Chamberlain’s information to announce that Sir
Thomas Fraser had been succeeded by Sir Thomas
McCall Anderson in the office of physician to the
King in Scotland, whereas, of course, he had only
been joined in that office by Sir Thomas, who
succeeded the late Sir William Gairdner. As
there had been other changes in the King’s medical
attendants, we hoped that the announcement was
preliminary to even higher honours. At any
rate, we trust that he will be spared for many
years to enjoy the marks of confidence he has
deservedly earned from the Sovereign.

A letter opening up a question
County Courts of much importance to medical
and men appears in our correspondence

Debt Colloctlnf. columns this week. It seems

that Judge Mulligan, K.C., who
has recently been raised to the bench, has
started by reversing the practice of his predecessor,
and we believe of most if not all County Court
judges of the present day, with regard to the
collection of small debts. Now, there are few
medical men with a large clientele, especially in
scattered and unsettled districts, who are not
compelled to make use of the County Court more
or less frequently to get in their small debts.
The total these small amounts reach in the course
of a few years is sometimes astonishing, and in
self-defence most medical men have to take steps
with regard to them, if only to get rid finally of
undesirable patients who call them up at all sorts
of hours and never pay their bills. Now the
collection of trivial debts by the full legal process
is an expensive and inefficient method, and though
no one grudges paying a solicitor for advice and
work, it is ridiculous that his costs for proceeding
in the case of a small debt should amount to more
than the debt itself, and that the money should
frequently never be recovered after all. It is
like using a steam-hammer to crush a fly. Of
late years, a class of debt-collectors have sprung
up who work entirely on commission, and who, by
means of calling on debtors, are frequently able
to make some arrangement with them whereby
instalments may be paid with reasonable regard
to the amount and frequency of their wages.
The remuneration of the debt-collector is very
small, but he is able, by making a speciality of
his business to get a living out of it. The debt-
collector is an honourable man, as a rule, and is a
good friend to doctor and poor alike.

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Digitize!

104 Ths Medical Puii.

LEADING ARTICLES.

July 31, 1907.

When a debtor has been found
Judge Mulligan impervious to argument and it is
tad decided to proceed by means of

Paid Agents. the County Court, it is a great
convenience for a medical man to
leave everything in the collector’s hands and not
to have personally to appear in undisputed cases.
Indeed, a common practice is for a collector to
arrange with a debtor as to when and how the
debt shall be paid, and, having got his formal
acknowledgement, to appear in Court and ob¬
tain an order to that effect. Now Judge Mulli¬
gan has decided to sweep away all this practice,
and he is refusing to hear collectors who appear
before him. He speaks of the previous custom as
a “ nefarious practice,” which he will not permit.
Now, if his Honour had given some reason for
his action it might have been possible to under¬
stand why he should regard it, the custom of his
predecessor and his senior colleagues, as nefarious,
but all we can gather from a lengthy report of
some proceedings in his Court is that he regards
it as very wrong for a paid agent, not a solicitor,
to appear for anyone else. As reasonable beings
we cannot think why it should be “ nefarious ”
.to pay an agent not a solicitor to appear in Court,
and not equally nefarious to pay a solicitor. As
a matter of fact it seems to be simply and solely a
question of solicitor’s privilege. A lawyer does
not like irregular practitioners to appear in Court
any more than a doctor likes an irregular prac¬
titioner to practise medicine, and we should cer¬
tainly wish to support the lawyer in such a claim
if it were not for certain points of public policy.

As law-courts and lawyers are
Lawyers made for the public, it stands to
aad reason that if they are not able

Collectors. to do the public work, the public
must make other arrangements.
This is what has happened with regard to petty
debt-collecting. It is in spite of the lawyers,
who did not find it worth their while to organise
the work on a large scale, that creditors have been
able to get in petty debts, and no doubt it is
hardly solicitor’s work to spend days and weeks
getting in half-crowns and five-shilling bills, many
cases involving several visits and letters. In fact,
if Judge Mulligan has his way, small debtors will
enjoy their previous immunity again. In these
circumstances we cannot see why it should be
proposed to forbid collectors of good character
to appear in court in purely formal and uncon¬
tested cases to prove debts. Only a fortnight
ago, in the Clerkenwell County Court, a company
sent one of its employees to conduct a disputed
case on its behalf, and Judge Edge held that he
ought to allow him to give his evidence of the debt
—which is all the debt collector wants—though he
would not allow him to examine and cross-
examine. If Judge Mulligan, who has yet to
earn his experience on the bench, proposes to
be a law unto himself, there will have to be
found means for testing the value of his decision.

Notification of Conaanptlon.

Dr. J. F. J. Sykes, medical officer of health, in a
recent report issued :—“ The experience of St. Pancras
during the time that voluntary notification of con¬
sumption has been in force appears to coincide with
that of nearly all other local authorities which have
adopted the same course. This experience is that
voluntary notification is ideal in theory, but of little
value in practice, because the number of cases notified
is very small, and the notifications often take place
when the patients are moribund.”

LEADING ARTICLES.

THE CAMPAIGN AGAINST QUACK MEDI¬
CINE.

The evil wrought by the yearly increasing sale-
of quack medicines has assumed the dimensions-
of a national scandal. Vast sums of money are
expended annually in advertising nostrums
claiming to cure the incurable and to work
miracles that are clearly outside the range of
human achievement. In other words the claims
of the vendors are false, therefore their business
is a fraud, and the newspapers that accept their
advertisements are participating in the proceeds
of a fraudulent transaction. That is the plain
English of the matter. Worst of all, this traffic
is sanctioned by the State, which draws a paltry
yearly revenue from patent medicine stamps.
This, be it remembered, is the great, omniscient
State that jealously insists upon the thrice-
tested knowledge of its qualified medical practi¬
tioners, but none the less allows its subjects
to be fleeced on all hands by quacks and nostrum-
vendors. This, too, is the paternal State that
wrings its hands in despair at the physical de¬
generacy of our race, at the high infantile
mortality, and the unnecessarily high death
rates of many of our great towns. It would
be interesting to speculate on how much of that
physical degeneracy, and how many of those
wasted lives are due to quacks and quackery..
Some day the State will doubtless wake up and
expel the enemy that is within our gates. Then
we shall probably have the Royal Commission
of Inquiry into quacks and quackery that has
been for some time past demanded in season
and out of season by The Medical Press and
Circular. Happily signs are not wanting that,
the conscience of the nation is being slowly
awakened to this great evil. The matter is
now and then dealt with forcibly by Coroners
who are brought face to face with many of the
disasters directly caused by this nefarious traffic.
The judges of the land occasionally utter a
scathing denunciation when a case of quackery
comes within their jurisdiction. The matter,
again, is discussed freely in medical journals^
and in medical societies in all parts of the world.
But perhaps the most significant movement is
the revolt of the dispensing chemists against
proprietary and secret remedies. Last week
the Federation of Local Pharmaceutical Asso¬
ciations met in Manchester and listened to
a capital paper by Mr. J. Cofman, of London.
For downright plain speaking this gentleman’s
essay would be hard to beat. He divides “ pro¬
prietary ” into three classes, of which one in¬
cludes what may be called the more respectable
articles, the composition of which is no secret,,
but which represent genuine drugs prepared by
special methods, and not sold under false colours.

A second group deals with “ frauds that have
somehow escaped the courts of law, all of secret
composition and claiming to cure every imagin¬
able disease.” “To stock and to sell these quack

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Digit

July 3 i, 1907.

CURRENT TOPICS.

Ths Medical Press. I05

medicines,” says Mr. Cofman, “ is a disgrace for
a respectable person.” The third class is that
of old or well-known drugs or compounds claiming
special virtues under the aegis of some par¬
ticular name. These “ proprietaries ” are spoken
of as "in the highest degree injurious to the
present interest, and to the future interest of
pharmacy.” The author of this vigorous on¬
slaught invokes the co-operation of the Pharma¬
ceutical Society and of the General Medical
Council in the attempt to secure legislation for
the proper control of the traffic in secret remedies.
There can be little doubt that if the chemists
decide to fight this great evil the proprietors of
the baser sort of proprietory remedies will find
their trade seriously threatened, if not, in
many instances, altogether destroyed. As far
as the policy of this journal is concerned we can
only say that we shall welcome the powerful
aid of the pharmaceutical societies in fighting
what we regard as a national scandal. There is
admittedly a material interest concerned in the
case of the chemists, but there is no reason to
assume that their motives are on that account
less straightforward and honourable than those,
let us say, of the medical profession. If the
pharmaceutical chemists resolve to rid their
profession of this unclean thing, they would
earn the esteem of all right thinking men. Should
they form a strong policy and a strong organisa¬
tion they will find abundant opportunity of dis¬
tinguishing themselves in a resolute campaign
that must sooner or later be undertaken.

CURRENT TOPICS.

The British Medical Association and the
General Medical Council.

For many years the British Medical Associa¬
tion has been debating the question of taking
on the functions of a defence society on behalf
of its members, but various obstacles, legal
and otherwise, have stood in the way. Although
there is some doubt as to whether the Association
has so far officially authorised actions apper¬
taining to a defence society, one of its many
committees has assumed authority in the matter,
and proposes to appear as prosecutor in penal
cases before the General Medical Council. The
Council of the Association has declined to ex¬
press any opinion as to the powers of the
committee so acting, and the position at
present is one of much confusion. The only
tangible result is that Professor Saundby and
some other members of the General Medical
Council who were also members of the Associa¬
tion, have cut their connection with the latter.
Whether it be wise or not for the Association
to take on such duties in defence of its members
is a matter for themselves, but obviously if it
is to be done it should be done regularly and
formally, and members should know where they
•tand. It is not for an irresponsible sub-com¬
mittee to decide a great question of policy for
an association of several thousand members.
Moreover, in the present state of the by-laws

of the Association, it is very doubtful if money
can be legally spent in the prosecution of cases
before the General Medical Council. It is to be
hoped that the Representative Meeting this
week will come to some authoritative decision.

Fourth of July Fatalities.

Though the full records of the Fourth of July
fatalities in the States are not yet available, it
is to be feared that the tale of victims will be
nearly as great as in previous years. Year after
year the medical and some lay journals have
preached against the insane antics to which t the
patriotic youth of the country gives itself up on
the national anniversary, but, except in one
particular, their preaching has had little effect.
Toy-pistols, fire-crackers, noise-producers of all
sorts, are as much in vogue as ever. And year
after year the national anniversary claims its
hecatomb of human victims. One of the Chicago
papers, appearing on the morning of the 6th,
was able to report 59 fatal accidents and 3,807
injuries which had occurred during the previous
two days. In Pittsburg alone, 15 violent deaths
occurred during the celebration of the national
festival. The one particular in which for the
past few years there has been progressive im¬
provement is the incidence of tetanus. Only
five or six years ago tetanus was a common sequel
of comparatively trivial wounds received from
toy explosives. The medical journals, by teach¬
ing that all wounds of the sort should be treated
by the open method, have succeeded in reducing
the mortality from this disease to a very low
figure.

The Effects of "Belated Ovaries.”

The complete reversal in the treatment of
certain uterine diseases, which has led operators
to discard principles which lead to the removal of
the ovaries and the retention of the uterus, in
favour of principles which lead to the removal of
the uterus and the retention of the ovaries has
been amply justified by its results. In conse¬
quence, there are now but few gynaecologists, and
their number is rapidly diminishing, who do not
recognise the extreme importance of retaining in
every possible case even of a portion of an ovary.
We publish in to-day’s issue a clinical lecture from
the pen of Mr. J. Bland-Sutton on this important
subject. His views are in entire accordance with
the most recent gynaecological opinions, and his
practical experience is very welcome as a means
of convincing the few who still remain satisfied
with the older teaching.

An Open-Air Schoolroom.

A novel and interesting experiment is being
conducted by the London County Council in the
shape of an open-air school, opened last week at
Plumstead. The scheme is carried out in connec¬
tion with the Woolwich group of special schools.
The children have been selected from certain
schools in Woolwich, Greenwich, and Deptford,
and admission is granted only to those who are
suffering from anaemia or from tuberculous

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CURRENT TOPICS.

July 31. 1907.

to6 Tire Medical Pbes >.

affections. There were no less than 300 applica¬
tions from parents for the 120 vacancies. In
fine weather the children recline in deck chairs in
the open, while a well-built shelter is provided for
use in rainy weather. This new departure is in
touch with the teachings of modern medicine,
and its wider application to healthy children, were
that possible, would be a desirable thing. Clearly
it is far better to cure children in an open-air
school rather than to have to attempt the same
thing in a sanatorium under the less promising
conditions of later life.

The Hygiene of the Swimming Bath. _

Now that public swimming-baths are being
adopted throughout the country, it is well to raise
a note of warning as to their hygienic aspects.
There is no need to insist that water should be
renewed at frequent intervals, and that the bath
should be emptied periodically and cleansed
throughout, for we understand that such measures
are already carried out. Clearly, however, the
frequency of renewal of the water should be regu¬
lated by the number of bathers. Some public baths
are immensely popular on cheap nights in the hot
weather, and are patronised by hundreds of per¬
sons. Under such circumstances it would, be
obviously desirable to provide a rapid and con¬
tinuous stream of water in and out of the bath.
Another point is that bathers should be obliged
to wash their feet, and obviously uncleanly per¬
sons should be thoroughly douched before going
into the bath. Spitting should be punishable by
expulsion, and a fine. In some parts of the Con¬
tinent, such as Frankfort, regulations of the kind
are enforced without any friction. The careful
consideration of municipal authorities may be
devoted with advantage to the hygiene of the bath.
Nor is it less necessary in many instances on the
part of those who are in charge of the cleansing
operations of our poor-law institutions, barracks,
prisons, and reformatories.

Pees for Certificates under Workmen’s
Compensation and Education Acts.

Under the new Workmen’s Compensat on Act,
there must inevitably arise a great many cases in
which medical certificates are necessary either in
the prosecution or the defence of claims. Medical
men, therefore, will do well to insist that an
adequate fee is paid for their signature to every
document of the kind, and it seems not unlikely
that the scale of future remuneration will be to a
great extent determined by their first stand in the
matter. The Council of the Irish Medical Asso¬
ciation has issued broadcast a resolution advising
all medical men to refuse any certificate in con¬
nection with the Workmen’s Compensation Acts
until payment has been guaranteed. The same
body also advises refusal of certificates under the
Education Act, un' il reasonable remuneration be
granted. As regards the latter Act, it is certain
that local authorities get a good deal of gratuitous
service out of the medical profession on various
pretexts. They demand, for instance, certificates
for hospital patients suffering from ringworm,

whooping-cough, and other infectious diseases.
Quite recently a healthy child was brought to an
out-patient department with a request for a cer¬
tificate that he was in a state of good health.
Unless medical men are warned in time they will
quite possibly drift into a similar position as
gratuitous (although, be it noted, indispensable)
advisers under the Compensation Act.

Medical Referees and Workman’s Com¬
pensation.

It will be of much interest to medical men to
see how the new medical arrangements under the
Workman’s Compensation Act, 1906, work in
practice, and whether the medical referee is going
to be the arbiter as to a workman’s destiny that
our reading of the Act and rules make him. No
doubt judges will not like to give up any of the
authority they already possess, and some of them
certainly will not do so without a struggle. A few
days ago a case under the old Act came before
Judge Shand sitting in the St. Helens County
Court, in which the medical referee’s report was not
acted upon through the most extraordinary legal
quibbles it is possible to conceive. The case was
one of a collier who met with an accident to his
knee in the course of employment last December,
and who was receiving ten shillings a week as
compensation from his employers, and six shillings
and sevenpence a week from the Miners’ Per¬
manent Relief Society. In March, the man went
to several doctors, who told him that his leg was
well and that he was fit to return to work, but he
was not satisfied, and was finally sent to the medical
referee for the district, who certified him fit to return
to work. However, later there was some further
trouble, necessitating an operation on the leg,
and the man sued the company for compensation.
It was argued at this case that the medical
referee’s certificate was of no avail because he had
not disclosed to the workman a statement at the
time of examination that he was acting as
referee, and also because the plaintiff went to
him on the advice’of a miner’s agent. After much
argument the judge decided that the referee’s
certificate was not conclusive evidence of the
man’s condition at the time of the accident, on
the latter ground, and entered judgment for the
workman. To the lay mind it seems the height
of fatuity that a medical man’s certificate is not
evidence of a patient’s health because one man
and not another advised the patient to consult
him, and still more that such a certificate should
be capable of being over-ridden by a Court

Leadless Glaze.

The desirability of the introduction of leadless
glaze in the interests of the workpeople engaged
in the pottery manufacture is obvious. From the
humane point of view it is imperative, and hardly
less so from the point of view of the social and
political economist. As an industrial measure to
prevent lead poisoning by eliminating the lead
is simply an ideal step, embodying, as it does, the
golden maxim that prevention is better than cure.
On the other hand, it is only fair to hear what the
manufacturers have to say upon the subject.

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July 31, 1907-

PERSONAL.

The Mkwcal Pum. 107

Recently one of them, writing to a London news¬
paper, stated that the leadless glaze involved a
loss of 25 per cent, of the total output as against
5 per cent loss when lead was used. In reply, it
may be urged that whereas the State has nothing
to do with the cost to manufacturers and con¬
sumers, its plain duty is to protect the lives of the
workpeople. The writer quoted went on to say
that lead might be used safely if only employers,
foremen, and workmen would work together and
carry out rules. Experience shows that that kind
of combination invariably fails in practice. The
writer winds up by remarking that “ there is a
greater remedy." After stating that most male
“ dippers ” have a female attendant working with
them, and that marriage follows in many cases,
he remarks : “ The offspring are pre-eminently

unfitted to follow their parents’ occupation, and
should not be permitted to do so.” The candid
employer has surely given his case away in the
last sentence. To what other cause than lead
could the degenerate offspring be ascribed ?

M otoring and the Opsonic Index.

Thb open-air treatment of consumption stands
out as one of the great therapeutic facts of the last
century; but it may be doubted whether we have
yet learned how to avail ourselves of its benefit to
the fullest extent. At present it might be imagined
that motoring would act as a sort of extension of
that method available, at any rate, in the less ad¬
vanced stages of pulmonary phthisis. Possibly the
advantages thereby gained would be more than
counterbalanced by the dust that is inseparable from
that mode of transit. Medical science has now
turned its searchlight upon the question of the effect
of motoring upon tuberculosis, and has at once
secured a striking and important observation.
Specimens of blood were taken from Mr. S. F.
Edge, both before and after his recent famous drive
of twenty-four hours on a Napier motor. The first
specimen was found to have a tuberculo-opsonic
index of 0.85, while the second, taken directly after
the race, gave 1.17. The fact that the active re¬
sistance of the body towards the tubercle bacillus
was raised after so great a feat of endurance is not
a little striking. The motorists may be pardoned
if they plume themselves somewhat upon this scien¬
tific aspect of their fascinating pursuit. The
remedy of a motor ride is more attractive than that
of cod liver oil, even when presented in the form of
a palatable emulsion.

PERSONAL.

Queen Alexandra, on the 24th instant, opened
the new buildings of the Hostel of St. Luke, which
have been built in Fitzroy Square, London, at a cost
of £24,000 (including the site).

On the 23rd inst. H.R.H. the Prince of Wales
accompanied by the Princess of Wales, opened the
new out-patients’ department at St. Bartholomew’s
Hospital, of which his Foyal Highness is the president.

We are informed that Sir James Beid, Bart., M.D..
G.C.V.O., K.C.B., has been appointed a director
of the Clerical, Medical and General Life Assurance
Society in the place of Sir John Williams, Bart.,
M.D., resigned.

Dr. Graham Steei.l, M.D. Edin., Fellow of the
Royal College of Physicians, London, has been
appointed Professor of Medicine by the Council of
the University of Manchester.

The Nettleship Medal, founded in 1902, to com¬
memorate the work of Edward Nettleship, and to
encourage research in ophthalmology, was presented
at the Annual General Meeting of the Ophthalmolo-
gical Society to Mr. J. Herbert Parsons, for his mono¬
graph on the “ Pathology of the Eye.”

Professor Friedrich Muller has been awarded
the Order of the Bavarian Crown in recognition
of his professional eminence.

Dr. Thomas H. Bryce, has been awarded the
Keith Prize of the Royal Society of Edinburgh for
two papers on the Histology of the Blood of the Larvae
Lepidosiren Paradoxa.

M. Gilbert Ballet has been recommended for
the Professorship of the History of Medicine and
Surgery in the Faculty of Medicine of the University
of Paris.

Deputy-Inspector-General Andrew Maclean,
who is ninety-five years old is father of' Kaid
Sir Harry Maclean who is now in the hands of Raisuli,
the brigand.

Mr. L. A. Dunn, M.S., F.R.C.S., Surgeon to Guy’s
Hospital, has been elected a member of the Court of
Examiners of the Royal College of Surgeons of Eng¬
land.

Mr. A. Pearce Gould, M.S., F.R.C.S., Surgeon
to the Middlesex Hospital, and Mr. W. B. Paterson,
F.R.C.S., Dental Surgeon to St. Bartholomew’s
Hospital, have been re-elected to the Board of Exami¬
ners in Dental Surgery in the same institution.

The estate of the late Sir W. H. Broadbent, Bart.,
Physician-in-Ordinary to the King, who died on July
10th last, aged seventy years, has been valued at
£86,209. _

Dr. D. S. Lazarus Barlow has been appointed
Croonian Lecturer for 1909.

Major C. E. .P. Fowler, Assistant Professor of
Hygiene at the Royal Army Medical College, has been
appointed for special duty at Gibraltar.

Dr. Julius Dreschfield, M.D., of 3 St. Peter’s
Square, Manchester, whose death took pla:e on June
13th, bequeathed everything he might die possessed of
in trust for his children. The value of the property
is sworn at ^71,016 15s. rod. gross, and

^68,914 12s. i id. net.

Dr. P. H. Pye-Smith will deliver the FitzPatrick
lecture of the Royal College of Physicians of London
this year.

Dr. Frederick Taylor has been appointed Harveian
Orator by the same college.

The following gentlemen have been appointed to
the other official lectureships as follows:—

To deliver the Milroy Lectures—Dr. J. W. H.

Eyre.

To deliver the Croonian Lectures—Dr. A. E.

Garrod.

To deliver the Goulstonian Lectures—Dr. H. S.

French.

To deliver the Lumleian Lectures—Sir James

Sawyer.

To deliver the Horace Dobell Lectures—Dr. L. S.

Dudsreon.

To deliver the Oliver-Sharpey Lecture—Professor
.Schafer, F.R.S.

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108 The Medical Pum.

CLINICAL LECTURE.

July 31, 1907.

A Clinical Lecture

ON

THE VALUE AND FATE OF BELATED OVARIES, («)

By J. BLAND-SUTTON, F.R.C.S„

Surgeon to the Middlesex Hospital, and Senior Surgeon to the Chelsea Hospital for Women.

The ovary is essentially an egg-producing organ,
and from this aspect alone it may be described as
a temporary and ductless gland, its period of
activity being coincident with menstrual life, with
an average period of thirty years. The structural
changes in the ovary according to its age support
the view that it should be classed with temporary
secreting glands, for, after the age of forty it
diminishes in size and after the forty-fifth year
the ova and follicles begin to disappear ; at fifty,
when the menopause is usually established, the
ovary may weigh about one-sixth of its weight
at puberty, and consist merely of fibrous tissue
traversed by a few blood vessels with thickened
(sclerosed) walls. Careful observations have shown
that complete removal of both ovaries is followed
by sterility, arrest of menstruation (amenorrhoea),
and in young women, by an alteration in the
general metabolism of the body which is mani¬
fested mainly by the curious vaso-motor pheno¬
menon known to women as “ flushings.” Obser¬
vations on the effects of removing the thyroid have
shown that this gland though ductless, supplies
a secretion which finds its way into the circulating
blood and exercises a great influence on general
metabolism, especially in young and growing
individuals ; this has led many to believe in the
production of an internal secretion by the ovary
but no one has succeeded in isolating such a secie-
tion, and its existence is hypothetical. One
observer (Heape) has suggested the name “ gona-
din ” for this secretion, but it is rather like fixing
the name for a baby before it is born. There is,
however, ample evidence to support the view that
the ovary performs other functions in addition to
ovulation, and that these, like some possessed by
the thyroid and adrenal, are exercised to their
fullest extent in early life, especially during the
growth and development of the sexual organs.
In regard to this matter it will not be out of place
to mention the interesting observations published
by Bullock, Sequeira, Adams, and others, con¬
cerning children who have exhibited precocious
development of the sexual organs in association
with the growth of tumours in the adrenals (supra¬
renal capsules). In some of these boys and
girls, the secondary sexual characters, such as
the growth of coarse hair on lips and chin, in
the axilla, and about the pubes, have occurred
at the age of ten and twelve years. In some of
them the changes have taken place so quickly
that in the course of a few months a boy or a girl
has become transformed into a sturdy little man
or woman, as the case may be.

It has long been known that in adults with
tumours in the adrenals, pigmentation of the
skin, different from that seen in Addison’s disease,
has been accompanied by an abnormal growth of
hair on the skin generally ; in at least one case
the abnormal hairiness disappeared after the re¬

moval of the adrenal tumour. This association of
precocious development of the sexual organs with
some disorders of the adrenal is of interest in con¬
nection with the investigations which Heape made
on the cause of rut in mammals, including mon¬
keys, and which led him to express the opinion
that the ovary is not the seat of the governing
power of the breeding function. This view has
not met with any support, and lately the obser¬
vations of certain German workers, notably
Frankel, tend to invest the ovary with more
extensive functions than'physiologists have hither¬
to assigned to it, for the peculiar yellow body
(corpus luteum) left in the ovary after the rupture
of a ripe follicle, and which becomes such a con¬
spicuous object on the cut surface of the ripe ovary
when pregnancy occurs, is now considered to play
an important part by means of an internal secre¬
tion it is supposed to furnish which assists the
embedding of the oosperm (fertilised ovum) in
the tubal or uterine mucous membrane. This
secretion, Frankel believes, is elaborated by the
lutein cells which are derived from the follicular
epithelium.

The result of modern research tends to exalt the
importance of the ovary and indicates that its
ovigenous function is by no means the only duty
it performs. Precisely what these accessory
functions are, and what the essence is in virtue of
which they are exercised, nothing is known, but
I am able to assert that a very small portion of an
ovary is sufficient for their maintenance. The
most obvious function associated with the ovaries
is menstruation, and although the cause of this
unpleasant phenomenon is obscure we know that
the complete removal of both ovaries completely
arrests it, and the congenital absence of both
ovaries is always accompanied by amenorrheea.
An ovary in a well-developed healthy woman may
weigh upwards of 100 grains ; nevertheless, the
presence of 15 grains of ovarian tissue containing
follicles is sufficient to maintain menstruation
and prevent the occurrence of flushings so charac¬
teristic of the natural, as well as the artificial
menopause.

I will give briefly the details of two observations
which illustrate this matter :—Some years ago, a
single woman, aet. about 30, suffered severely from
painful menstruation, and at her earnest entreaty
her medical attendant performed what he believed
to be a complete bilateral oophorectomy. His
chagrin was great, but the patient’s disappoint¬
ment was greater when she found during con¬
valescence that her menstruation continued as
regular and the pain as bad as before the operation.
Many months later the patient sought my opinion,
and I explained to her the difficulty of complete
ablation of the ovaries and that there could be
little doubt that a portion of at least one ovary
had been left behind. For a long time I refused
to interfere with the case, but at length, at the

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(a) A Clinical Lecture delivered at the Middlesex Hcapital.

July 31.1907.

CLINICAL LECTURE.

The Medical Press. 109

request of some of her friends, I re-opened the i
abdomen two years after the primary operation
and found a portion of the ovary and the corre¬
sponding stump of the Fallopian tube with the
ligature attached to the uterine cornu. That this
piece of ovary was capable of fulfilling its function
was proved by finding in it a recent corpus luteum
a ripe follicle, and, on microscopic examination,
■ova in its tissues. The remnants of the ovary
and tubes were carefully ex-sected from the uterus,
menstruation ceased permanently, and in the
course of convalescence flushings began to annoy
the patient.

This is by no means an isolated case. On
another occasion in which bilateral oophorectomy
had been performed by a gynaecologist for the
relief of dysmenorrhoca, the operation produced
no abatement of menstruation and apparently
aggravated the pain. A year later I operated
upon the patient and found active pieces of ovarian
tissue on each stump, and to ensure complete re¬
moval of the ovarian tissue I removed the uterus.

For many years I have insisted that the com¬
plete ablation of ovarian tissue, except when the
pedicles of the ovaries are elongated by the
dragging of a tumour, is by no means an easy
matter. On the other hand, when the uterus is
occupied by a' fibroid, the ovarian ligament is
sometimes so short that the one or other ovary
appears to be almost sessile on the uterus ; in such
conditions the complete removal of the ovary is
an impossibility. I am able to demonstrate this
by an actual specimen :—

A single woman, when aet. 28, had both ovaries
removed at the Samaritan Hospital, London, lor
the relief of profuse menstruation due to a uterine
fibroid. The operation did not arrest menstrua¬
tion, but made it irregular and it remained pro¬
fuse. Seven years later it completely ceased and
remained in abeyance two years ; then the flow
reappeared and the patient noticed a swelling in
the hypogastrium which increased in size, was
painful, and interfered with micturition. In
April, 1906, I performed hysterectomy, and found
the uterus occupied by an interstitial fibroid which
had undergone red degeneration (aseptic necro¬
biosis). On the right corner of the uterus there
was a piece of ovary the size of a large ripe white
currant. I have always maintained that it was
an excellent effort of reasoning which led Lawson
Tait in 1872 to the deduction that as uterine
fibroids usually cease to grow after the natural
cessation of menstruation, it would be useful to
induce an artificial menopause in women with
troublesome fibroids by removing their ovaries.
He not only conceived the idea, but possessed the
ability necessary to carry out the operation and
convince the whole surgical world of the sound¬
ness and utility of the proceeding. In the quarter
of a century succeeding Tait’s brilliant observa¬
tion, the surgery of the female pelvic oigans had
been brought to a high state of perfection, and
hysterectomy can now be performed with less risk
than bilateral oophorectomy. This induced me to
reverse Tait’s operation by removing the uterus
and leaving the patient at least one ovary. The
reasons were practical enough, because as I have
already mentioned, it is difficult to remove com¬
pletely all the ovarian tissue and leave the uterus ;
the relief is neither prompt nor certain ; con¬
valescence is slow and often tedious, and with all
these inconveniences and uncertainty there was a
great disadvantage to the patient if the ovarian

tissue was completely excised, for she would have
the annoying signs of an artificial menopause.

These opinions were advocated at a meeting
of the London Obstetrical Society in 1897, and led
to much opposition, but they quickly gained
support, and the speaker in the discussion who
treated the idea of the conservation of the ovaries
with derision, within a year became one of its most
ardent advocates. To-day I am justified in stat¬
ing that every surgeon who performs hysterec¬
tomy for the treatment of uterine fibroids always
seriously considers the conservation of at least
one ovary in women aet. under 40 a matter of
prime importance, and some believe in the value
of preserving an ovary even at any age.

It is now admitted by surgeons who have had
much experience of hysterectomy for fibroids that
the immediate results of preserving at least one
ovary in this operation are admirable ; but I have
already pointed out elsewhere that the expected
benefits have been over-estimated, and the pre¬
servation of ovarian tissue is of value within
certain limits. In 1901, Dr. Crewdson Thomas
obtained the after-history of 100 patients who
had been submitted to hysterectomy for fibroids,
and he came to the conclusion that subtotal
hysterectomy does not interfere with the sexual
passion and that the retention of an ovary is of
striking value “ in warding off the severity of an
artificial menopause,” more especially when the
patient is aet. below 40 ; above that age the
ovaries decrease in value every year. This enquiry
interested me very greatly because many of the
patients included in this investigation had been
under my own care, and I was so satisfied with
the deductions that it became with me a working
rule to take unusual pains to preserve at least one
ovary in women aet. under 40, but in patients
above that age I do not hesitate to remove both
ovaries and Fallopian tubes if the removal facili¬
tates the operation, or if these structures do not
appear satisfactory and seem in any way likely to
give subsequent trouble, because it must be borne
in mind that the retention of one or both ovaries
is not free from risk. My practice in this matter
rests on the following basis : When both ovaries
are diseased, I remove them, taking care to dis¬
tinguish between an oedematous and a diseased
ovary. The annoyance caused by flushings is
slight compared with the dangers caused by
suppuration in a Fallopian tube or in an ovary.
I have had an example of each in my own prac¬
tice, and the facts of each case may be briefly given.

In March, 1898, I performed subtotal hysterec¬
tomy on a spinster, set. 50, on account of a very
large interstitial fibroid which caused her to lead
a semi-invalid life. Both ovaries and tubes were
left and for some weeks after the operation the
stump which suppurated gave some trouble and
the right Fallopian tube became a pyosalpynx.
This I removed in November, 1900. The ovary
was large and oedematous, and on microscopic
examination seemed to be made up of inflamma¬
tory tissue. I found no traces of either ova or
follicles. The patient is in excellent health at
this date, July, 1906.

The second case is very instructive. In 1906, I
removed the uterus from a married lady on
account of fibroids which had caused the uterus
to become impacted ; great pains were taken to
preserve both ovaries and tubes. At the time of
the operation they were normal in size and shape.
The patient did not recover from the operation

IIO The Medical Psess.

CLINICAL LECTURE.

July 31.190;.

in the usual satisfactory manner. There was
pelvic pain, particularly on the right side, accom¬
panied by a slowly progressive rise of tempera¬
ture. After six weeks spent in vain temporising,
it became necessary to reopen the abdomen, when
to my great surprise I extracted an ovary the size
of a tennis ball, which had become converted into
a sac filled with blue pus. which proved to be
sterile in the laboratory. The Fallopian tube had
undergone no change. The patient made a tedious
but satisfactory recovery.

It must be borne in mind that belated ovaries
may become the source of tumours, as in the case
of ovaries which have remained in union with a
normal uterus ; of this condition I have only had
one example. I performed vaginal hysterectomy
on a single lady, aet. 36, for carcinoma of the
body of the uterus ; both ovaries and Fallopian
tubes were left. She remained in excellent health
five years, then a tumour the size of a fist formed
in the left half of the pelvis. Coeliotomv was
performed and the left ovary was converted into
a tumour displaying the microscopic characters of
the growth for which hysterectomy had been
performed. It was easily removed. The right
ovary had atrophied and was represented by a
small body the size of a holly berry ; the corre¬
sponding Fallopian tube appeared as a thin cord
attached to it. The patient reported herself in
good health three years later. I am unaware of
any observations relating to cysts or tumours
arising in ovaries which have been left after hyste¬
rectomy for fibroids.

Although I have left one or both ovaries in the.
performance of hysterectomy for fibroids in more
than 300 patients, since I advocated the practice
in 1897 (see Trans. Ohstet. Society, London, for
1897), in only two instances have I found anything
detrimental in the practice. The last case, how¬
ever, has led me to consider carefully whether it
may not be more judicious to leave only one
ovary, and since the beginning of 1906, I have
systematically removed one ovary, and find that
the immediate good consequences of the operation
are in no sense impaired ; and in some of the
patients I have for greater safety removed the
corresponding Fallopian tube.

Those surgeons who have critically studied the
conditions of women after hysterectomy are
unanimous in the opinion that it is a great advan¬
tage to the patient, to say nothing of comfort,
to preserve at least one ovary ; and I think there
is also substantial agreement that whatever good
effects follow the practice of leaving ovaries
divorced from the uterus in the pelvis they are
only temporary, for in the course of a few years
the ovarian tissue disappears, and the patients ex¬
perience the usual symptoms of the menopause
like their healthy sisters. I think it possible that
the rate of atrophy of the secreting tissue of a
belated ovary largely depends on the age at which
the patient is submitted to hysterectomy.

My opportunities of learning the fate of such
ovaries have happened when patients who have
been submitted to hysterectomy have required a
second operation for such troubles as appendicitis,
or gall-stones, then on the performance of these
operations I have taken especial pains to examine
the ovaries. On three occasions on which I
examined the condition of ovaries conserved in
the course of hysterectomy, two three, and five
years after the operation, they had shrunk to
small nodules about the size of cherry stones, but

all these patients had passed their fortieth year
at the time the uterus was removed. In April
1899, I removed the uterus and left ovary from a
single w'oman, set. 29, on account of a growing
fibroid. In February, 1905, she again came under
my care, and w’as operated upon for appendicitis.
The belated right ovary occupied its normal
position at the brim of the pelvis, appearing normal
in size and function, for it contained a ripe corpus
luteum.

Some writers, particularly Doran, refer to the
occurrence of menstruation after subtotal hysterec¬
tomy with conservation of one or both ovaries,
and in the performance of the operation he has
carried out a method ( Abel-Zweifel) by which a
small segment of the menstrual area of the uterus
is left w'hich permits menstruation to be continued
in a subdued form. Doran’s paper, in the Trans.
Ohstet. Society, 1905, Vol. XLVII., p. 363, is worth
perusal, but I cannot express any opinion as to its
value as I have never had the courage to try it.
My aim in performing hysterectomy for fibroids
is to abolish as completely as possible the men¬
strual area of the uterus, and up to the present
my efforts have been successful, and I have no
complaint from any patient that this disagreeable
phenomenon has manifested itself, although I have
been at great pains by my own exertions as well
as by the kind efforts of those who have been
associated with me in my hospital work to keep
in touch with women who have been so unlucky
as to require such a serious operation as the re¬
moval of the uterus.

The experience which I have gathered as the
result of studying the after-effects of hysterec¬
tomy in the treatment of uterine fibroids teaches
me that in the performance of the operation there
are three very important points requiring con¬
sideration in women aet. under 40, apart from the
main inconveniences which render the operation a
necessity, such as haemorrhage, impaction, sepsi 9 ,
interference with pregnancy, obstruction to de¬
livery, &c. These three points relate to (a) the
patient’s comfort in securing freedom from
flushings; (6) if she be married her marital rela¬
tions ; and (c) if single, her nubility. These three
conditions depend mainly on the conservation of a
healthy ovary.

In regard to marital relations, nothing trust¬
worthy is forthcoming, but I believe the retention
of an ovary is an additional factor in promoting
domestic bliss, and many husbands in giving con¬
sent to hysterectomy are particular to insist that
some amount of ovarian tissue shall be conserved
if possible. The question of nubility is an in¬
teresting one. I am able to state that single
women who have had subtotal hysterectomy
performed with conservation of an ovary have
married and lived happily writh their husbands,
and I am of opinion that the preservation of the
vaginal segment of the neck of the uterus is an
important factor, as it leaves the vagina intact,
and though such women are sterile they are cer¬
tainly nubile.

I have endeavoured without overstating the
case to show that a belated ovary is of high value
to a woman aet. under 40, whether she be married
or single. In regard to the fate of such ovaries,
I think in the present state of knowledge it may
be expressed in this w*ay :—In women aet. under
40, a belated ovary remains active and discharges
ova.

An ovary belated after the fortieth year rapidly

Digitized by GoOgle

3 m.*y 31, 1907.

Thi Medical. Pus«. Ill

ORIGINAL PAPERS.

atrophies and menopause symptoms may ensue in
the course of a few months after the operation.
The retention of the ovary minimises the meno¬
pause disturbances, and they are never so acute
and prominent under these conditions as they are
when an acute menopause is induced artificially.

Up to this point the observations which I have
ventured to relate are based mainly on clinical
experience, and it is a matter of interest for me to
find that they have received experimental confir¬
mation of a remarkable kind. Mr. Rond has
published a series of experiments on rabbits per¬
formed for the purpose of clearing up some doubt¬
ful points in uterine and ovarian physiology
[British Medical Journal, 1006, i, p. 121). Among
these experiments some bear directly on the sub¬
ject of this lecture, especially those performed with
the object of investigating the effect of removal of
the whole uterus on ovarian growth and function.
The experimental removal of the whole uterus has
no deterrent effect on ovulation, and it does not
prevent the occurrence of oestrus and ovulation at
periodica] recurring intervals.

Note. — A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture
for next week will be by Ii. H. Woods, M.D., F.R.C.S.I.,
Throat Surgeon to Sir Patrick Dun’s Hospital. Sub¬
ject ; “The Treatment of Suppurative Otitis.”

ORIGINAL PAPERS.

ABSTRACT OF THE

PRESIDENT'S ADDRESS

Delivered July 30th, at Exeter,

AT THE

ANNUAL MEETING OF THE BRITISH
MEDICAL ASSOCIATION.

By HENRY DAVY, M.D., F.R.C.P.

Physician Royal Deron and Exeter Hospital.

SCIENCE IN ITS APPLICATION TO NATIONAL HEALTH.

The most important function of the medical pro¬
fession is the practical application of the science
of their day to the health and life of the individual,
and through him to the community, and our success
and usefulness depends on the truth and the value
of the knowledge which the science of the day has
reached. In earlier times there was very little in
the knowledge of the day of which medical men could
avail themselves usefully to explain or to combat
disease, and the place of true scientific knowledge
was occupied by more or less inaccurate theories
as to the causes and best way of treatment of various
diseases ; such theories, for instance, as those of
Brown and Rasori, which held that all disease was
due to too much or too little stimulation and which
lead to bleeding and the abuse of stimulants, in the
treatment of disease, that may be observed right
down to the time of our last meeting in Exeter. Theories
which, as the late Dr. Moxon once said, “ were then
thought to be the pride of medicine, but which we
now consider as at any rate the curse of the patients
who were hurried into the next world with the lancet
or the brandy bottle on rational principles.”

In considering the changes which have taken place
in medical knowledge and treatment during these
sixtv-five years, we have to remember that the know¬
ledge which we use in the profession of medicine is
of two kinds—empirical and scientific, using these
terms in their highest sense. Each of these systems
is of great importance. Much of the best information
about disease and many of the most useful plans for

its treatment have been handed down to us from
remote ages as the product of experience and obser¬
vation. and are thus truly “ empirical,” and a large
part of the empirical observation of the early Forties
is as good to-day as it was then. The knowledge
which we call scientific—that gained by systematic
experiment and reasoning—is of even more importance
in fact, when founded upon proved truth, it is all-
important, and it is the possession of such accurate
and true knowledge that distinguishes the medicine
of to-day from the medicine of the early Forties.

M uch of this accuracy is due to the perfection of the
microscope and to the development of organic chemis¬
try, which have enabled us to gain a more or less
complete knowledge of the organs of the body and to
understand the chemical changes which are constantly
taking place in them, both in health and in disease ;
while it has in some cases also revealed to us the
actual germs to which many diseases are due, and the
actual toxins which these germs form in the body.
These discoveries have entirely reconstructed our
knowledge of the various organs of the human body
and of their functions, and in the same way they
have revolutionised our theories of diseases, of their
causes and modes of onset, so that, for the first time
in the history of medicine, we are possessed of scientific
facts on which to base both theories and practice.
And what a gain is this for the profession of medicine
in its relation to the public!

We have reached a position with splendid opportu¬
nities for usefulness, and a position which will have
to be much more definitely recognised by the nation
at large if all its advantages are to be fully utilised.
It is a position which also carries with it great respon¬
sibilities, and we must be careful how we use it. Let
us be careful that we teach only what we know to be
the truth, avoiding the “ premature generalisation ”
and “ rational theories ” of the ancients, using both
our empirical and our scientific knowledge when
necessary, but not attempting to force the acceptance
of anything unless it can be demonstrably proved to
be true.

The ancient Greeks showed a true appreciation
of health when they gave divine honours to Aesculapius,
the first physician of the Argonauts, and to his daughter,
Hygeia, the Goddess of Health. It would be well if
in these days people could be made to understand
thoroughly that the cultivation of health is the first
necessity of useful lives, and, if they strove to attain
it, as the first object of their solicitude ; if they re¬
collected that the chief and best asset of a nation is
the number of healthy individuals it contains ; and
if they would also recognise the great principle that
no educational system is good which does not aim at
producing well-developed, healthy bodies as well as
well-trained minds.

Now, in considering all questions of health we have
to consider not only the individual patient, but also
his environment; meaning by this the sum total of
influences which modify and determine the develop¬
ment of his life and character. This question of
“environment” has of late years come very much
to the front with regard to the question of physical
deterioration of the nation as illustrated by the number
of would-be recruits for the army who are found to be
so physically undeveloped that they do not come up
to the requisite standard. It has been carefully and
ably dealt with in the report of the Inter-departmental
Committee of Physical Degeneration of 1904, a report
which ought to be studied by every one who has the
health and welfare of the nation at heart.

Time will not allow me to deal very fully with the
subject, but I would ask your attention to one or
two points, marking them carefully, because they so
fully illustrate the scientific teaching which we
have gained during the last sixty-five years.

History repeats itself ; the first physicians appointed
by the authorities of the ancient Greek towns were
trained gymnasts from more or less celebrated gym¬
nasia, who treated their patients with regulated diet
and regular exercise ; and if the English in the twen¬
tieth century are to keep themselves free from physical

112 The Medical Peess.

ORIGINAL PAPERS.

July 31, 1907.

deterioration, our profession must put themselves
in the van of a similar movement and show how neces¬
sary physical culture and muscular activity are to a
nation of “ muscular degenerates.”

Physical culture is, in my opinion, one of the most
pressing questions of the day, for it is by it alone
that we have a proper remedy for the state of muscular
degeneration which is so prevalent. It ought to be
considered by every educational authority, for by
its use dwellers in city and country alike can have
their muscular systems built up and developed to
a healthy standard. There is no need that any
collection of children who are not diseased should
become a class of muscular degenerates.

For the children of to-day are the men and women
who compose the nation of to-morrow, and if they
are diseased and physically deteriorated, the nation
in the near future will be equally effected. Is it
sufficiently recognised how greatly the future of the
nation is decided during the school life of its children ?
It is while the children are at school that you must
give them the foundations on which the whole of their
future, physical, intellectual, and moral, is to be
reared, and if they are not shown how to develop
their bodies and keep them in health, the only chance
of their learning it has been missed. It is also essential
to see that during their school life they are not ex¬
posed to contamination from disease, and this caD only
be done by placing them under the supervision of a
trained and qualified medical man, as is done in Japan
and in nearly every other country in Europe except
England. As the Committee of Physical Deterioration
emphatically recommends, every school in the country
without exception should be under the supervision
of a properly trained medical officer. It should be
.his duty, with his assistants, to examine every pupil
to see who are healthy and who are diseased, who are
fit for a course of physical culture and who are not,
and generally to look after the health and develop¬
ment of the children. How necessary such medical
supervision must be is proved by the fact that Dr.
Alfred Greenwood, Medical Officer of Health for
Blackburn, in an examination of 388 school children
of that town, found that no less than 54 children were
affected with some form of tuberculosis, and of this
number 34 had tuberculosis of one or both lungs.

I would recommend to the notice of all educational
authorities the example of Rugby School and of the
scheme originated there by Dr. Dukes, one of the best-
recognised authorities on the health of public schools.
There every new boy undergoes a carefully-recorded and
rather full physical examination, and the games and '
exercises that he “ may play ” and “ ought to be made
to play ” are also recorded. But we must go further
than this system of games. I quite agree that every
boy in every school ought to have a course of physical
exercises prescribed for him, adapted to his particular
need, and that he should not be allowed to play any
game unless he has attained a certain level of muscular
development; then we should have a very different
condition of affairs from that just revealed. In a
public school it would be a point of honour to reach
the necessary degree of muscular development to
play games, and in the elementary schools the physical
exercise would itself develop the muscular tone which
is wanted. I would urge on the educational authorities
that they are responsible for the development of the
pupils' bodies as well as their minds, and that it is of
little use to the nation to bring up men with their minds
stored with facts but their bodies left ill-developed
and generally degenerate.

Next to this question of physical culture, and of
equal importance, is the question of the feeding of
the people, and it is one of the problems on which we,
as teachers of the science of our day, ought to have
much to say. “ Food,” says Dr. Eichholz in his
evidence before the Committee, “ is the point about
which turns the whole problem of degeneracy; ”
and no one who reads the Report of the Committee
on Physical Degeneracy can doubt that the ignorance
of people in relation to this matter is truly lamentable.
Now. during the last sixty-five years we have gained

an immense amount of accurate knowledge with
regard to food. We have accurately determined
the elements of food and the kind of work which each
performs in the system ; we know the actual pro¬
cesses by which they are digested, and the part which
the various organs take in each process; we have
determined the metabolisms they undergo and the
excretory products which they form, and how, and by
what channels, these products are eliminated. We
can estimate the amount of each element required to
keep a person in health, and understand the diseased
states which are produced by the consumption of
too much or too little of the various elements. But,
although we have learnt so much about food, I do
not think that we have ever yet succeeded in teaching
this knowledge in a practical and useful way to the
world at large.

We want then, as a profession, to set out clearly,
plainly, and shortly the scientific knowledge we have
gained, as regards food, in a really practical way
that can be understood by the multitude and can be
applied to their everyday life; and until this is done
I do not see how we can deal with the popular ignorance
which prevails on the subject.

It is a sad reflection that we are obliged to appoint
a committee to inquire into the physical deterioration
of our people when we possess enough knowledge to
mairtain a very high standard of health if only this
knowledge was utilised; and I am glad that this
Association is pressing this point on the attention of
the Government, and that the views of the deputation
which it recently sent seem to have been more or
less accepted by the educational authorities.

We shall never be able to deal satisfactorily with
physical degeneracy and the prevention of disease
so long as the majority of the men and women in the
nation remain in absolute ignorance of the very rudi¬
ments of science and hygiene. It is not creditable to
our educational systems that a so-called “ well-
educated ” gentleman, who may one day be called
on to legislate for his country in Parliament, should
be able to go through one of our best public schools,
and take a degree at one of our oldest universities,
without the least knowledge of the composition
of the atmosphere, and without the most elementary
ideas as to food and hygiene ; but so it is, and I
despair of improving the health of this country, and
of preventing a mass of preventable disease, so long
as this anomalous condition of education exists.
For in the prevention of disease we as a profession
can do little or nothing unless we have the support
of public opinion behind us to assist in carrying out
the precautions which science shows to be necessary.
It is, I think, greatly to our credit that we have accom¬
plished as much as we have in diminishing disease
under the present condition of affairs ; that we can
do little or no more until public opinion is aroused
in the matter I will illustrate by asking you to consider
the history of pyaemia, typhoid, and tuberculosis.
These three diseases have been proved to be caused
by the development of certain microparasites which
have all been discovered within the last thirty years.
Pyaemia and typhoid are, as you know, in the category
of diseases which come under the supervision of the
Act which deals with infectious diseases, while tuber¬
culosis is not; so that in the latter case we have no
means of enforcing the precautions which we know
to be necessary.

Now, in the case of pyaemia, the magnificent work
done by Lord Lister has shown the world not only
the cause of this disease, but the actual precautions
by which it may be prevented, the use of these
precautions depending on the surgeon and his assistants
and on no one else. And so well are these precautions
carried out that pyasmia has become almost extinct
within these past ten years throughout the civilised
world, with a saving of life and misery which cannot
be calculated.

Typhoid is also becoming more and more infrequent,
and this is generally credited entirely to the improved
sanitation and better water supply of the country.
But I think these are by no means the chief factors

le

JULY 31 , I907.

ORIGINAL PAPERS.

The Medical Press. 113

in the case, for there are plenty of insanitary houses
still remaining in England and the water supply
is too open to the gravest suspicion.

The decline of typhoid fever is largely due to the
fact that medical men have done much to destroy it.
Its bacilli nowadays are never allowed a chance,
at any rate in this country. In every case of the slight¬
est doubt, days before there is any possibility of
making a certain diagnosis of typhoid, it is the invari¬
able practice to thoroughly disinfect the patient’s
stools; and it is to this constant and systematic
destruction of its bacteria by disinfectants that, I
believe, the diminution of typhoid is chiefly due;
and that if these measures of disinfection are con¬
tinually carried out, this disease will in a few years
be as rare as its kindred disease, pyaemia.

Far different is the history when we come to examine
tuberculosis, the exact nature of which as an in¬
fectious parasitic disease was discovered by Koch
twenty-five years ago.

Consumption is an infectious disease in precisely
the same manner as is typhoid. In the one you
have the bacilli of infection in the sputum, and in
the other in the motions, and unless you disinfect
them both the infection becomes generally distributed.

Now compare the history of tuberculosis with those
of typhoid and pyaemia. I am quite aware that it
has decreased under the influence of improved sanita¬
tion during the past few years, but yet its prevalence
is even now appalling. Approximately, its death-
roll in Great Britain is 60,000 persons a year ; and
Dr. R. W. Philip, of Edinburgh, has shown “ that
the ascertained mortality from consumption may be
safely multiplied by ten in order to represent approxi¬
mately the number of persons living and already
seriously affected at the time, so that Great Britain
at the present moment contains 600,000 poor patients
with a preventable infectious disease, the large majority
of whom are bound slowly to die of an illness which
will linger on for from two to five years.

I think it is time that we spoke out the truth about
this disease with no uncertain voice; for surely
it is time that something was done officially in this
matter, and that the attempt to stay the ravages
of this terrible disease be no longer left to voluntary
associations who must of necessity be unable satisfac¬
torily to deal with a task of such magnitude. Are we
to admit that tuberculosis alone amongst the infectious
diseases is to have no precautions insisted on with
regard to disinfection ? . Are we for ever to allow
consumptives to disseminate their infectious sputum
in the streets of our towns ; or are we to allow them
alone of infectious patients to stay in any hotel or
lodging in England without taking any precautions ?
Nearly every nation in Europe, except England,
has awakened to the need of dealing with this disease
on scientific lines, and it is time that we followed their
example.

I am quite aware of the difficulties which surround
the whole question, and I do not wish to put forward
my own views as to the measures which are practi¬
cable in dealing with the disease. All one-sided state¬
ments only tend to obscure the issues and increase
the difficulties of the situation. Satisfactory legislation
can only be obtained by its careful consideration
from many points of view; but is it not time for the
the Government to make a careful inquiry into the
subject, and that, having obtained the best expert
and other opinion available, and having considered
the precautions which other countries are taking,
they should bring forward legislation to deal with
this disease, which yearly destroys nearly 60,000
of our people and brings misfortune and sorrow into
some 600,000 homes in our country.

In one of his most striking passages Rudyard
Kipling says: “ We are a great people and very

strong, but we build our empire in a very wasteful
way—on the bones of the dead who have died from
disease!” It is for our profession, gentlemen, as the
advisers of the nation on all matters of health, to
show how much of this terrible waste can be prevented ;
and just in proportion as we succeed in doing this,

in that proportion we shall be carrying out the highest
purpose of our profession in maintaining the health
of the individual and in preventing the degeneration
of the nation.

HEADACHES AND THEIR CAUSES.

By Prof. FREDRICH PINELES, M.D.,

Vienna.

[SPECIALLY REPORTED FOR THIS JOURNAL.]

This is a vague subject, but a common complain t
of every-day occurrence, and so complicated in it 3
origin that a lecture devoted to the subject cannot fail
to be useful and instructive. A pain in the abdomen,
chest, or limbs may be located and relieved at once,
but in the head it is more complex and uncertain,
though the history may assist us in many cases to
make a correct diagnosis. Our first suspicion will be
directed toward a pathological change in the brain
substance, its coverings, or communicating tracts, the
latter having their distribution throughout the body
and conveying impulses to the sensitive mass in the
encephelon. The brain being the great centre of
motion, for the whole body, will affect the whole
organism when any morbid change takes place in that
organ, and vice versa, any pathological change in a
distant organ will be reflected on this sensitive centre
and may exhibit changes from the long exposure to
abnormal excessive stimuli. Headache from this
varied origin must be carefully investigated, and every
organ of the body minutely examined. The pain in
the head may only be a symptom of the disease going
on elsewhere, and immediately relieved when the
disease is ameliorated or removed.

Among the principal causes of headaches are hyper-
semia or anaemia of the brain substance; irritation of
the dura mater; and toxines, which adversely in¬
fluence the vaso-motor centres. Here are a few of
the causes whose action we know little of, though
vague theories are frequently proffered for acceptance
and subsequently disproved by facts.

Let us begin with that form of headache associated
with pathological changes in the cranium, including
skin, muscle tendon, and periosteum, included under
the more common terms of rheumatic, cicatricial,
luetic, and nervous parasthesia.

The rheumatic arises in the muscles of the head, and is
specially designated as myalgia capitis, and is further
specialised as temporalis, frontalis, occipitalis, or galea
aponeurotica, according to site. These are usually
aggravated by chewing, moving the jaws or any of the
facial muscles, as well as by pressure on any of the
muscular groups. The pain may be unilateral or
bilateral, but it rarely produces trismus which resembles
tetanus in its appearance.

There is another form of cephalalgia indistinctly
understood by us in Vienna, probably owing to its
rarity, but well defined according to Edinger, of
Frankfort, and Henschen. It commences with severe
pain in the back of the head and down the neck ex¬
tending to the shoulders, the incidence falling heaviest
on females about middle-age and upwards. It is
usually preceded by cold and shivering extending over
a considerable period. The great peculiarity of this
form of cephalalgia is the tubercles, or small nodules,
that form in the cellular tissues on the posterior part
of the head and down the neck ranging in size from
peas to large beans. The nodules form lines across the
posterior part of the head, down the neck, and around
the mastoid, which have led to the name cicatricial,
or band-like headache.

Another peculiar characteristic is the readiness with
which this form of headache yields to massage. To show
how rare this disease is in Vienna, not a single case
has been seen in or out of the hospital during the last
twelve months. At the present time it seems to be
confined to the north of Germany, where it may be
indigenous.

In the maculose, papulose, or later stage of syphilis
periostitis is a frequent cause of headache, and as these
inflammatory centers usually select the forehead and

114 The Medical Pecss.

ORIGINAL PAPERS.

July 31. 1907.

temporal region, they may be mistaken for other dis¬
eases than syphilis. This form of headache forms 28
per cent, of the total met with in Vienna, and should
not be lost sight of in all our diagnoses with this as
the prominent symptom. It is usually recognised by
the patient’s description of a tearing or boring pain,
increased by pressure over the site, and is intermitting
in character, with nocturnal exacerbations, commenc¬
ing about midnight and lasting two hours very severe,
gradually becoming less in the morning. This increase
of pain is probably due to some change in the circula¬
tion. Immediately the periosteal deposit becomes
absorbed, the pain subsides, and the patient is relieved.

The nervous parasthesia is a troublesome form of
cephalalgia, affecting every hair follicle of the head,
giving pain to the touch ; it is usually ushered in by
an itching sensation in the scalp, as if some noxious
insect were present, while stroking the hair gives pain,
though severe pressure gives relief. Closer investiga¬
tion of these cases reveals some other nervous trouble,
of which the headache is but a symptom, of the neurotic,
neurasthenic, and the hysteric type ; but we may also
have the graver affection of haemicrania and other organic
affections of the brain substance. In the neurasthenic,
the pain is complained of as a great pressure in the
head, although it may be localised to the brow, the
temples, or back of the eyes. There are such a variety
of symptoms given that careful judgment is required
to discern the real seat of lesion. Some will describe
the pain as a plank in the forehead, others that a load
of lead is bearing the head backwards ; but most of
them will call it a splitting or wrenching pain. A
continuous localised pain usually gives the greatest
concern as it reduces the strength and incapacitates
the patient for any useful work.

The hysteric headache may last for weeks or months
at a time, depriving the patient of sleep or rest, varying
in intensity, and locating itself to the brow, parietal,
temporal, and occipital regions, resembling in every
particular the neurasthenic headache, but the latter
is more frequent in the forehead, while the hysteric is
usually confined to the parietal region. In the hys¬
terical, the headache has its exacerbations in the
parietal region, which is usually described as the
clavus hystericus, limited to a narrow area and re¬
presented by the patient as a nail driven into the
sagittal line of the head, though others may call it a
boring or stabbing pain, but all localising it to the
sagittal region. Touch or pressure over this area gives
great pain, and the skin is usually very hyperaesthetic.
This clavus is sometimes associated with general
malaise, vomiting and dimness of vision, which
may be mistaken for migraine. Another mistake
that may arise is where the hysteric headache 1
assumes the form of occipital neuralgia, which begins
at the posterior part of the head and extends forward ;
but the hyperaesthesia or sense of touch may differen¬
tiate the two diseases. Again, the occipital headache
may be associated with malaise, vomiting, stiffness
in the neck and feebleness of the legs, which we recog¬
nise as hysteric pseudo-meningitis.

Migraine usually commences in the middle of a
disease. It is more frequently unilateral and circum¬
scribed, selecting the eyebrows, the back of the eyeballs,
radiating to the upper jaw or settling down in the
posterior part of the head and neck. The character
of the pain is varied, having the feeling of being situated
in the bone or located to the interior part of the brain,
and radiating to the cranium, while others describe it
as if tearing the head open. It usually lasts from
twelve to twenty-four hours, but it sometimes extends
over many days. One of its pathognomonic symptoms
is the alternate rise and fall of the attack, the’ succeed¬
ing attack always appearing before the preceding one
has disappeared, which produces the status ha?mi-
cranicus. It is usually hereditary, and attacks the
young and may be assumed to depend upon some
morbid condition of the central system. The diagnosis
and prognosis of this disease is a difficult but important
factor in the treatment, as tumours or other growths
may be the remote cause of the pain. When a cerebral
tumour is present, vomiting without relief and at very

short intervals is usually present. The patient is
apathetic though the sensorium may be normal and
where tabes is present the progressive paralysis soon
declares itself. Another differential diagnostic sign
would be the hereditary family weakness commencing in
young persons as idiopathic migraine, but subsequently
diffusing itself as a general headache and yielding to
syphilitic treatment. When individual symptoms of
epilepsy and haemicrania are present, it will be difficult
to decide the origin. It is usual in these cases to
observe the presence of cramp for deciding on epilepsy,
which may be present in the tongue or some of the
facial muscles.

The most important change in the central system,
when there is a neoplasm is a constant head¬
ache. The great characteristic is the severe pain,
which is intense and constant, causing the patient to
despair of relief. The character of the pain in tumours
of the brain is for the most part diffuse and not
localised, although it is dangerous to lay this down as
a rule as many of the tumours give rise to localised pain
which moves from place to place and cannot properly
be localised. When the pain is confined to the posterior
part of the head and neck, it is possible to locate the
growth to the cerebellum; where it radiates down the
dorsal region to the arms, we may be able to diagnose
the neoplasm to be located in the tentorium.

If the pain be located in the anterior part of the head
the neoplasm may be suspected near that site, but this
is always a very dangerous conclusion, as many of
these tumours radiate widely and are far removed from
the site of pain. For instance, any irritation in the
dura mater may act on some of the branches of the
trigeminus, which might be considered the vehicle of
pain, and thus lead to a false diagnosis of the case.

Another common headache is associated with
meningitis in all its different forms and degrees. In
lepto-meningitis it is an early symptom, and appears
with unerring constancy.

Syphilitic headache is the early stage of basilar
meningitis. It commences with great severity with
nocturnal exacerbations about the same hour every
night, and passes off on the following morning at the
same time as on the previous day. It is diffuse in
character, but locates itself within the cranium. This
form of headache commences early in the disease and
may continue for months or years.

In contrast to syphilitic basilar meningitis comes
the convex meningitis or the meningitis of the upper
vault of the cerebrum. Here the pain is not so con¬
stant as in the basilar form, although it is more cir¬
cumscribed both by pressure and percussion. The
primary syphilitic arteritis is the probable cause of
the pain, which is not so severe or protracted as the
basilar form.

Cerebral abscesses cause the pain to be constant
and well localised in one hemisphere or the other. If
the abscess be due to otitis media, the pain will be
located in the temporal or occipital region.

Besides these more important causes, there yet
remain a few minor sources of headache, all more or
less affecting the brain indirectly, and producing severe
pain. Diseases of the nose and its proximate cavities,
such as chronic rhinitis, adenoid vegetations, hyper¬
trophy of the turbinate bones, septum deviation,
polypi, fibroma, &c. The pains associated with these
are varied and of different intensities, and are described
as boring, stabbing, tearing, and crushing, appearing
over any part of the cranium. The chronic form of
any of these diseases may set up empyaema, with acute
exacerbations, by checking secretions, producing con¬
gestion or preventing the easy flow of secretions along
natural channels. Empyasma may be induced by
over-exerting the corporal and psychical functions as
well as the intemperate use of alcohol and tobacco,
which must be carefully differentiated from the above
for treatment.

Frontal sinus changes may produce intractable
supra-orbital neuralgia, recurring daily at particular
periods, but the character of the headache in these
cases is so different that no clear description can be
given. All are more or less diffuse and ill-defined about

Digitized by GoOgle

July 31. 1907.

ORIGINAL PAPERS.

The Medical Piess. 115

the forehead, and may arise from the maxillary sinus,
ethmoid or sphenoid cells as well as the frontal sinus.
Morbid changes in these centres not infrequently cause
pain in the occipital, parietal, and temporal regions, as
well as in the forehead, and have no fixed character.
Teeth, again, particularly carious teeth, cause pain
in the temporal region, which disappears rapidly on
extraction.

The anaemic headache is well known to every prac¬
titioner. The chlorotic girl, the parturient exhausted
mother, the female suffering from some chronic genital
trouble, or the over-worked student, accountant, and
teacher, are well known examples of sufferers from this
malady.

The toxic headaches form another extensive class.
These are often divided into exogenic and endogenic,
which is not a very scientific arrangement, as all exo¬
gens taken soon become endogens. The former com¬
prehend alcohol, nicotine, mercury, &c., while the
latter are well represented by the toxines of fevers,
infections from abscesses, the abscess of lungs in tuber¬
culosis, constipation, arterio-sclerosis, &c. These have
no particular symptom or site that can distinguish
them from any of the other causes ; the general con¬
dition of the body must be the guide. There is one
of these toxines, uraemia, that deserves special note
in the diagnosis; it can be defined as a piercing,
pressing pain in the forehead though sometimes met
with in the occiput. It may be continuous for days
or recur hourly for some time.

A pathognomonic symptom in uraemia is that
the headache may continue days and weeks accom¬
panied with sickness, and vomiting unconnected with
error of diet, and defying every drug in the pharma¬
copoeia

Headache from disturbance in the alimentary canal
is often complex and difficult of solution from its
close connection with errors in diet, nervous dyspepsia,
or neurasthenia with atony of the digestive tract.
We have already referred to people who suffer from
severe headache, of which constipation alone is the
cause, and when this is relieved the headache dis¬
appears. This is a plausible explanation, as the
accumulation of fasces presses on the surrounding
vessels and diaphragm, disturbing the vascular system
and deranging the reflex action and this finally
affects the cerebral circulation, and in consequence
headache supervenes. There is another source of
headache in the ptomains that are liberated in sul¬
phurous media.

The arterio-sclerotic suffer from severe headache
owing to the disturbance in the circulation as well as
that toxic products are liberated and thrown into the
circulation.

It may seem strange that the genital organs should
produce headache, but gynecologists record cases
where a displaced uterus has kept up headache for
months without relief till the displacement was cor¬
rected, when the headache was instantly cured.

The eyesight is a well-known cause of headache;
even in children this complaint is not unknown, arising
from some refractive anomaly, insufficiency of the
internal muscles, or enfeebled accommodation. A
holiday for such children promptly cures the headache,
which is characteristic in this form.

Cephalsea adolescentium is common to both sexes
about the sixteenth or eighteenth year, it is re¬
lieved at night, but recurs on waking, and locates
itself to the forehead. The youth is dull, weak, and
unable for duty without great effort. This is an
obscure form, and attributed by many authors to the
development of the generative organs; others, to
masturbation or abuse. The lecturer related other
cases coming under his personal notice where the
father had been a “ Potator.” while the mother suffered
from hjemicrania, which suggested to his mind a con¬
stitutional origin for the cephalalgia.

Vasomotor disturbance is another fruitful source of
headache and generally due to a congested state of the
vessels which may arise from a variety of functional
disorders.

A general rule for the diagnosis of headache is to first

examine the nose, ears, eyes, and urine, and, on
nothing being found to explain the cause, the dura¬
tion is the next point to investigate.

If the headache be of recent origin, it may confirm
the suspicion of neurosis, affections of the nose, otitis
media, meningitis, teeth, or unemia. On the other
hand, if the duration be long, covering four or eight
weeks, constipation, lues cerebri, uraemia, arterio¬
sclerosis, periostitis, or tumour may be the cause.

The therapy of this diverse disease cannot be confined
to any particular line, but must be directed towards
removing the cause. In the neurotic the patient should
be supplied on waking with a little milk, chocolate, or
fruit ; never leaving the bed in a fasting condition.
Many of these patients require a little food every two
or three hours, and when engaged in outdoor work
should carry small biscuits or such-like for the occasion.
Against the localised pain in the head, a 10 per cent,
menthol ointment may relieve it if applied twice a day.
Vibratory massage sometimes acts favourably, but
cold douches increase the pain. When the pain in the
head is diffuse, high elevations, rest from work, or the
“ Winter Kur ” will be found most beneficial, especially
in hysterical cases.

In severe migraine cases, the diet should be strictly
vegetarian, and free from every form of alcohol. The
bromides must be given freely, from 2 to 3 grammes, or
30 to 50 grs. a day for six or twelve months, with 5 or
10 mimims of an arsenical solution. In addition to
this, many cases require a gramme of sodium salicylate
or aspirin recently introduced. Some obtain good
results from antipyrin (0.5 to r.o grm), phenacetin
(0.5 grm), migrainin (1.1 grm), pyramidon (0.5 to
0.75 grm), caffein (0.2 to 0.4 grm), &c. ; but the
necessity of the case may require a variety in the
protracted course. The adjuncts are quiet, therma-
phor, warm foot-baths, and, only in very severe cases
is morphia admissible. In the hemicrania permanens,
residence at great altitudes gives most relief.

Headache in children improves with hygienic atten¬
tion. never allowing them to go fasting to school. In
many cases a good breakfast will dispel all headache,but
hot schools or badly ventilated class-rooms, with im¬
perfect, or too strong light, may be the sole cause of
the trouble. The medicine should be bromide of
potassium, arsenic, and bathing the body with water
at summer heat.

It only remains to consider the cicatricial or glan¬
dular headache of which we have little experience in
Vienna. Our nothern colleagues prescribe sudoriftes,
sodium salicylate, or aspirin, thermaphor and massage.

For the adolescent form, arsenic, iron, country air,
with a generous diet of milk or fruit. Those in
whom syphilis is suspected mercury, iodides, &c. In
uramic cases, laxatives, sudorifics, and caffein sub¬
cutaneously are useful.

SUGGESTED IMPROVEMENTS

IN THE

NOTIFICATION OF DISEASES, (a)

By J. C. McWALTER, M.A., M.D., D.P.H., F.F.P. & S.

(GLAS.)

Of the King's Inns, Barrister-at-Law.

Municipalities are concerned with the interests of
mankind in the mass, and not as individuals—with
the series or class and not with the mere units. Ob¬
viously the good of citizens at large is of greater moment
than the ease or the privacy of individuals, and no
private person is entitled to any right or privilege
which materially interferes with the interests of
society.

Therefore the interests of society demand that public
notice be taken of the diseases from which individuals
suffer—not from mere caprice or curiosity, but in order
t hat they may be stamped out—the private individual
c annot be heard to say that his privacy is invaded, or

(a) Paper read at the Congress of the Royal Institute of Poblic
Health held at Douglas, July, 19074

jbyGooqle

O

Il6 The Medical Pbess

July 31, 1907.

ORIGINAL PAPERS.

his rights trampled on. No people were so conser¬
vative of their rights as the ancient Romans, and none
were so little disposed to pander to the prejudices of
others ; but the maxim of their law still prevails that
we may use our advantages only when they do not
injure others.

The law requires the medical practitioner, under
pain of penalty, to apprise the Public Health Authori¬
ties when cases of certain contagious diseases come
under his notice. This is an apparent invasion of
the rights and privacies of his patient, and an apparent
breach of the confidence placed in the physician. But
public opinion has long since sanctioned it, and the
most lo dly person recognises that his convenience must
make obeisance to the public good.

The question which now arises for consideration is
whether the principle of notification of diseases should
not be extended far beyond the few infectious diseases
in respect of which notification prevails. Is it worth
while having the vast machinery of notification only
that we may hear of a few cases of typhoid or scarla¬
tina or diphtheria ? A tendency now prevails among
medical officers of health to look on zymotic diseases
as the only ones which they can be expected to check,
and if they can point to a diminution in the death-rate
from zymotic diseases, to claim that they have fulfilled
their functions.

This is one of those fallacies which are the oppro¬
brium of medicine; one of those half-truths which
have led scientific men into absurdities which persons
of ordinary common sense should except. There
appears to be a painful absence of the logical mind
amongst the faculty which leads them to advocate
measures of which the consequences have not been
calculated or the effects foreseen. Thus we have gone
to expense and brought on odium by our efforts to
have every case of scarlatina notified. We were then
forced to hold that our duty was to prevent the spread
of the contagion, and hence we removed the patient
to a hospital built at great expense. One consequence
of this is that patients who think their children have
scarlatina carefully avoid calling in the doctor, and
another consequence is that when the patients are
brought together in hospital the gravest case infects
the lightest and the mortality and sequelae are far be¬
yond those of cases treated at home; whilst the length
of stay and the resultant expense have been so great
on municipalities compared with the trifling benefits,
that doctors have fallen into great disrepute. Further,
the fact remains that scarlatina has become of so mild
a type that the mortality of untreated cases is but |
slight. Quite different has been our action with
regard to measles and whooping-cough. Many muni¬
cipalities paid at one time for the notification of these
diseases, but the expense became so great, and the im¬
possibility of making hospital provision so obvious
that few authorities made any attempt to treat them.

We have then, an elaborate system of notification of
disease carried out on the theory that contagious
diseases being preventible should be prevented and
that the adequate means of prevention are isolation
and disinfection. We have also the anomalous posi¬
tion that out of the small number of infectious diseases
prevalent in Britain, those which are amongst the
most contagious and the most fatal—whooping-cough
and measles—are, in most cities, not notifiable, and
even when notified no adequate attempt is made to
segregate them. Of the remaining diseases notifiable
as infectious, scarlatina, diphtheria, and enteric are
so liable to be confounded with other diseases that
many practitioners hesitate to diagnose a disease as
scarlatina, typhoid, or diphtheria until it has become
so unmistakable that much danger from contagion has
already occurred. The recent outcry in the press about
the figures so unwisely published by the London
Metropolitan Asylums Board—where it was shown
that some 20 per cent, of cases were inaccurately
diagnosed—has made the public much more critical
about practitioners generally, and much more prone
.to proceed to law if the practitioner does not exhibit
more than human sagacity in foreseeing the develop¬
ment of a disease. It is also to be feared that a recent

decision in the High Court of Ireland—where it was
laid down that the skill and care which the practitioner
should exhibit must extend to the foreseeing of and
the foreguarding against the unexpected results of his
treatment—might induce a judge to hold with a
litigant who contended that the fact of a doctor having
made a mistaken diagnosis of a disease was pnma facie
evidence of negligence which the practitioner must
suffer for unless he can completely misprove.

It becomes, then, under modern conditions, a very
grave matter for the physician to diagnose a case as.
one of notifiable infectious disease. The patient and
his household have a relation to society which is imme¬
diately altered in a very unpleasant fashion by the
diagnosis. If it be a child at school, it must be kept away
for several weeks, the other children in the house must
be kept away, and the school authorities are indignant
at the implied slight on the school. If it be a man or
woman in a factory or large business place they, with
those in the house, will scarcely be permitted to attend
work. A species of interdict is placed over the place,
and everyone’s hand is against the unfortunate doctor
who gave the no-ice. Afterwards the sanitary authority
comes to disinfect—often with little tact—and if it
be a public shop or other place of resort, it may be
ruined by the suspicion of sickness. We have all had
experience of this, and all this disturbance of society
is due to the expression of opinion of a medical man
who himself knows that the evidence on which he bases-
his view is far from being conclusive

Thus a practitioner is put in peril of a lawsuit every
time that he reports a case, and every time that he
neglects to do so he is liable to a fine. The benefit
of the system to the public health is altogether illusory,
because although the spread of an epidemic may be
checked in a few instances, in many more people who
suspect an infectious disease are careful not to call in
a doctor, lest he should report them, and it is practic¬
ally impossible to bring those people under the law,
first, because they are not found out, and, secondly,
because if they were they would probably escape on
the plea that they did not know what the disease was.
I have known dairy keepers to have children with
scarlatina, and, suspecting the disorder, to bring the
child out to a doctor; when he stated the nature of
the disease they simply refused to give their address,
and nursed the child probably at the back of the shop.
To such an extent has this feeling grown that all such
people have now simply a horror of bringing a doctor
to their place, and will do anything to avoid it.

The sanitary authority, I submit, cannot do much
to check the ravages of disease until it is accurately
informed of what diseases exist in its midst. It has
now no means of knowing except in the case of a few
infectious diseases, unless from the Registrar-General’s
returns. But these returns necessarily come too late,
and they deal only with the immediate cause of death.
Each of us may suffer a hundred ailments, possibly
preventible and certainly discomforting, but we shall
augment only one item in the Registrar-General’s
mortality list, and that surely will give an inadequate
account of our clinical history.

I submit that a far more satisfactory mode of noti¬
fication of disease would be if the sanitary authorities
got from each practitioner in the district an account
each week of the diseases which he had treated.
Something like this is done in the Poor-law system,
each person’s ailment is noted and the presence of any
particular disease can be seen at once ; but I do not
know that any special statistical use is made of those
lists of affections. If the practitioners were furnished
with lists containing the usual heading of diseases—
as of fevers, influenza, whooping-cough, dysentery,
syphilis, gonorrhoea, septicaemia, pneumonia, phage-
daena, tuberculous and parasitic diseases, rickets,
anaemia, alcoholism, &c., he could fill up the particulars
in a few minutes; and if a small fee were forthcoming
for punctual attention, the medical officer of health
would have a clinical picture of the state of health in
his district every week, and could at once cope with
the more prevalent diseases.

The suggestion, then, is that the notification system

Google

JPI.V 31, 1007.

ORIGINAL PAPERS.

should be extended to diseases of every class, but that
the individual names be not disclosed except where
already required. Thus much valuable information
about venereal diseases, abortions, alcoholism, and
several other important social factors can be obtained
which practically make no show on the Registrar-
General's returns.

This system prevails already, I understand, in
many important cities. Thus even so far away as
Buenos Ayres a weekly return can be had, in English
or Spanish, of every case of disease treated in the
city, and at a glance one can see that tvpe of ailment
which needs attention most, and is wreaking most
havoc.

It is an established axiom in preventive medicine
that the petty meddling of the private practitioner,
however individually able, can do nothing to lower
a death-rate. This is the task of a sanitary authority
having extensive powers and an able staff. But those
powers and the efforts of the staff are often rendered
futile because they have no adequate means of becom¬
ing aware of the state of public health at any given
moment, their only means of information being a few
notifications of some of the infectious diseases and the
mortality returns. Obviously, either of these, or even
both of them, is inadequate to give such a picture of
the amount of sickness in a locality at any moment
that effective steps can be taken to check it. The
mortality statistics of the Registrar-General are pre¬
pared at enormous expense, and the notification of
infectious diseases also causes great expenditure, but
we consider the money well spent if it enables us to
grapple the better with disease. A necessary comple¬
ment of these returns is that we should have a means
of knowing, week by week, what diseases were preva¬
lent, whether infectious, or fatal or not. These
would be, on a general scale like the hospital statistics
which have 1 proved of such service ; but hospital
statistics are vitiated by the fallacy of being true only
of a picked class and under special circumstances.

It must be insisted on that the disclosure of the class
and kind of disease which a physician is treating in¬
volves no breach of confidence ; there is no need to
give the names of the parties suffering ; it suffices to
have something like an accurate account of the number
of cases of a disease in order to show its prevalence.
It will also probably have a healthful effect on certain
practitioners that they would be forced to make a
definite diagnosis ; we are all prone to a non-committal
attitude as to diagnosis, which induces slovenliness of
treatment, and, therefore, needs correction.

In brief, the improvement in the notification of
diseases which I have to suggest is, that all diseases be
notified to the sanitary authorities at regular intervals,
and that a small fee be paid to the practitioner for his
trouble. Thus the sanitary authorities become at
once cognizant of all the forms of disease which exist
in their locality, and can take steps to check their
progress.

ANTI - PUTRESCENT MEDICATION
BY SPECIALLY-SELECTED LACTIC
ORGANISMS,

WITH REMARKS ON

MUCO-MEMBRANOUS ENTERO¬
COLITIS.

By M. DUTOUR, M.D.,

Of the Faculty of Medicine of Paris.

[Specially Translated for this Journal.]

The biological researches of Professor Metchnikoff
and his followers have not only served the purpose
of calling attention to the dangers of intestinal putre¬
faction, but they have indicated the lines on which
they may be fought.

The remedy is not to be found in mineral chemical
agents but in the domain of bacteriology. We must
destroy the putrefactive agents by other varieties
of micro-organism, carefully chosen so as to obtain
them in a state of absolute purity, taking care also

The Medical Press. 117

to prefer varieties which produce large quantities of
lactic acid so that 1 he latter, being produced in a
nascent condition within the organism, may bring
about antisepsis and effect a salutary change in the
humours.

According to Metchnikoff and his school we must
combat the deleterious microbes of putrefaction by
the aid of judiciously-selected lactic microbes. The
latter, however, must fulfil certain conditions so that
in practice we may not be exposed to the drawbacks
inherent to kephyr and yaourt as these not infre¬
quently comprise organisms injurious to the human
economy which determine abnormal alcoholic fer-
| mentations.

Researches carried out on these lines at the Paris
Inslitut Pasteur, in which the Bulgarian bacillus
which is a powerful producer of lactic acid, was asso¬
ciated with certain selected paralactic microbes,
resulted in a combination that exerts a most remarkable
anti-putrescent action, and which is perfectly harm¬
less, viz., lacto-bacilline, now commonly employed
in contemporary therapeutices.

This remedy must therefore be taken to represent
the outcome of a long series of investigations under¬
taken by Professor Metchnikoff’s pupils, and we
must emphasize the fact that it represents especially
“ the superior action of the Bulgarian bacillus without,
the least trace of abnormal fermentations ” (see
Etudes sur La Nature Humaine. Paris, 1906; Essais
Optimistes, Paris, 1907).

It is necessary on the present occasion to recall
the physiological investigations on lacto-bacilline.
Bertrand and Weisweiller demonstrated the fact
that, alone among the lactic ferments, the Bulgarian
bacillus elaborated from 25 to 30 grammes of lactic
acid, transforming into this substance the whole of
the milk sugar. M. Belonowsky, quoted by Metchni¬
koff, showed that mice which were subjected to the
action of this bacillus thrived better and were more
prolific than the others and that at the same time
all fcetor disappeared from their dejections.

We will not insist on the protective influence which
the authors of this treatment attribute to it as pre¬
disposing to longevity. Following Metchnikoff, who
dwelt particularly on the absolutely hygienic part
played by lactic ferments, Maurice de Fleury in his
turn dre%v attention to the prophylactic, i.e., curative,
action of these organisms (see Annales of the Institut
Pasteur, No. 12, 1906 ; Essais Optimistes, pp. 221,
222 ; Quelques Conseils pour Devenir Vieux. Paris,
1907).

On the present occasion we are more particularly
interested in the clinical effects that may reasonably
be anticipated from this substance, and our object
is to bring to the notice of practitioners the results
that we have obtained in the treatment of seven
cases of muco-membranous entero-colitis.

To begin with we must be careful to enjoin the
consumption of a sufficient quantity of sugar when¬
ever we propose to employ the ferment treatment.
Sugar, in fact, constitutes the indispensable food
of these protective microbes, and it is from sugar
that they elaborate the lactic acid. A suitable dietary
must also be imposed, indeed, the patient must become
vegetarian or semi-vegetarian for, in spite of Cohendy’s
statement that the anti-putrescent action of lacto-
bacilline is manifested independently of all dietetic
restrictions, if we wish to obtain immediate results
we must avoid introducing into the intestine
alimentary substances which are peculiarly prone
to decomposition (Comptes Rendus de la Soci6t6 de
Biologie, No. 13, 1906).

Of the four therapeutical forms in which lacto-
bacilline is presented—curdled milk, peptonised
bouillon, a powder, and tablets ; the last two were
principally employed by us in the following doses :
half a tube of powder in the twenty-four hours, in
two parts, given at the end of the two principal meals ;
three or four ;ocg. tablets daily, as above, associated
in both instances with the ingestion of some sugai
containing food.

The results of this treatment were produced in !•

Google

Il8 The Medical Pun.

CLINICAL RECORDS.

July 31,1907-

very short time. Beginning with diminution of the
diarrhcea and the pain, the foetor of the stools was
diminished in a marked degree. In some instances,
however, there is an initial phase of constipation,
but this never lasts long and need not be taken into
account.

As a rule, in the course of a fortnight, the glairi-
ness disappeared, and although the elimination of
false membranes persisted somewhat longer they
were rarely present after a month’s treatment, where¬
upon all the symptoms of entero-colitis subsided.

In two instances there were acute exacerbations
accompanied by a good deal of pain. On palpation
the colon could be felt to be spasmodically contracted
and the diarrhcea was obstinate and extremely foetid.
In these cases we had recourse to the peptonised
bouillon, two wineglassfuls daily, the patient being
placed on a rigid diet wilh daily irrigation of the
bowel. In both cases the acute attack subsided
within a week.

It is obvious that the peptonised lacto-bacilline
bouillon exerts very rapid effects, and is better adapted
for the treatment of acute cases than the tablets,
but in chronic affections the tablets are preferable
and, moreover, they are easier to make use of.

In our opinion the complete cure of old-standing
cases of entero-colitis, which took place in about six
weeks on an average, can only be explained by a
salutary modification of the microbial contents of the
intestine. It is, however, possible that some share
in the effects must be credited to the hyper-secretory
influence on the liver which most authors ascribe
to laeto-bacilline. However this may be, many
observers have noted this curative action, among
others, Combe, of Lausanne, Brochet, Jeanselme,
Rodenthal, Nigoul, Gottschalk. etc., who have all
published cases in which favourable effects were noted.

All the other manifestations of intestinal decom¬
position appeared to be improved by this lactic ferment.
We have given it in the treatment of infantile diarrhoea,
constipation and ordinary colitis, as well as in the
tuberculous form when the patients were anaemic.
"Such patients do better on curdled milk, which possesses
remarkable nutritive properties, in virtue of the
solubility of its caseine and phosphates.

To sum up, in combating intestinal putrefaction
and especially in the treatment of chronic enteritis
nothing has appeared to us to give as good results
as lacto-bacilline. In any event our personal experience
enables us to stats that in the last-named affection
lacto-bacilline appeared to act more energetically than
any treatment previously employed. As to the
influence of the Bulgarian bacillus with paralactic
bacilli in the prophylaxis of senility and arterio¬
sclerosis we are not at present in a position to make
any statement, but we do affirm without hesitation
its clearly curative action in euceric f roubles and its
absolute innocuousness.

CLINICAL RECORDS.

MALIGNANT DISEASE OF OVARIES AND
VERMIFORM APPENDIX OCCURRING IN
A PATIENT. AGED 69. (a)

By J. H. Swanton, M.D., M.Ch.

PbjrilcUn for DIsomm of Women, Kensington General Hospital, ete.

The patient, A. J., from whom these tumours were
removed, was a married woman, ast. 69, who was en¬
gaged in domestic work. She came to hospital in
January, 1907, complaining of dysuria and a slight
red vaginal discharge. The only previous illness was
influenza, of which she had several attacks.

Her menstrual history presented no unusual devia¬
tion, and the menopause occurred more than fifteen
years ago without any complication. Although she
had been pregnant nine times, only three children were
living; there had been two premature births, one
stillbirth, and several miscarriages before the birth of

(«) Read before (he British Gynaecological Society, July lith, 1907.

the last child. The youngest living was aet. 30, and
the eldest 35.

Her present illness began in July, 1906, with a scanty
blood-stained vaginal discharge. In November, 1906,
there was incontinence of urine and a consciousness of
failing strength, but there was no pain.

The patient was well-nourished for her time of life.
The mammae were atrophied. The abdominal wall
was distended and resonant, but the veins in the lower
portion were distended. On deep palpation a tumour
was felt low down in the true pelvis, situated centrally
and fixed.

The vulvar outlet was relaxed and the vagina
atrophic. The uterus was enlarged and directed for¬
wards, but moved with the mass situated posteriorly.

The utero-rectal pouch was occupied by an irregular
mass firmly fixed in the pelvis, and extending towards
the lateral walls. On rectal examination the tumour
was found to extend laterally, but the upper limit could
not be reached.

The diagnosis was that of a uterine fibroid under¬
going malignant degeneration.

The radial arteries were thickened, the pulse in¬
frequent and intermittent. A basic systolic bruit was
heard over the praecordial region. Early in March, 1907,
she had an attack of bronchitis. When seen again, the
i growth was found to have increased towards the left
I side and was obvious on inspection of her abdomen.

| Her stools were frequent, liquid, and defecation was
painful. There was oedema of her left foot. At the
end of March, 1907, she was admitted into hospital,
when the greatest abdominal circumference was
82 ins., the distance from the right anterior spine of
the ilium to umbilicus was 6 ins., and the corresponding
measurement on the left side was 6J ins. ; from upper
margin of symphysis pubis to umbilicus, 6 ins. The
upper limit of the growth was 4 ins. above the sym¬
physis.

The upper part of the growth was irregular and some
limited fluctuation was felt on the left side. There
was some free fluid in the abdomen and palpation caused
pain. On vaginal examination the growth was found
almost on the pelvic floor ; the external os was behind
the symphysis and a blood-clot was found extruding.
Early in April, 1907, I performed abdominal ccelio-
tomy by a median vertical incision, when about one
pint of ascitic fluid came away ; the great omentum
was adherent to the tumour occupying the pelvis.

After separating the adherent omentum, two tumours
partly cystic and partly solid, were found filling the
pelvis, firmly adherent to the surrounding structures,
but more so on the left than the right side. The
1 uterus was 4 ins. in length, hyperaemic, and slightly
attached to the tumour on the left side by a whitish
I band, which was easily broken down. The adnexa
I could not be identified on either side.

The tumours were in contact in the cavity of the
| pelvis, and each consisted of a solid and cystic portion,
j After separating all adhesions, the tumours were lifted
; out. the pedicles ligatured and removed. On making
! an examination of the vermiform appendix, the meso-
appendix was puckered in one part and the consistence
of the adjacent wall increased so as to necessitate
removal.

There was little haemorrhage throughout the opera¬
tion. The abdominal wall was closed by a continuous
cat-gut suture for the peritoneum, and interrupted
silkworm gut sutures for the muscles, fasciae, and
skin. The temperature rose on one occasion to 104°,
but fell to 99 0 within twenty-four hours. After the
fifth day, the stools became frequent and loose for
three days, and then were passed once daily after¬
wards.

The tumour on the left side was 6| ins. in length and
2| ins. in width. The surface was irregular, of dusky
hue, and covered with tags of tissue. On section,
numerous cysts were found in the periphery containing
a limpid reddish fluid. The central portion was
mottled, white and red, with processes radiating out
towards the cystic portion. The tumour on the
nght was 4J ins. by 4J ins., and presented a more
irregular surface, while the cysts were larger and

oogle

JPLY 31. 1007.

OPERATING THEATRES.

Thx Medical Puss. 119

situated inferiorly. The internal structure was similar
to that on the left side. The vermiform appendix was
situated mesially to the cscum, directed obliquely
upwards to the left, and 3 ins. in length.

On microscopical section, after staining with hema¬
toxylin and eosin, the growth was seen to consist of
oval spaces lined with several layers of columnar cells
passing through the basement membrane in some
places, and encroaching upon the lumen. These cells
were in different stages of degeneration. In some of
the spaces a colloid material was found occupying the
central portion, and in these the layers of lining cells
were not so numerous. The interstitial tissue con¬
sisted of connective tissue undergoing hyaline degenera¬
tion, with many polymorphonuclear cells scattered
throughout it.

A transverse section of the appendix showed the
same variety of growth invading the muscular layer
and passing in towards the submucous. This growth
in the appendix probably arose by implantation rather
than by metastasis from the original. The genesis of
this growth would appear to have been from a previous
cystic condition of the ovaries, which became the seat
of malignant degeneration after the menopause. The
patient was discharged on the twenty-fourth day after
admission, and the last report was that she had resumed
her domestic duties and had developed a ravenous
appetite. There is, however, little prospect of ulti¬
mate recovery, as this type of growth is particularly
malignant.

THE OUT-PATIENTS’ ROOM.

GREAT NORTHERN CENTRAL HOSPITAL.

Congenital Elevation of the Scapula (Sprengel's
Deformity).

By Arthur Edmunds, B.Sc.Lond., M.S., F.R.C.S -

Among the out-patients was a woman, aet. about 50’
who came complaining that she had swallowed a
threepenny-bit. There were no obstructive symptoms,
and there was no evidence of any impaction of a coin
in the oesophagus. The patient was obviously ex¬
tremely hysterical—indeed, almost melancholic; but in
the course of the examination it was discovered that
she was suffering from the deformity of the scapula
first described by Sprengel, and named by him Con¬
genital Elevation of the Shoulder.

The condition had never inconvenienced the patient
in the slightest degree, but on examination it was seep
that the right shoulder was considerably higher than
the left. The upper border of the scapula could be
felt from the front apparently as a projection forward

of this part of the bone. Extending from the upper
part of the scapula to the occipital region was a thick
mass of muscle composed mainly of the upper fibres
of the trapezius. This mass of muscular tissue was
not only thicker but denser than normal, as if a con¬
siderable portion of the muscular fibre had been con¬

verted into fibrous tissue. Below the scapula the
muscles of the back were not very markedly affected,
and the inferior angle of the scapula did not project
much beyond the one on the opposite side. Move¬
ments at the shoulder-joint were quite normal, but
the movements of the scapula upon the trunk were
distinctly limited, the patient being unable to raise
the arm above the right angle, and it was easy to make
out that further progress was prevented by the superior
angle of the scapula impinging upon the cervical spine.
This point was confirmed by a skiagram. Mr. Edmunds
remarked that this condition was comparatively rare
and that although many cases had been described in
children, very few had been described in adults, and
the present case was valuable and interesting as show¬
ing the ultimate condition of this deformity. The
causation of the deformity has not been definitely
settled, but it is extremely significant that a large
number of the cases have been born with a posterior
displacement of the arm. As many of these intra¬
uterine displacements are present comparatively early
and are maintained by a deficiency in the liquor amnii,
it is very probable that they play an important part
in the production of deformities. Another explana¬
tion is that the muscles connected with the lower
portions of the scapula, namely, the rhomboids and
the inferior fibres of the trapezius, are atrophied,
allowing the upper muscular fibres to pull the scapula
upwards. The fact, however, that some of these cases
show a scapula which resembles in shape the type of
bone found in the ungulata (sheep and oxen) in which
the long axis of the bone is parallel to the spinous
process, the supra-and infra-spinous fossa; being almost
equal in size, suggests that some developmental error
is also present.

These animals also possess a large supra-scapula and
in some cases of Sprengel’s deformity a well-developed
bone is found extending from the superior angle of the
scapula to the spine, possibly representing a supra-
scapula. In the present case there was no bone of this
description present, and the scapula was normal as
regards shape and size. The hooked condition of the
upper border of the scapula which could be felt above
the first rib was due merely to the position of the
scapula, which, as it is drawn upwards, rides forwards
over the curve of the upper end of the thorax.

Treatment in these cases is not very satisfactory; any
attempt to divide the muscles and bring the scapula
into line with the opposite side should not be at¬
tempted, the muscles being usually so contracted and
sclerosed that an extensive operation would be neces¬
sary. Even if this could be satisfactorily accom¬
plished the weakness of the opposing muscles would
lead to a recurrence of the deformity. If a supra¬
scapular bone be present it should be removed and
some cases have been benefited by removal of the
upper angles of the scapula, allowing the arm to be
raised above the right angle.

OPERATING THEATRES.

WESTMINSTER HOSPITAL.

Nerve Transplantation for Paralytic Talipes
Calcaneus.—Mr. A. H. Tubby operated on a case
of talipes calcaneus due to infantile paralysis. The
patient was a child, aet. 5 years, who had attacks of
infantile paralysis in infancy affecting the right
leg. A large measure of recovery had taken place
but there was considerable loss of power in the gastroc¬
nemius and soleus. On examining the movement
of the foot it was found that the child was unable
to plantar-flex or point the foot fully. The ankle
could not be extended beyond a right angle. By
electrical test it was noted that the muscles reacted
to faradism, but reaction to galvanism was feeble,
thus showing the degeneration of a considerable portion
of the fibres of the large calf muscles. The child
had been in the hospital for seven weeks, during which

Diaitized bv

y CjOO^I

e

time massage and electrical treatment had been
assiduously carried out, but no improvement had taken
place. Photographs we e shown indicating the range
of movements at the ankle. Mr. Tubby pointed out
that the nervous supply to the gastrocnemius and the
soleus is by two branches of the internal popliteal,
one nerve passes to the outer head of the gastroc¬
nemius and the other nerve to the inner head of the
same muscle and supplies also the soleus. These
branches have a fairly long course and can be separated
for some distance up the main trunk without inter¬
fering with the remainder of the nerve fibres in it.
The child having been duly prepared and every
precaution taken, inasmuch as one of the main features
of success in these operations is to obtain primary
union, a vertical incision three inches long was
made in the middle of the popliteal space, and the
internal and external popliteal nerve trunks were
defined. By a little careful dissection the nerves
passing to the gastrocnemius and soleus were found
and isolated; sterilisable electrodes were then used
for stimulating these nerves and their identity con¬
firmed. Finding that contraction of the affected
muscles followed stimulation the next steps of the
operation were proceeded with. The length of nerves
required to bridge the distance between the internal
and external popliteal nerves was estimated, and just
below the points of intended division a strand of the
finest sterilised gut was passed through the rerves
These were then divided from their origin at the
internal popliteal. The next step was to prepare
the external popliteal for the reception of the nerves
to be transferred. In doing these operations Mr.
Tubby said the best instruments were fine tenotomy
knives and forceps, such as are used in ophthalmic
surgery. Care must be taken not to nip the nerve
trunks with forceps under any circumstances. A
small vertical incision was made with a tenotomy
knife through the epineurium of the external popliteal
nerve in two places until white matter began to
exude. The nerves to be transplanted were then
brought across to these incisions and their proximal
ends inserted and secured by the strand of gut pre¬
viously passed through the nerves. The greatest
care was taken to see that the tips of the transferred
nerves were actually imbedded in the external popli¬
teal trunk. The external wound was then closed
and the limb put on a splint. Mr. Tubby remarked
that previous experience of two similar cases operated
on by him, and shown at the Clinical Society last
session, had proved that this operation was a satisfac¬
tory one and was justifiably undertaken when ordinary
measures, such as massage and electricity, had failed.
In one of the cases a partial recovery of power in the
gastrocnemius and soleus had taken place, and in the
other case the recovery was nearly complete. In
the first instance no signs of restored power were
seen till seven months had elapsed, but in the other
case return of power was noticed earlier, in fact,
four months after the operation.

At Edinburgh University last week, the honorary
degree of LL.D. was given, in his absence, to Dr.
William Bayard. Sir Ludovic Grant said Dr. Bayard
graduated at Edinburgh in 1837, and next month he
would attain the age of 90. Dr. Bayard was in St.
John’s, New Brunswick, in vigorous health, actively
prosecuting the duties of his profession He was the
patriarch of the whole tribe of Edinburgh graduates
throughout the world.

CORRESPONDENCE

PROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Paris. July 28 th, 1907,

Sued for Malpraxis.

An interesting case between doctor and patient
has just been decided in favour of our confrere in the
Paris Courts. A young lady was treated for appen¬
dicitis in the usual way ; the icebag over the seat
of the inflammation and opium by the mouth. Her
attending physician omitted to place a layer of flannel
between the ice and the skin and the consequence was
congelation of the) skin (the ice was kept on for
twenty-five days I) with subsequent sloughing. She
recovered from the aopendicitis, but remained three
months under treatment for the large superficial
sore.

Two thousand pounds damages were claimed, but
the Court gave judgment for the defendant. From
the testimony voluntarily given by some of the highest
medical authorities in favour of their confrere, the
judges concluded that the doctor was not guilty of
negligence, that the malady the patient suffered
from was extremely dangerous and required heroic
treatment.

All the same, were it not for the good backing he
received, our friend would not have got off so well,
In any case it is elementary prudence to place
the ice-bag over (me or two folds of flannel, and this
he will not fail to do another time.

Moved with pity at the thought of suffering humanity
constantly falling into the hands of those ogres,
otherwise denominated medical men, a rich man in
Paris wrote letters to the Charity Commissioners
offering the sum of ope million francs with
a view of organising a system for controlling the acts
and gests of the hospital staffs, imposing the condition
that no medical man should be on the committee
of this extraordinary organisation, which otherwise
was to be composed of competent men of science !

The strange proposition on the part of a seeker
of notoriety was treated with the merit it deserved,
and the Charity Commissioners seized the opportu¬
nity for pronouncing their sympathy with the physicians
and surgeons of the Paris hospitals and expressing their
esteem and confidence in the staff whose devotion
aDd scientific knowledge were never found at fault.

Early Diagnosis of Typhoid Fever.

Prof. Chantemesse, who discovered the serum of
typhoid fever, made an interesting communication
this week before the AcadSmie de Medecine on a
method for the early diagnosis of typhoid fever.
He succeeded in producing a toxin which, when an
infinitesimal dose is dropped into the eye, produces
an inflammatory reaction of more or less intensity.
Where the fever is not of a typhoid nature the reaction
is very slight, lasting only two or three hours. The
conjunctiva becomes red and the eye smarts a little.
If the case is really one of typhoid fever the inflamma¬
tion is almost intense, accompanied with more or less
pain and epiphora. After two or three days, however,
the eye returns to its normal condition without leaving
any trace of the disturbance.

An Ostrich Stomach.

A few days ago, Jake, whose speciality consisted
in swallowing everything that was brought to him,
was brought to the Necker hospital with all the signs
of perforation of the stomach.

Laparotomy was at once performed, and the fol¬
lowing articles were removed : a boot hook, two steel
chains, a handful of nails, needles and pins without
number. The man succumbed.

Such cases are not rare among a certain class who
exhibit themselves in low class music halls or od
the fair green.

Some time ago a young girl who exercised the
profession of swallower of pins, was presented to the
Medical Society. For three years she went from cate

120 The Medical Pkess.

CORRESPONDENCE.

July 31. 1907.

Digitized by GoOgle

JOLY 31, I9Q7-

CORRESPONDENCE.

The Medical Peess. 121

to cafe and before the public who likes this kind of
spectacle, swallowed pins, broken glass and, above all,
nails. Her health did not seem to sutler much and
beyond a few colics attributable to a pin or nail
badly placed, she enjoyed good health; the incon¬
gruous objects were expelled naturally.

In many cases these foreign bodies have remained
weeks and months m the stomach without causing
inconvenience.

It will be remembered that in 1866 a Japanese
surgeon removed a tooth-brush from the stomach of
a man which he had swallowed fourteen years pre¬
viously.

Procreation of Sexes at Will.

M. Hurry, of Geneva, pretends that if concep¬
tion takes place four or five days before the appear¬
ance of the menses, the child will be a girl. If it
takes place five or six days after the menses, the child
will be a boy.

An agriculturist presented his cows to the male
two or three days after the rut to have a male and
the first day of the rut to have a female. His in¬
tentions were realised twenty-nine times out of twenty-
nine experiments.

Dr. Guiard reports thirty-five cases in which the
law of Hurry was verified thirty-one times.

GERMANY.

Berlin. July s8tb, 1907 .

At the Medizinische Gesellschaft, Hr. Ewald showed
a patient who had suffered from

Recurrent Hemorrhages
from ulcer of the stomach, in which all the remedies
tried, including escarine, had failed. In consequence
of this, gastro-enterostomy was performed, with the
result that no more bleedings took place.

Hr. Placzek communicated a note on
Circumscribed Adhesive Cerebral Arachnitis.

In the case of a young lady, aet. 25, the speaker had
diagnosed a tumour in the right posterior cerebral
fossa. The symptoms on which the diagnosis was
based were the following: Vomiting, headache, giddi¬
ness, altered gait, inclination to fall to the right,
almost complete paralysis of all the external ocular
muscles of both sides, with implication of the frontal
branches, and complete paralysis of the right side of
the face. An operation performed by Krause showed
a meningeal cyst of the under surface of the right
cerebellar hemisphere, out of which an enormous
quantity of liquor escaped. All the paralytic symptoms
at once subsided, and the general condition became
good. Then, on the tenth day after the operation,
the temperature went up with sharp rises to z,o° C.
and more, then a rapid fall, followed by several days
with a normal temperature. This condition lasted for
several months and was occasionally accompanied by
rigors and vomiting. In sharp contrast to this the
general condition was excellent. As healiDg took
place normally, and as every imaginable cause for the
hyper-pyrexia could be excluded, there only remained
the assumption that pressure on the medulla at the
operation was the cause. The importance of the case
lay in the clear determination of the fact that circum¬
scribed collections of fluid in the soft cerebral mem¬
branes might set up symptoms similar to those of the
tumour group.

Hr. F. Krause, who had performed the operation in
the case, showed a series of projection pictures illus¬
trating the method of procedure he now followed in
cases of tumour of the posterior cerebral fossa. The
skin and bone flap were naturally different, according
to which side was being exposed. In that case there
was supposed to be a tumour in the right posterior
fossa. After opening up the dura it was seen that it
did not project, and that it pulsated ; it was thickened.
It was opened, and, after being reflected back, the
cerebellum was palpated. Nothing was found, and it
was only near the medulla oblongata that a cyst was
found, which contained about 150 cm. of clear fluid.
After this had been emptied, cerebro-spinal fluid
escaped, which up to then had not done so in any

quantity. The cyst lay in the meshes of the arachnoid.
That an adhesive process was present in the parts was
shown by the fact that adhesions were present on the
surface of the cerebellum that had to be dissected off.

The meshes of the arachnoid contained a good deal
of fluid in the normal state, but under ordinary con¬
ditions it was diffuse; if adhesions were present
anywhere, however, collections of fluid cysts formed
The acute form of this condition had long been known
to the aural surgeon. The existence of the condition
in the chronic form could no longer be doubted. These
cysts presented all the symptoms of cerebral tumours
and had to be treated by operation.

Hr. Loewenthal related a case of amblyopia from
poisoning by methyl-alcohol. A workman, a?t. 29,
three days alter drinking a small quantity of methyl-
alcohol, besides the general symptoms of poisoning,
showed atrophy of the optic nerve in its early stage.
Although the general symptoms had disappeared the
sight had not returned, and the man was quite blind.
The speaker concluded that methyl-acohol was a
poison with strong elective affinities, which was very
fatal, and the very few that survived remained blind.
Its poisonous property was developed not only when
taken io tern ally, but also when applied externally,
and when the vapour of it was inhaled. Individuality
played the same part here as in other poisons. A dose
of 8 cc. might be a very serious one for individuals
with a predisposition to be affected by it.

AUSTRIA.

Vienna, July 28th, 1907.

Gall-Stone Colic.

Haberer presented a female, aet. 47, from Eisel-
berg’s wards, who had suffered for fourteen years
from gall-stone colic, which resulted in absolute
closure of the ductus choledochus near its entrance
into the duodenum, where the ulceration and finally
the cicatrisation had so contracted the duct that
absolute closure was the result.

Haberer had performed choledocho duodenostomy
with an excellent result by maintaining temporary
drainage of the lever for the bile during the period
of healing. This was considered a crowning feat
over the ravages of cholelithiasis.

Histological Changes in Stomach.

Bondi next gave the members a long description
of the various changes that took place in the walls
of the stomach in cases of diabetes when appearing
as a morbid change and when induced by the adminis¬
tration of phloridzin. From microscopic preparations
of the mucous membrane of the stomach in a case of
pancreatic diabetes, as well as that from the stomach
of a healthy dog, which had been treated with phlo¬
ridzin. the glands contained drops of fat while the
covering epithelium was quite free. Similar changes
were present in the crypts of the small intestine as
well as troma of the shaggy epithelial.

It was shown at a previous meeting that these
changes took place in the liver in pancreatic and
phloridzin diabetes, but not in the stomach and
bowels, this is incorrect. In support of this con¬
dition Lombroso some time ago found by analysis
that more fat came from the bowel of the pancreatic
dogjthan from the healthy animal, this he could not
account for at the time, but can now understand
from the histological proofs. This fat is not obtained
from the food taken into the alimentary canal, as dogs
when hungered give the same result.

Erosions from Caustic Soda.

Preleitner has collected all the cases from the eight
hospitals in Vienna that have been admitted within
the last seven years, numbering 362 cases, mostly in
children Of these 18.6 per cent, died in consequence
of the erosion, 93.3 per cent, of the remainder suffered
from cicatricial narrowing of the oesophagus, 10 per
cent, having to be operated on in the form of gastros¬
tomy to admit of alimentation and distension of the
canal with bougies. Such a large number of children
should be protected by some legal enactment modifying

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122 The Medical Peess.

CORRESPONDENCE.

July 31. 1907.

the sale of strong caustics and, if they must be sold
compelling them to be delivered in a different form
of bottle that might arouse caution.

Teleky quite agreed with Preleitner as he had
drawn attention to this great sacrifice of life six years
ago, but failed to arouse the government to action.
It is scarcely possible to prohibit the sale of these
powerful caustics, but they can be sold with more
safety to the public than they are at the present
time, by suitable bottles and attaching proper direc-
tons. It is scarcely possible to go as far as Preleitner
would have us, as probably other more powerful sub¬
stitutes might take their place in the domestic cleansing
armamentaries.

Aggressin and Toxin.

Bail, of Prague, has been investigating the various
fluids in disease, and assures us that there is always
present the aggressive and toxic fluid as seen in diph¬
theria, where the antitoxic and anti-aggressive both
exist. He affirms that all the semi-parasitic bacteria
such as typhoid and dysentery have these two fluids
in common which can be individually separated, though
this is sometimes difficult. In the toxin itself there
is a component part which is not poisonous of itself
but is powerful in laming or weakening the cellular
function which opens the path for the operation of the
toxin. In the semi-parasitic group this aggressive
immunity is equal to an antitoxin.

Lipomatosis.

Kirsch in a long article on this subject enumerates
the various causes of super-nutrition, engorgement of
vessels occurring in the anasmic as well as the healthy.
He now adds t;he climacteric changes, juvenile de¬
generation, morbid changes in the genitals and meta¬
bolism. The most important of all are chronic
alcoholism, syphilis, and the pastose or lymphatic
form of scrofula. Balneo-therapeutics with chaly¬
beate waters should be prescribed.

HUNGARY.

BaiMNt, July 28 th, 1907.

At the recent meeting of the Budapest Interhospital
Association, Dr. Boros read a paper on

Swelling of the Testis and Epididymis.

He classifies the enlargements of the testis and
epididymis under the following heads:—(1) Acute
(a) Gonorrhoea almost invariably involves the epi-,
didymis, seldom the body of the testis, or orchis
proper. (ft ) Trauma almost always involves the body
of the testis proper and but seldom the epididymis
(c) Epidemic parotitis, or mumps, as a rule, affects
only the orchis, or body of the testis proper. ( d) Cys¬
titis of non-gonorrhoeal origin is a frequent secondary
complication, as is also inflammatory enlargement of
the epididymis. (2) Chronic : (a) Tuberculosis is the
most frequent cause of chronic enlargement and, as
a rule, first involves the epididymis, especially the tail
of this portion of the organ, an! later involves the
body of the testis proper. It gives rise to a peculiar,
nodular, very firm condition of the epididymis, feeling
like a series of beads, and often extending in a similar
minner up the vas deferens, (ft) Syphilis in the
majority of cases involves the body of the testis proper,
and but rarely the epididymis. There are, however,
exceptions to this, in which tertiary syphilis involves
the epididymis, as well s the body of the testis. ( c)
Tumours or neoplasms of the testis may be either
benign or malignant; the benign be'ong to the class
of adenomas or chondromas, the malignant most
frequently to the class of sarcomas.

Clean Milk Movement in Budapest.

The city health officer recently inaugurated a
crusade for pure milk. The members of the city
board, through personal visitation of dairies within
and outside the city limits, acquired a first-hand
knowledge of the situation that enabled them to
effectively squelch the offending dairymen and their
political backers in an attempt put forward to have
the requirements and penalties laid down by the
board set aside. From a number of analyses by the
city bacteriologist, the board has decided that a dairy

selling milk containing more than 500,000 colonies of
bacteria to the cubic centimeter shall be the subject
of investigation—surely, by the widest stretching of
official amiability, no unreasonable standard. The
situation is reviewed by a Budapest medical journal.
There can be little do ’bt but that a large proportion
of the vast number of digestive diseases among infants,
with the many fatalities therefrom, can be traced to
an impure mUk supply. 1 his being the case, it cer¬
tainly becomes the duty of the . unicipality to safe¬
guard the lives of the children of the citizens. The
Board of Health and the health department officials
deserve the he Tty co-operation of all citizens in this
much-needed work. Medical men, knowing the potent
influence of an impure milk supply in inducing disease
among infants, are especially obligated to lend the
health authorities of Budapest their cordial co-opera¬
tion and aid.

Dr. Roth read a paper on

Cancer of Intestinal Tract.

He said that cancer of the alimentary tract repre¬
sents over 50 per cent, of all cancer. It used to be
considered as most likely to develop in the middle life,
and seldom under forty years. Now it is known to
occur much earlier at times, and Dr. Roth saw a
cancer of the rectum not long since in a new-born child.
Often in these cases there is a little temperature and
some tension of the rectus muscle, and while the
surgeon is waiting for complete quiescence to do an
interval operation, the cancer progresses too far for
successful removal. Of the cancer of lower intestinal
tract the most important sign is unsatisfied movements
of the bowels. There is a sensation of unfinished
business. Sometimes this tymptom alone is suffi¬
cient to lead to investigation which discloses the cancer.
Chronic constipation should not be treated for a con¬
siderable time, especially if it proves obstinate, without
suspicion of cancer, and careful investigation along
that line. In cancer of the intestines, where the new
growth cannot be removed, the fatal current may be
switched round the obstructions without the necessity
for the inconvenience of an artificial anus. In inoper¬
able cancer of the rectum, curettage followed by the
cautery gives comfort and prolongs the patient’s life.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

GLASGOW UNIVERSITY GRADUATION CERE¬
MONIAL.

The annual summer graduation ceremony was held
in the Bute Hall on July 23rd. The only honorary
degree conferred was that of D.D. on the Rev. Ralph
Wardlaw Thomson, Foreign Secretary of the London
Missionary Society. After the ordinary degrees in
medicine had been granted, the graduates were ad¬
dressed by Professor Noel Paton, who dwelt on the
effect of the study of medicine in stimulating a passion
for the acquisition of knowledge for its own sake.
The equipment gained during the five years of the
curriculum was all too little to convert the raw recr uit
into a trained soldier, and he counselled the young
graduates to delay their entry into practice until they
had received further guidance and training. This
might be got as resident in a hospital or by work in a
laboratory, and he was glad to say that the two groups
of workers, clinicians and laboratory researchers,
were, year by year, coming more closely together. He
spoke of the facilities for research now arising near
home, making it unnecessary for students wishing to
do research work to go abroad for that purpose, and
in conclusion urged his hearers to be on their guard
against following the easy path of quackery and
humbug, and to follow the arduous path of straight
dealing with themselves and their patients—the only
path for honest men.

EDINBURGH UNIVERSITY GRADUATION
CEREMONIAL.

This function took place in the MacEwan Hall on
July 26th. The honorary degree of LL.D. was con*

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]T 3 LY 31 , I 907 -

CORRESPONDENCE.

The Medical Press. 123

ferred on Wm. Bayard, M.D., St. John, New Bruns¬
wick, a graduate of the University of Edinburgh of
sixty years’ standing, who next month will attair the
great age of 90, yet is still in vigorous health himself,
and even engaged in ministering to the health of
others. Dr. Bayard is the patriarch of Edinburgh
Graduates, but not this, but the high esteem in which
he is held by his Fellows, and the ennobling influence
which he has exercised on the medical profession in
New Brunswick, entitle him to the distinction his
Alma Mater has conferred upon him. The graduates
in medicine, law, and science having been capped
and the various prizes and medals distributed, the
address was delivered by Professor Sir Halliday
Croom. He first spoke of the obligations which mem¬
bership of the University brought with it, and of the
inspiration which the traditions of their Alma Mater
ought to give to the graduates. Not only this, but
by enrolling themselves among the votaries of medicine
they assumed responsibilities which only grew heavier
as the years rolled on. Remembering that most of
his hearers would become general practitioners, air
Halliday Croom ventured on this parting advice:
" First of all,” he said, “ however inconsistent this
statement may seem to you, you must never have a
practice. You must never think to have under any
circumstances any vested right in your patients.
Your patients constitute a practice just so long as
you attend them, and no longer. They have a perfect
right to demand the best of your skill and energy,
and they have equally good right to demand the same
from someone else the next time they require attend¬
ance. When you bid your patient ‘ Good-bye,' after
attending him, it ought to be ‘ Good-bye,’ and not
necessarily ‘ Au revoir.’ You must be independent of
your patient, and vour patient must be independent
of you. The old-fashioned relationship of the family
doctor, like that of the regimental surgeon, who re¬
garded his clientele as his strict preserve, has in our
day been much modified, and in this age of strenuous
competition it is well that it is so." Speaking next of
medical ethics, he asked : "What, in fact, are medical
ethics ? What are the ethics that regulate the con¬
duct of one gentleman to another ? Nothing, abso¬
lutely nothing, but the words to which we have been
accustomed since childhood : “ And, as ye would that
men should do unto you, do ye also to them likewise.”
No rules or regulations, no code of ethics, no marual
of etiquette, would ever be a better guide than abiding
by the old formula. Sir Halliday Croom then urged
that the art as well as the science of medicine should
be cultivated. The problems yet unsolved were
many. In anatomy there was still much to be done,
especially in regard to the nervous system. In
obstetrics, putting aside all other questions, the great
subject of eclampsia, in its pathology and treatment,
still remains unsolved, while gynaecology offers ample
opportunity for original work. It remained also for
some of them to complete in surgery the work of
Lister and Pasteur.

After the ceremony, a House Luncheon was held in
the Union. Last year, it may be remembered, Sir
Donald Currie and Mr. Carnegie each promised £6,000
conditionally on the Union raising a similar sum.
The total £18,000 being the sum required to pay off
the debt on the extension. The Union succeeded in
doing its part, but the estimates for the extensions
were exceeded by £1,200, leaving the institution still
indebted to that amount. About half the requisite
amount of this second sum has also been raised, and
at the luncheon Sir Donald Currie intimated his
willingness to clear off the balance. The University
union has indeed been fortunate in its benefactors ;
we doubt whether anywhere a more luxurious and
well-managed club exists with so low a subscription,

ABERDEEN UNIVERSITY GRADUATION
CEREMONIAL.

The Summer Graduation in Arts, Science, and
Medicine was held in the Mitchell Hall on July 25th.
After the degrees had been conferred, Principal Laing
reviewed the present position of the university. In

the quinquennium that had now nearly terminated,
they had received from the Carnegie Trustees for
equipment, teaching, and research, the sum of £45,000.
With balance remaining, and the assurance that
equally liberal treatment might be expected in future,
there is reasonable prospect of further additions to
the professional staff, and further contributions to
the efficiency and sufficiency of university instruction.

LETTERS TO THE EDITOR.

THE GENERAL PRACTITIONER.

To the Editor of The Medical Press and Circular.

Sir, I have read with pleasure the articles that
have appeared in the Medical Press entitled I he
General Practitioner. I quite agree with Dr. Tayler
that it is very difficult for a medical man in a busy
and exacting practice to find time for reading, and
many of us have to do most of it in our broughams whilst
visiting our patients, and undoubtedly there has
been in the past a deficiency of books written specially
for the general practitioner.

The voung practitioner just entering into practice
finds difficulties which have not been encountered
by him during his hospital curriculum.

1st.—He is puzzled and does himself no credit
when patients come to him complaining of minor
ailments. He cannot do better than read carefully
Dr. Leonard Williams’s readable book on “ A.inor
Maladies.”

2nd.—During his hospital career he has seen the
major operations of surgery performed by brilliant
operators, nearly all of which he will never be called
upon to perform in practice, but the management of
these cases after the operation in the patient’s house
or in a private home he will be expected to look after.
He will find Lockhart Mummery’s " The After-Treat¬
ment of Operations ” of great help to him.

3rd.—The general practitioner finds it difficult
to decide what operations it would be safe and advis¬
able for him to undertake. The recently published
work, “ Operations in General Practice,” by Corner
aod Pinches, he will find a God-send. As these authors
say : “ At the beginning of his career the practitioner
is prepared to do much surgery, but experience teaches
him what he may safely undertake, and from what
he should abstain, he has learnt that it is not so much
the question of operation as the question of policy
which must determine his professional action, a prac¬
titioner may refuse to do a so-called minor operation
and the next dav perform a major one.”

If I had read’this book twenty years ago I should
have attempted to do many operations that I have
not done, and left undone many operations that I
have attempted to do. Having in a town practice
the best operating surgeons within easy call, the
trouble and anxiety of many of these operations is
not in proportion to the comparative small fee that
a general practitioner can charge.

In conclusion I wish to protest against the laboratory
refinements that a student is expected to learn in
these days. When in practice it will pay him better
to subscribe annually to a pathological laboratory
and have the sputum and diphtheritic membrane
examined, the “ Widal reaction ” test, the " Diazo
i eaction ” of urine, etc. done for him by pathological
experts, and devote his time to more remunerative
work.

I am, Six, yours truly,

James Edwards,

Surgeon to the Liverpool Police Force, etc.

To the Editor of The Medical Press and Circular.

Sir —The majority of the profession being general
practitioners, your readers are no doubt mainly com¬
posed of the same class, and these all must feel under
an obligation to Mr. J. Lionel Tayler for the series
of suggestive papers he has contributed to your
valuable journal. Successful general practitioners,
the minority who are doing large practices among the

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124 The Medical Press.

SPECIAL ARTICLES.

July 31. 1907-

wealthier classes, have no time to think of the difficul¬
ties of the mass of their brethren, whilst specialists
and consultants have even less knowledge of and
probably less sympathy with their case. If the
general practitioner is to be helped into a better
moral and material position it must be done by his
own hand. Until an organised combination can be
formed p ogress in any direction will remain im¬
possible. An association of twenty thousand men
speaking with one voice might easily make itself
heard and felt. Of course the British Medical Asso¬
ciation is already in existence, but I would ask what
has it ever done to advance in any way the interests
of the mass of the profession ? It is almost entirely
a co-operative society for the publication of a medical
journal—a journal which rarely discusses or advocates
reforms upon which the vital interests of the general
practitioner depend. If these men will not set to
work with determination to help themselves they
may as well bear their grievances in silence—no help
from outside will ever come to them.

I am, Sir, yours truly,

London, W. G. P.

July 25th, 1907.

DEBTORS AND CREDITOR}.

To the Editor of The Medical Press and Circular.

Sir, —Can you comment on Judge Mulligan as
reported in the Cambridgeshire Times? He has only
recently been appointed in place of Judge Willis,
K.C., and the latter judge and his predecessor. Judge
Price, K.C., for a period extending over the last twenty
years allowed deDt collectors to appear and prove
debts thus saving a lot of time and trouble to
creditors and a lot of expense to poor debtors. J udge
Mulligan, like the proverbial new broom, not only
sweeps all this practice away but pretty plainly
singles out four medical men insinuating that their
conduct has been “ nefarious.” The practice for
twenty years having been for the debt collector to get
in his debt by small payments as convenient to the
debtor as possible; when the debtor ceases to pay,
the collector then gets written acknowledgement
of his debt and the court always gave judgment
for the acknowledged debt, the collector getting in
his debt by instalments and charging 2s. in the £ to
the creditor for his trouble—the debtor being put to
no other expense than the court fees.

The way proposed by Judge Mulligan is the same
as was in vogue some twenty-five or thirty years ago,
before debt collectors were known, which was to give
your list of debts to a solicitor who applied to such
debtor by letter for which a fee was charged, then
another fee for appearance in court, both fees being
added against the debtor, and after judgment was
obtained in court the debt was never followed up and,
in fact, the county court for collection of small debts
was a mockery, a delusion and a snare. Judge Mulli¬
gan by his inconsiderate action is making his court
useless to small creditors, expensive to small debtors
and an exception to every other court in the kingdom.

I am. Sir, yours truly,

Medicus.

SPECIAL ARTICLE.

ANNUAL MEETING OF
THE BRITISH MEDICAL ASSOCIATION.

Exeter, July 27th to August 3rd, 1907.

[From our Special Correspondent.]

Exeter, the capital of England’s West Country, is
a peculiarly fit, proper and delightful meeting place for
the annual picnic and yearly conference of so repre¬
sentative a body as the British Medical Association.
This year’s gathering already promises to be one
of the most interesting and attractive of recent years.
The meeting has opened under auspicious circum¬

stances. Evidences of open-handed hospitality are
apparent everywhere. Elaborate preparations have
been made for the coming of the visitors. A pro¬
mising programme has been arranged for those intent
on the acquirement and dissemination of knowledge.
The pleasure-seeking medicos from crowded cities
and restless towns will find in this ancient cathedral
centre a soothing and restful atmosphere; and in
its surrounding country a veritable paradise of varied
charms, which will provide restorative powers for
the body as well as endless delights for the mind.

The New President.

All will be wishful to tender hearty congratulations
to the incoming President. Dr. Henry Davy has
long been a prominent and honoured leader of Medicine
in the West. His courtesy and consideration, know¬
ledge and tact have won him wide popularity among
both practitioners and patients. He has always
maintained a high ethical standard and sought to
further the interests of his profession and secure
the benefits ot science for the welfare of his fellow
countrymen. His modesty and dislike for anything
savouring of advertisement is well known by all his
friends, but they will thank us for having secured,
and here presenting, a photograph of the head of the
B.M.A.

President of the British Medical Association.

Dr. Davy is an old Guy’s man. He qualified in
1877. In 1880 he took the Membership of the College
of Physicians of London, and was elected a Fellow
in 1894. At his M.B. of London, in 1878, he took
honours in Medicine, Obstetrics and Forensic Medicine,
and, in 1882, proceeded to the M.D.

Dr. Davy has enjoyed much hospital experience,
having served as House Physician and Resident
Obstetric Assistan t at his own school of Guy’s Hospital,
as House Surgeon at the Evelina Hospital for Children,
and as Resident Clinical Assistant to St. Luke’s
Hospital for the Insane.

Settling in practice in Exeter he quickly made for
himself a name and a place, and as Physician to the

HENRY DAVY, M.D., F.R.C.P.,

July 31. 1907.

The M edical P ress. 125

REVIEWS

Devon and Exeter Hospital and the Exeter Dis¬
pensary he exercised a wide influence on the local
medical life of his city and its neighbourhood.

As evidence of his popularity in the profession
jt will be sufficient to note that when, in 1897, he was
elected President of the South-Western Branch,
every medical practitioner in Exeter contributed to
present him with a peculiarly fitting token of esteem:
his badge as a Sheriff of the City.

Dr. Davy has not only proved himself a popular
and successful physician but has shown himself a
valued contributor to Medical Science, having written
on the pathological features of pernicious anaemia,
movable kidney, pyrexial states in children and
Addison’s disease. His presidential address, an
abstract of which we print elsewhere, in this number,
affords abundant evidence that he views matters
medical through a wide-angled lens and fully realises
the important place that the physician and surgeon
must take in the public life of the nation and the
urgent need for an extension of scientific methods
to all pertaining to the development of the best life
of our country.

An Artistic Handbook.

Through the courtesy of the President we have
been favoured with a copy of “ A Book of the South-
West,” a handsome and charmingly illustrated
work specially prepared for the delight and edification
of medical visitors to our Western land. It will prove
a, revelation to many of the glories of the Delectable
Duchy and the beauties of the Shire of the Sea
Kings, and will long be treasured and, if we mis¬
take not, be frequently used as an authoritative volume
of reference. Mr. A. Wallis contributes a graceful
and informing sketch of Devon and Cornwall, and
Mr. A. T. Quiller Couch reveals something of “The
Secrets of Cornwall.” There is much valuable in¬
formation on the physical and climatic features of
the two counties and reliable directions regarding
poipts of local interest and matters which may guide
in the choice of a suitable health station for particular
classes of patients. But the most striking and fasci¬
nating features of this most artistic volume are the
many varied and admirably executed photographic
reproductions. Everyone concerned in the produc¬
tion of this attractive and permanently useful momento
of the Exeter meeting deserve warm congratulations
and sincerest thanks. This volume will, for many
a long day to come, serve to keep in remembrance
the winning beauties of the West and very pleasant
recollections of a thoroughly enjoyable annual meeting.

A Week’s Programme.

Business, science and pleasure are amply provided'
for. The official representatives of the Association
gathered on Saturday, the 27th, and continued their
meetings on Monday and Tuesday, the 29th and 30th.-
On Monday the Mayor of Exeter held a reception in
the Guildhall. Yesterday (Tuesday, July 30th) a
service was held in the Cathedral at noon ; in the
afternoon a garden party was given by the Mayor ;
and at night the President delivered his official
address. The Pathological Museum offers many
objects of much interest. The Annual Exhibition
of Foods, Drugs and Appliances promises to be well
patronised. The work of the thirteen sections will
doubtless prove to be of se vice, although there is no
likelihood of the presentation of any startling novel¬
ties. Several discussions are likely to arouse heated
argument. In so delightful a centre excursions,
tours, and entertainments not unnaturally occupy
a foremost place in the arrangements of the majority
of the visitors. The list provided is most attractive.
Only a real, old-fashioned Devonshire summer
weather is wanted to crown the seventy-fifth annual
meeting of the B.M.A. with complete success.

DR. Vacher, the medical officer of Cheshire, in his
annual report for 1906 says Stalybridge has the
highest infant mortality rate in the county—206 per
thousand.

OF BOOKS.

OBITUARY.

SURGEON-COLONEL EDMUND G. McDOWELL,
C.B., L.R.C.S.

We regret to announce that Surgeon-Colonel Ed¬
mund Greswold McDowell, C.B., died at Portland on
July 26th last, at the residence of his son-in-law,
Major E. W. Briscoe. The deceased officer was born
on November 30th, 1831, and, after qualifying

L.R.C.S.I. in 1855, entered the Army Medical Service
as an assistant surgeon in the 44th Regiment. He
was promoted surgeon on September 3rd, 1870, sur¬
geon-major on March 1st, 1873, brigade surgeon in
the Army Medical Department on August 4th, 1881,
and deputy surgeon-general on March 4, 1886, retiring
as a surgeon-colonel of the Medical Staff on Novem¬
ber 30th, 1891. He served with the 44th Regiment in
the campaign of i860 in North China, including the
action of Sin-ho and the storm and capture of the
Taku forts (medal and clasp), and in the Egyptian
war of 1882 (medal, 3rd Class of the Medjidieh, and
Khedive’s star). He also served in the Sudan expedi¬
tion under Sir Gerald Graham in 1884 as principal
medical officer, and was present in the engagements of
El Teb and Tamai (twice mentioned in despatches,

C. B., and two clasps). Besides one daughter he leaves
two sons, Major F. McDowell, R.A.M.C., and Dr.

D. K. McDowell, C.M.G., Principal Civil Medical
Officer, Straits Settlement.

SURGEON-GENERAL ALEXANDER FRANCIS
PRESTON, B.A., M.B.Dub.

We regret to announce that Surgeon-General Alex¬
ander Francis Preston, M.B., honorary physician to
the King, late of the Army Medical Service, died last
week at his residence in South Kensington, at the age
of sixty-five Graduating at Trinity College, Dublin,
in 1863, he joined the medical service of the Army
the same year, and served in medical charge of the
66th Regiment in the Afghan War of 1880, when he
was present at the affair at Ghirisk, the battle of
Maiwand, where he was severely wounded, and through¬
out the siege of Kandahar, obtaining mention in de¬
spatches. He was promoted surgeon-major, with the
relative rank of lieut.-colonel, and awarded the medal.
In 1896 he reached the rank of surgeon-geneial, was
temporary director-general of the Army Medical De¬
partment in 1901, and the following year was placed
on ihe retired list. Surgeon-General Preston had been
a honorary physician to the King since 1901.

REVIEWS OF BOOKS.

RECENT WORKS ON TUMOURS (a).

Mr. Sampson Handley’s work on the dissemination
of cancer is already well known to surgeons and
pathologists by his Hunterian lectures, his Astley
Cooper Prize Essay, and his contributions to the
" Archives of the Middlesex Hospital.” In the present
volume (a) he has systematised his observations and
conclusions in so far as they bear on the subject of
Cancer of the Breast. The result is the most important
work in surgery or pathology which has appeared in
England for many years.

Mr. Handley starts with a criticism of the fashion¬
able theory of the dissemination of cancer—the embolus
theory. He shows, by citation of cases, how un¬
satisfactory the theory is. “ Blood embolism must
by its very nature, be an indiscriminate process ;
the cancerous emboli must be distributed impartially
to all the organs. Why then in certain cases do the
cancerous emboli gain a footing only in the abdominal
organs, and in other cases only in the thoracic organs ?
The hypothesis of tissue predisposition does not meet
the difficulty.” ...” Quite clearly it (the
embolic theory) is not, standing alone, an adequate
and complete explanation of all the remote metastases
of cancer.” ...” Blood embolism, far from being
a dominant and universal factor in the dissemination

(a) “ Cancer of the Brea.t and Ita Operative Treatment." By W.
Sampson Handley. London: John Murray. 1906. Pp. xll and 23?.
Price 12a. 6d. net.

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126 The Medical Puss.

REVIEWS OF BOOKS.

July 31, 1907*

of breast cancer, appears to bean event of exceptional
occurrence, and one which, even when it occurs, is
usually rendered ineffective by the destruction of
those cancer cells which gain access to the blood
stream.” (Pp. 14, 15).

Having scotched the dominant theory, Mr. Handley
proceeds to develop his own. He first describes
the topographical distribution of the secondary
growths in cases of cancer of the breast, and he next
shows the paths by which the disease spreads. The
main point of his teaching can be put in a short sen¬
tence—Cancer spreads by direct growth along the
lymphatic channels. Moreover, this "permeation takes
place almost as readily against the lymph-stream
as with it.” This growth Mr. Handley is able to
demonstrate with the microscope. At some distance
from the primary tumour “ the principal lymphatic
pexus of the part, the pexus which lies upon the deep
fascia, is found permeated throughout, that is to say,
its vessels are obstructed by the growth of lines of
cancer cells along them ” (p. 93). Somewhat nearer
the primary tumour these permeated lymphatics are
not found, a fact which seems to present some difficulty.
It is shown, however, that the permeated lymphatics
have been destroyed by a process of perilymphatic
fibrosis. These various statements, though made
boldly, are by no means unsupported. Mr. Handley
marshals his evidence clearly and firmly, and it is
all but impossible to impugn any of his views, however
revolutionary they may appear.

Having acquired a knowledge of the mode of spread
of cancer, Mr. Handley proceeds to study the particular
case of the relation of visceral dissemination to cancer
of the breast. He shows by purely anatomical con¬
siderations how readily the epigastric angle and, sub¬
sequently, the liver become affected.

Finally, he comes to the practical question of the
application of his views to operations on the breast.
As the disease spreads not at the level of the skin,
but at the level of the lymphatic plexus on the deep
fascia, it is obvious that in the removal of the part
the deep fascia must receive special attention. The
glands, however, are to be seen to as carefully as
heretofore, since, when the permeation process reaches
a gland, emboli may be formed which carry on the
disease to more distant glands. In Mr. Handley’s
words, therefore, " the object of the operation should
be the removal of the permeated area of the lymph-
vascular system which surrounds the primary growth,
and of the lymphatic glands which may have been
embolically invaded along the trunk lymphatics
of the area concerned ” (p. 178). He details not
merely the principles governing the operation, but
gives all the steps clearly enough to guide the surgeon.

In an appendix, the author discusses lymphatic
permeation in the spread of melanotic sarcoma.

Mr. Handley’s work comes from the Middlesex
Hospital Cancer Research Laboratories, and would
be, even if it stood alone, sufficient justification
for their existence. No one, however crusted he may
be in tradition, can read the volume without seeing
that, whether accepted in every detail or not, Mr.
Handley’s researches and conclusions cannot be
overlooked. Most readers will come away convinced
that a great step forward has been made in our know¬
ledge of ar important branch of pathology. What
Mr. Handley has done for cancer of the breast must
be done by himself or by others for cancer of other
regions, and we are glad to learn that he is at present
investigating the problem as it concerns the stomach.

In the presence of so much important material, it
is hardly worth mentioning that the style of the
author is excellent, and that his argument is both
clear and concise. The general form of the book,
as is usual with Mr. Murray’s house, is all that can
be wished.

Mr. Charles Cathcart’s book ( b) comes as a useful
protest against the current fashion of treating of the

(ft) “The Easentlal Similarity of Innocent and Malignant Tumours:
A Study of Tumour Growth." By Charles W. Cathcart, MA, M3.,
O.M. Edin.)., F.B.C.8. (Eng. and Edin.). Illustrated. Bristol: John
Wright and Co. Pp. zli and 79. Price 9s. 6d. net.i

! “ cancer problem ” as a thing apart from the general
| problem of tumour formation. Such isolation of
part of a question can only lead to confusion and
wasted labour, and although the distinction between
“ innocent ” and “ malignant ” is of great importance
; both clinically and pathologically, yet it is never
; absolute, and there is a wide debatable land between
the two territories. Mr. Cathcart arranges his argu¬
ments in three battalions which reinforce each other
in attack. First, he shows by description of several
I series of tumours, the easy gradation from the obvi¬
ously innocent to the obviously malignant. Next,
he details instances of the transformation of innocent
into malignant growths. Finally, he gives examples
of tumours presenting various combinations of in-
nocency and malignancy. Mr. Cathcart’s series are
illustrated by excellent photographs of gross specimens,
but he does not supply the series of microscopic
sections which would prove equally instructive.
There is nothing particularly novel in the ideas pre¬
sented, but the book will be of service in emphasising
the essential unity of the tumour problem.

Mr. Bland-Sutton’s book on Tumours is so well
known to the profession that the appearance of a
new edition (e) hardly calls for prolonged notice. The
special features of Mr. Bland-Sutton’s book have
always been its comprehensiveness and its elucidation
of the subject by the aid of comparative pathology;
while it had the added interest that it vigorously
expressed the views of a teacher of marked originality
and wide experience. These features it possesses still,
the last mentioned perhaps to an extent hardly satisfy¬
ing to the demands of the logic of science. Dogmatic
statements abound where tentative opinions would
have been more fitting. For example, the discussion
of carcinoma of the ovary (p. 515) opens with the
statement, “ Primary cancer of the ovary is a rare
disease, and one concerning which we know little.”
In the bibliography at the end of the chapter only one
reference is given to any work on cancer of the ovary
more recent than 1902; if Mr. Bland-Sutton had
consulted more recent literature he would have found
that in the practice of other surgeons the disease is by
no means rare. The present reviewer has had sub¬
mitted to him for pathological examination no less
than three cases within a fortnight. On p. 61, we
meet the extraordinary statement that “ Myomata,
or tumours composed of unstriped muscle fibre, are
very rare,” although the author immediately quotes
the uterus as one of the sites for them. We have
been unable to detect the difference between the
myeloma or myeloid sarcoma, described in chapter
iv., and the sarcoma of bones, in chapter vii; both
microscopically and macroscopically they appear
from the description to be indistinguishable. It is
an ungrateful task finding fault with an old friend
such as this book, but it is just because the book is
regarded as an authority that we are constrained to
point out that the pathological sections have not
been sufficiently revised or brought up to our m odern
knowledge. In regard to treatment, Mr. Bland
Sutton is a more trustworthy guide.

Those who are interested in Poor-law reform will
be interested to learn that a fund is being collected
to present a suitable testimonial to Dr. Milson Rhodes.
The movement was started at Didsbury, Dr. Rhodes’
own district, and close to the Chorlton Union, with
which his name is so closely associated. It will be
remembered that he was one of the founders of the
Association of Poor-law Union. A considerable sum
of money has been already subscribed, and the Editor
of the Poor-lam Officers' Journal, Whitefriars Street,
London, E.C., will be pleased to receive any further
contributions to the fund.

(c) “ Tumour*, Innocent and Malignant, their Clinical Character*
and Appropriate Treatment.” By J. Bland-Sutton, F.B.OB. Fourth
edition. With 355 engrarlng*. London: Caiaell and Co. 1906. Pp.
ill and 675. Prloe 21*.

izedbyGooqle

1 O

J ULY 31 . 1907 -

WEEKLY SUMMARY.

The Medical Press. 12 7

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for The Medical Press ahd Circular.

RECENT GYNAECOLOGICAL AND OBSTETRICAL LITERATURE.

Relation of Ovarian Cysts to Abdominal and Pelvic
Pain. —Sampson (Surg. Gyrtacol. and Obstetrics , June,
1907).—The sensibility of the walls of eight large
ovarian cysts was studied and all were found to be
insensitive to touch and pain. Traction on the
pedicles caused pain which became greater as the
traction was increased. The pain was usually at
first localised in the side of the abdomen at or about
the pelvic brim but as the traction was increased
it became more diffuse. When diffuse it was felt
over the entire side of the abdomen or in the back,
and as soon as the pedicles were released the patients
were immediately relieved. His observations on
the sensibility of the normal tube, ovary, and uterus
do not entirely accord with those of Linnander, who
thinks that they are insensitive, for while finding them
so in some cases when pinched with a mouse tooth
forceps. Yet in a number pinching these structures
caused pain. Again intraperitoneal pelvic operations
have been found by the writer to be less painful in
women past the menopause, and the instances of
apparently sensitive ovaries, tubes, and uteri have
occurred in younger women, but even here the
apparent sensibility to pain has been inconstant, and
when present it has always been much less than
that of the parietal peritoneum, and the ovary has
seemed the least sensitive of the three. In all cases
the parietal peritoneum was found to be very sensitive,
and especially to traction The omentum and intes¬
tines were found to be irsensitive to pinching. He
sums up as follows: The presence of abdominal
or pelvic pain in patients with ovarian cysts usually
indicates either secondary changes in the cyst
involving some sensitive near-by structure or the
presence of some other condition, independent of the
cyst, which may cause pain. The principal causes
of pain from ovarian cysts are traction or twisting of
the pedicles or the traction of the parietal peritoneum
from adhesion. F.

Ectopic Gestation with special reference to the
Treatment of Tnbal Rupture.— Robb (Amer. Jour.
Obst. and Gynacol ).—The writer quotes the opinions
of recognised authorities and then concludes his
paper with the following account of the method
adopted by him for tubal rupture during the past
four years. If there are signs of improvement in the
patient’s condition (and this in his experience always
takes place) he keeps the patient under further obser¬
vation. The change for the better is brought about
by carefully stimulating the patient by means of
saline infusions under the breasts, and in some instances
also by means of hot saline eremata. If the patient
is not vomiting or not nauseated, a stimulant in small
quantities is administered by the mouth. In addition
morphia is given hypodermically for the pain and
nervousness. External heat is applied to the body
and the lower end of the bed is slightly elevated.
Sulphate of strychnine is also given hypodermically
in doses of 1-10 to 1-20 of a grain every half hour or so,
according to the indications. While this treatment
is being carried out, the operating room is prepared,
so that it can be used at a moment’s notice. This
treatment is also carried out at the patient’s homes.
Then as soon as the woman had recovered from the
shock of the rupture she was transported to the
hospital, where an operation could be carried out at
any time that the necessity might arise. Every patient
in the series of twenty had gradually improved, so
that after two or three days, ahd in some instances
after twelve day’s time, the operative procedures have
been carried out with very little, if any, shock to the
patient. The writer is not prepared to state dog¬

matically that women do not bleed to death from
hasmorrhage following ruptured tubal pregnancies,
but he is of the firm conviction that surgeons are
losing many of their desperate cases from over-haste
in operating upon them. F.

Valvular Disease of the Heart in Pregnancy and
Labour. —Newell ( Sur. Gynacol. and Obst., May, 1907).
Any organic heart lesioD, even if perfectly com¬
pensated under normal conditions of life, should arouse
apprehension and call for constant watchfulness if
pregnancy supervenes. In case pregnancy comes as
a complication when the heart lesion is imperfectly
compensated, the indication is for immediate relief
by emptying the uterus, since a heart which is not able
to care for its ordinary work has no chance of supporting
the added burden of pregnancy. When a previously
well compensated heart fails under the extra work
thrown on it by pregnancy an attempt may be made
to restore compensation by test and appropriate
treatment, but unless the measures are promptly
successful the heart must be relieved by the removal
of the extra burden. In any case in which an organic
heart lesion can be demonstrated, even though it
may have caused no symptoms during pregnancy,
labour should be regarded with apprehension, and every
means should be taken to shorten the strain of labour
and thus relieve the heart of its extra burden, although
it may seem to be doing its work satisfactorily. F.

Hyperemesis gravidarum and its relation to eclampsia.

— Skorbanski ( Zentralbl. fur Gyn, Nr. 27 1907).
Four hypotheses exist concerning the aetiology of
Hyneremesis gravidarum: (1) The hypothesis of the
simple reflex from the uterus to the stomach ; (2) The
auto-intoxication hypothesis which declares that the
hyperemesis is the result of intoxication of the body
by toxines which arise in the intestine, in the stomach,
in the liver, or in other organs ; (3) That it is hysterical
in origin ; (4) That the intoxication of the organism
arises from poisons which develop in the ovum. In
the author’s opinion the last hypothesis best explains
the different cases of hyperemesis ; it also explains
the relationship between hyperemesis and eclampsia.
Hyperemesis in the first half of pregnancy can arise
as a result of the immunisation of the organism by an
antitoxin produced from products of the disappearing
villi. This antitoxin is necessary for the organism
at the end of pregnancy, when large masses of toxines
arise. When immunisation at the beginning of
pregnancy is successful, the organism easily over¬
comes these poisons at the end of pregnancy, but
when it is unsuccessful eclampsia is observed. Thus
eclampsia most frequently assails healthy women
who felt perfectly well during their pregnancy. Some
cases of eclampsia which came under the author’s
observation in Prof. Rein’s klinik in St. Petersburg
strengthen the author’s belief in this hypothesis, the
first half of pregnancy gave them no trouble. There
are, however, eclamptic patients who suffered during
the first half of their pregnancies from severe hypere¬
mesis ; one must conclude that in these cases in spite
of the poisoning of the organism during the first
half of pregnancy a sufficient amount of immunisation
material was not produced. In conclusion the author
describes a case of hyperemesis for which abortion
had to be induced. G.

The Corput Lntenm. —Fellner (Med. Klinik, 1906,
Nr. 42) reviews all the latest investigations and opinions
concerning thecorpus luteum and its internal secretion.
The difference has long since disappeared, which was

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128 Tbs Medical Puss.

WEEKLY SUMMARY.

July 31. 1907-

formerly made between the corpus luteum of men¬
struation and that of pregnancy. While Sobotta
considers that the lutein cells arise from the granulosa
cells a not inconsiderable number of authors adhere
to the investigation of Stoeckel, who sought to prove
their origin from the theca cells. Numerous in¬
vestigations have been made concerning the cystic
changes in the corpus luteum, which by the presence
of blood one can generally distinguish from cysts of
the Graafian follicles. Haemorrhages into the interior
of the cysts can be very dangerous, even fatal. Accord¬
ing to Stoeckel multiple cysts depend on an abnor¬
mally fast rate of ripening of the follicles and corpus
luteum formation, which passes off without opening
of the follicle and thus leads to cyst formation. The
investigations concerning the simultaneous appea -
ance of ovarian changes on the one hand and hydatidi-
form mole and syncytioma on the other have excited
especial interest. All the properties which were
formerly entirely attributed to the ovary are attri¬
buted now by Fraenkel, on the ground of numerous
experiments, to the corpus luteum alone. Although
we do not yet know anything certain concerning
the function of the corpus luteum, we must conclude
that the corpus luteum is a gland with an internal
secretion. G.

Prolonged Pregnancy. —Bossi ( Zentralbl . fur Gyn.,
No. 27, 1907) regards pregnancy as prolonged
when it exceeds the term of 285 days, without any
symptoms of labour. Such a condition exists among
2—3 per cent, of all pregnant women, and may cause
severe complications during delivery. The charac¬
teristics of the ovum are as follows: (1) Unusual
length of the foetus ; (2) the bones of the head are
larger and more ossified ; (3) a well marked dis¬
proportion between the length, ossification, and the
size of the head bones and the weight, which is usually
less than is expected. The author fully describes
some cases out of the fifty-two obsetved by him
in order to illustrate the difficulties which often arise.
The frequency of uterine inertia is remarkable. Bossi
is inclined to refer this to the fatty degeneration
which the muscle fibres undergo when gestation
exceeds its normal length. The treatment indicated
is artificial induction of labour, and pubiotomy when
the head is so ossified and hard that even with Wal-
cher’s position safe delivery is uncertain. G.

Haemorrhages at the Beginning of Puberty. —Fischer
(Monatssch. fiir Geb. und Gyn., Bd. XXV., Hft. 4)
records the case of a girl, aet. 12, who for two years
had suffered from practically continuous haemorrhage'
from her gums. She was extremely anaemic. She bled
very severely during her first menstruation. Examina¬
tion revealed a normal condition of the genitals.
Ergot, adrenalin, vaginal plugging, and even plugging
of the uterus with perchloride of iron wadding and
tannin gauze were of no avail. Finally she was
curetted, and this was successful. The endometrium
removed proved to be normal, but rather poor in
glands. A second case, a girl, set. 14, had bled unin¬
terruptedly for six weeks. She was very anaemic, the
quantity of haemoglobin in the blood being 10 per
cent. On the trunk and on the extremities there were
little points of haemorrhage. Curettage stopped the
bleeding, but did not give sufficient material for micro¬
scopical examination. Eight days afterwards she died
from profuse nasal epistaxis. The first case was one
of haemophilia, the second of purpura hasrnorrhagica.
There have been several cases of haemophilia in women
recorded lately. As regards the second case, uterine
haemorrhages have been observed complicating purpura
haemorrhagica. In conclusion, the author discusses a
series of eleven cases in which severe haemorrhage was
associated with the first menstruation. G.

High Forceps. —Riemann (Monatssch. fiir Geb. und
Gyn., Bd. XXV., Hft. 4) reports the results obtained
with high forceps in <he Breslau school for midwives.
In his opinion they are not so dangerous for the
mother and child that they should be rejected gene¬
rally, especially in cases of contracted pelvis. The
fcetal mortality was 22 per cent. ; maternal injuries,

7 per cent.; fcetal injuries, 10 per cent.; and the puer¬
perium was prolonged in 16 per cent, of the cases.
All this proves that high forceps should not be em-
| ployed without the strongest indications— i.e., danger
! for either the mother or child. The best results are
! obtained when the head is well moulded and the child
in good condition ; that is when the forceps are indi¬
cated for the mother’s sake. In such cases it is pos¬
sible to deliver relatively large uninjured infants,
when the conj. diam. measures from 8-8$. The useful¬
ness of the high forceps diminishes as the contraction
of the pelvis increases. G.

Ovariotomy during Pregnancy, Labour, and the
Puerperium.— Retzlaff [Monatssch. fiir Gcb. und Gyn.,
Bd. XXV., Hft. 4).—In the first case a IV.-para.,
aet. 35. During bimanual examination a tense and
elastic tumour was found in Douglas’s pouch, which
laparotomy showed 10 be a parovarian cyst the size
of an apple, with its pedicle twisted, lying behind the
pregnant uterus. In a second case the uterus was
enlarged to the size of three months’ pregnancy and
retronexed ; on top of it was a cystic tumour the size
of a child’s head. The laparotomy revealed a dermoid
of the right ovary. Operation did not interrupt the
pregnancy in either case. In a third case the uterus,
slightly enlarged, was pressed against the symphysis
by a tumour in Douglas. A dermoid cyst was removed
by colpo-cceliotomy. The pregnancy went to full term.
The author now discusses the combination of
pregnancy and ovarian tumour, and says that it is
difficult to declare which is the best procedure to adopt
regarding operation. One must consider the period of
the pregnancy, the size and nature of the tumour, its
position, and the condition of the other ovary. It is
more unfavourable when the tumour does not reveal
itself during pregnancy, but is first discovered at the
beginning of labour, when it may prolong the expul¬
sion of the ovum or perhaps render it impossible. As
examples the author describes two cases. If the
ovarian tumour is diagnosed intra partum, and it is
an obstruction to labour, an effort may be made to
replace it either from the vagina or rectum with an
anaesthetic if necessary, so that the labour may pro¬
ceed as naturally as possible. If it is impossible to
replace it, an ovariotomy must be performed. The
puerperium can also be complicated in a most un¬
pleasant manner by ovarian tumours. It seems as if
the long-continued compression and crushing produced
by difficult deliveries so very much lowers the vitalit}'
of the tumour tissues that they afford an especially
favourable breeding-ground for the development of
1 infection spreading upwards from the genital tract.

G.

Appendicitis and Pregnancy.— Puech [Provence Med.,
1906, Nr. 52) reports two cases. In the first, appen¬
dicitis developed at the seventh month of pregnancy,
and was not recognised at the beginning. Three days
later the diagnosis was made, and, owing to the
severity of the case, an operation decided on. It was
not performed, however, as the patient began to im¬
prove. Less than 24 hours after this decision the
patient died. In a second case a patient six months
pregnant was suddenly seized with very severe pains,
vomiting, etc. A diagnosis was first made of kidney
colic. The author, when summoned, made the correct
diagnosis, and as the patient’s condition did not im¬
prove, he operated. A day and a half later she
delivered herself spontaneously of a dead six months’
foetus. The convalescence was uneventful. As a result
of these observations the author warmly recommends
operation in such cases. G.

Arrangements for the amalgamation of the I-ondon
Royal National and City Orthopaedic Hospitals have
now been completed. Dr. Hughlings Jackson has
been elected Honorary Consulting Physician to the
Royal National Orthop edic Hospital, and Dr. Suther¬
land, Mr. John Poland, and Mr. J. Jackson Clarke
have been elected Honorary Physician and Honorary
Surgeons respectively. The new building operations
have been begun, and a hospital for 213 in-patients
is being built on the site of the old hospital and the
adjoining premises.

ed by Google

July 31, 1907.

MEDICAL NEWS IN BRIEF.

The Medical Press.

129

Medical News in Brief.

R*yal Collere of 5urgeons of England.

An ordinary meeting of the council of the Royal
College of Surgeons was held on Thursday last, Mr.
Henry Morris, president, in the chair. Mr. Louis A.
Dunn, F.R.C.S., Surgeon and Lecturer at Guy’s
Hospital, was elected a member of the court of
examiners in the vacancy occasioned by the retire¬
ment of Mr. Golding-Bird. Mr. Pearce Gould,
F.R.C.S., Surgeon to Middlesex Hospital, and Mr.
William^B. "Paterson, F.F.C.S., Dental Surgeon to
St. Bartholomew’s Hospital, were re-elected members
of the board of examiners in dental surgery.

Upon the recommendation of the committee of
management it was decided to add Alleyn’s School,
Dulwich, to the list of institutions recognised by
the examining board for instruction in chemistry
and physics. The balance sheet and statement of
receipts and expenditure for the past collegiate year,
submitted to the council by the Finance Committee,
was approved and adopted, and it was decided to
publish the statement of receipts and expenditure
as usual in the college calendar.

A letter was read from the honorary secretary of
the British Dental Association communicating the
following resolution adopted at the annual general
meeting of the association held at Cardiff on May 18th,
1907 : “ That any resolution, prescribing ‘ not less
than two years’ instruction in mechanical dentistry,’
instead of three years as heretofore, is seriously
detrimental to the efficiency of the profession.” It
was decided to refer the same to the court of ex¬
aminers to consider and report.

The secretary having reported the death of Pro¬
fessor Edward Hallaran Bennett, of Dublin, an
Honorary Fellow of the College, the president in¬
formed the council that he had conveyed to Mrs.
Bennett the sympathy and condolence of the council,
and a letter from Mrs. Bennett was read thanking
the council for their sympathy in her bereavement.

The Institute et Hygiene.

Lord Robert Cecil held a reception at the Institute
on Friday evening last, which was largely attended by
members of the medical profession. Both the exhibi¬
tion and lecture hall were very crowded at times, but
the guests found much to interest them in examining
the various foods and beverages on exhibition, as well
as in the demonstrations of new appliances and
machines in the hospital section. Among those who
accepted the invitation were:—Dr. Appleby, Dr.
Anderson, C.I.E. ; Mr. Arthur Barker, Sir William
Bennett, K.C.V.O. ; Prof. Rose Bradford, M.D. ;
Mr. Jackson Clarke, F.R.C.S.; Dr. Leigh Canney,
Colonel Drake-Brockman, F.R.C.S. ; Dr. A. H. Payan
Dawnay, Mr. T. J. Faulder, F.R.S.S.; Dr. W. Ewart,
Mr. H. A. T. Fairbank, F.R.C.S.; Dr. Clement
Godson, Dr. Griffith, Mr. Pearce Gould, F.R.C.S. ;
Professor Halliburton, M.D. ; Sir Constantino Hol¬
man, M.D. ; Dr. Havilland Hall, Mr. Arbuthnot
Lane, F.R.C.S. ; Dr. McLeod, Dr. Ogilvie, Mr
Openshaw, C.M.G., F.R.C.S.; Dr. Steele-Perkins,
Dr. Priestley, Mr. Mayo Robson, F.R.C.S. ; Sir
William Ramsay, F.R.S. ; Dr. Sandwith, Dr. John C.
Thresh, Mr. Tubby, F.R.C.S. ; Mr. Arch. S. Vasey,
F.I.C. ; Professor Sims Woodhead, M.D., etc.

Actlao ter Damages by a Medical Man.

At Leeds, on July 27th, before Mr. Justice Ridley
and a special jury, was tried the action of “ Rhodes
v. Lancashire and Yorkshire Railway Company.”
This was a claim by a Dr. Rhodes, of Manningham
near Bradford, for damages for personal injuries sus¬
tained in a railway accident at I.owmoor between
Halifax and Bradford, on January 7th, 1907. The
railway company did not.dispute liability, and the
issue tried was that of damages only.

The plaintiff stated that in the accident his head
was violently thrown against the carriage. He
suffered from severe pain in the lnmbar region and
sciatic nerve ; he was unable to walk without great
discomfort for a considerable period. He went for

electric treatment to a hydropathic establishment at
Southport during February ; but, as he received very
little benefit from this, he ultimately went on a voyage
to South Africa. His practice averaged £400 a year,
and it had suffered in his absence. He claimed
£1,500 damages. The defendants called evidence to
show that the plaintiff was much less seriously injured
than he represented himself to be. Their medical
witnesses were of opinion that the voyage to South
Africa was unnecessary, and that the plaintiff not
only would have been able to resume practice earlier
than he did, but that he would have benefited thereby.
It transpired during the course of the case that while
the plaintiff was staying at the Southport establish¬
ment an official of the company stayed there and
watched his movements.

The learned Judge, in summing up, commented
strongly on this conduct, and said that in a case where
it was clear there had been considerable injury it was
very regrettable that the railway company had thought
fit to employ a detective to spy on the plaintiff.

The jury awarded the plaintiff £600 damages.
Second International Congreae of School Hygiene.

At the request of the King, Lord Crewe, Lord
President of the Council, has consented to open the
Second International Congress of School Hygiene on
the morning of Monday, August 5th. While st'll
adhering to their resolution not to issue official invi¬
tations to foreign Governments to send delegates, the
Board of Education has arranged with the Foreign
Office to take such steps as are likely to remove any
misunderstanding which might prevent some foreign
delegates from accepting the invitations issued. It is
hoped, therefore, that all hindrances to the complete
success of the Congress have been removed.

PASS LISTS.

Royal Collage of Physicians of London.

At the comitia of the Royal College of Physicians
of London, held on July 25th, the President, Sir R.
Douglas Powell, in the chair, the following were
elected officers of the college :—Censors, David Ferrier,
M.D., j. Mitchell Bruce, M.D., T. Clifford Allbutt,
M.D., j. F. Goodhart, M.D. ; treasurer, Sir Dyce
Duckworth, M.D. ; Emeritus registrar. Sir Henry’A.
Pitman, M.D. ; registrar, Edward Liveing ; Harveian
librarian, J. Frank Payne, M.D. ; assistant registrar,
Oswald A. Browne, M.D. ; Library Committee,
Norman Moore, M.D., William Osier, M.D., H. D.
Rolleston, M.D., A. Mercier, M.D. ; curators of the
museum, William Cayley, M.D., W. H. Allchin, M.D.,
S. J. Sharkey, M.D., and Dr. W. Hunter.

The following, having passed the required examina¬
tions, were admitted members of the college :—A. W.
Falconer, V. S. Hodson, M.B., B. Hudson, M.A., M.B.,

L. R.C.P., H. C. C. Mann, M.D.Lond., L.R.C.P. ;
R. H. Miller, M.D.Lond., L.R.C.P. ; H. Pritchard,

M. D.Lond., L.R.C.P. ; E. A. Ross, M.D. ; G. M.
Campbell Smith, M.A., M.D. ; T. E. Tylecote, M.D.
Viet. ; S. A. K. Wilson, M.A., M.B., Edin.

The following were elected examiners in the sub¬
jects indicated for the ensuing collegiate year :—

First Examination. —Chemistry, J. M. Thomson,
F.R.S., G. Senter, Ph.D., B.Sc ; physics, Dawson F. D.
Turner, M.D., A. W. Porter, B.Sc ; materia medica
and pharmacy, C. Ogle, M.B., J. J. Perkins, M.B.,
R. A. Young, M.D., J. P. Stewart, M.D., O. F. F.
Grunbaum, M.D. ; physiology, W. D. Halliburton,
M.D., E. H. Starling, M.D. ; anatomy, P. Thompson,
M.D. ; medicine, J. A. Ormerod. M.D.', S. H. C. Martin,
M.D., W. Collier, M.D., W. M. Murra>, M.D., N.
Dalton, M.D., H. D. Rolleston, M.D., Sir E. Cooper
Perry, M.D., F. J. Smith. M.D., A. P. Luff, M.D.,
W. E. Wynter, M.D. ; midwifery, J. Phillips, M.D.,
H. R. Spencer, M.D., W. J. Gow, M.D., T. W. Eden,
M.D., G. H. D. Robinson, M.D. ; public health,
W. H. Wilcox, M.D., A. G. R. Foulerton, F.R.C.S. ;
Murchison scholarship, S. I. Sharkey, M.D., W. Hale
White, M.D.

The Baly gold medal, instituted in 1866 by Dr.
F. D. Dyster, of Tenby, “ In Memoriam Gulielmi Baly.

' 130 Th* Medical Peess.

PASS LISTS.

July 31, 1907

which is awarded every alternate year on the
recommendation of the president and council to the
person who shall he deemed to have most distinguished
himself in the science of physiology, especially during
the two years immediately preceding the award,
was awarded to Ernest H. Starling, M.D., F.R.C.P.,
F.R.S., Jodrell Professor of Physiology, University
College, London.

Dr. James Rr.msav, of York, presented the college
with an autotype copy of a portrait of James Atkinson,
1759-1830, author of “ Medical Bibliography,” Letters
A.-B. The thanks of the college were accorded
to the donor.

On the recommendation of the committee of manage¬
ment the following institutions, which have been
visited by a member of the committee and reported
as fulfilling the requirements of the board, were
added to the list of institutions recognised bv the
examining board in England for instruction in chemistry
and physics:—The Municipal Technical School,
Birmingham ; Aldenham School, Elstree; Alleyn’s
School. Dulwich.

The following gentlemen, having conformed to the
by-laws and regulations, and passed the required
examinations, had licences to practise physic granted
to them at this meeting :—S. H. C. Air, N. G. Allin,
M. D. Anklesaira, R. E. Apperly, J. Applevard, F. W.
Aris, H. P. Aubrey, F. J. F. Barrington, R. L. Barwick,
J. W. B. Bean, T. H. C. Benians, H. S. Berry, F. A. B.
Bett, R. G. Bingham, J. W. Bintcliffe, F. R. Bray,
A. Camacho, L. B. Cane, H. B. Carlyll, R. G. Chase,
R. N. Chopra, F. Clayton, M. Cohen, F. G. Collins,
P. C. Conran, R. N. Coorlawala, J. E. Copland. E. M.
Cowell, A. J. Crawford, L. Croft, G. W. M. Custance,

H. G. Daft, D. W. Daniels, W. Deane, H. C. Devas,
W. C. M. Dickey, A. W. C. Drake, J. Duncan, J. E.
Ellcombe, T. Evans, E. G. Foote, C. L. Forde, S. R.
Gleed, E. S. Goss, H. Granger, W. B. Griffin, J.
Hadwen, A. Hanau, W. W. Hellyer, * 0 . H. Hensler,
T. S. Higgins, J. E. Hodson, G. Holroyde, A. E. lies,
W. A. M. Jack, W. J. Jago, A. G. Jenner, W. F. Jones
J. L. Jovce, C. G. Kemp, *F. E. H. Keogh, S. M.
Khambata, A. S. Khan, H. I. S. Kimbell. P. J.
Kolaporewalla, C. F. L. Leipoldt, j. F. Lessel, J. R.
Lloyd, J. J. Louwrens, L. G. J. Mackey, P. W. N.
Mathew, J. E. Middlemiss, E. P. Minett, G. N. Mont¬
gomery, *E. Morris, H. W. Nicholls, H. Nockolds,

F. W. O’Connor, H. P. Orchard, E. V. Oulton, R. C.
Paris, J. G. Phillips, B. J. Phillips-Jones, A. H.
Pollard, M. A. Rahman, J. Ramsay, A. B. Rooke,

V. K. Sadler, *B. Saul, G. H. Sedgwick, G. A. Simmons

G. M. Simpson, F. O. Spensley, S. F. St. J. Steadman,
R. Y. Stones, E. Sutcliffe, R. S. Townsend, H. T.
Treves, J. R. H. Turton, B. Varvill, H. F. Vellacott.

W. G. H. M. Verdon, P. J. Verrall, S. Vosper, *F. J.
Waldmeier, G. H. Watson, J. N. Watson, R. J. Willan,

I. S. Wilson, J. F. Windsor, G. E. Wood, W. H.
Woodburn, L. H. Wootton, O. K. Wright. (*Under
regulations dated October 1st, 1884.

Revel Caller* ®f Surgeons of England.

At the meeting of Council, on July 25th, the following
candidates received the Diploma of Membership :—
Samuel H. C. Air, Norman G. Allin, Manekjie D.
Anklesaria, Raymond E. Apnerly, James Appleyard,
Frederick W. Aris, Harold P. Aubrey, Frederick J.
Barrington, Richard T. Barwick, John W. B. Bean,
Thomas H. C. Benians, Horace S. Berry, Raymond G.
Bingham, John W. Bintcliffe, Frederick D. Bray,
Angel Camacho, Leonard B. Cane, Hildred B. Carlyll,
Robert G. Chase, Ram N. Chopra, Frank Clayton,
Meyer Cohen, Francis G. Collins, Philip C. Conran,
Rustom N. Coorlawala, James E. Copland, Ernest M.
Cowell, Andrew J. Crawford, Lawrence Croft, Gustavus
W. M. Custance, Hedley G. Daft, Davis W. Daniels,
William Deane, Horace C. Devas, William C. M.
Dickey, Arthur W. C. Drake John Duncan, John F.
Ellcome, Trevor Pvans, Edmund G. Foote, Cecil T.
Forde, Seymour D. Gleed, Edward S. Goss, Henry
Granger, Walter B. Griffin, John Hadwen, Alfred
Hanau, William W. Hellyer, Oscar H. Hensler, Tom S.
Higgins, John E. Hodson, Gerald Holroyde, Arthur E.
lies, Willi.i"' \. M. Jack, William J. Jago, Arthur G.

Jenner, William F. Jones, James L. Joyce, Charles G.
Kemp, Frederick E. H. Keogh, Sohrab &j. Khambata
Abdus S. Khan, Henry J. S. Mimbell, Phirozeshaw J.
Koloporewalla, Christian F. L. Teipoldt, John F.
Lessel, John R. Lloyd, James J. Louwrens, Philip W.
Mathew, James E. Middlemiss, Edward P. Minett,
Gordon N. Montgomery, Edward Morris, Harry W.
Nicholls, Humphrey Nockolds, Francis W. O'Connor,
Harry P. Orchard, Ernest V. Oulton, Robert C. Paris,
John G. Phillids, Benjamin J. Phillips-Jones, Arthur H.
Pollard, Mohamed A. Rahman, Jeffrey Ramsay,
Alfred B. Rooke, Vyvyan K. Sadler, Barnett Saul,
George H. Sedgwick, George A. Simmons, George M.
Simpson, Frank O. Spensley, Sidney F. St. J. Stead¬
man, Robert Y. Stones, Edward Sutcliffe, Reginald S.
Townsend, Harold T. Treves, James R. H. Turton,
Bernard Vasvill, Harold F. Vellacott, Walter G. H. M.
Verdon, Paul J. Verrall, Sydney Vosper, Frederick J.
Waldmeier, George H. Watson, John N. Watson,
Robert J. Willan, Ivan S. Wilson, James F. Windsor,
George E. Wood, William H. Woodburn, Leonard H.
Wootton, Oswald K. Wright.

Royal Coll*?* of Physicians and Surgeons.

The Diploma in Public Health of the Royal Colleges
of Physicians and Surgeons was issued to the following
candidates :—Isodore M. Bourke, L.R.C.P., M.R.C.S.;
Edwin Eckersley, M.B., C.M.Edin. ; Robert J. Ewart,
F.R.C.S., L.R.C.P., M.D.Vict. ; Matthew H. Fell,
L.R.C.P., M.R.C.S. ; Harry A. Foy, L.M.& S.Bombay,

L. R.C.P.& S.Edin., 1 .F.P.& S.Glas. ; Frederick W.
Lewis, M.B.Lond. ; William G. Liston, M.D., Ch.B.
Glas. ; Edward D. Parsons, L.R.C.P., M.R.C.S.;
Wentworth F. Tyndale, C.M.G., L.R.C.P., M.R.C.S.,

M. B.Lond. ; Brian Watts, L.R.C.P., M.R.C.S., M.D,
Bruxelles; Bernard H. Wedd, L.R.C.P., M.R.C.S.;
M.D.Lond. ; James E. Wilson, M.B., B.Ch., R.U.I.,
Charles R. Wood, L.R.C.P., M.R.C.S., M.D., B.S.
Durh.

Royal College of Physicians of Edinburgh, Royal College of
Surgeons of Bdlabargb, and Paculty of Physicians and
Surgeons of Glasgow.

The quarterly examinations of the above Board,
held in Edinburgh, were concluded on the 22nd inst.,
with the following results :—

First Examination ( four years' course). —Mr. Thomas
Kennedy, Belfast, passed the examination.

First Examination ( five years' course). —Of 37 can¬
didates entered, the following 17 passed the Examina¬
tion : John Richard Smith, Maneck B. Motafram,
Hormusji J. Dadysett, Arthur Saldanha, Robson E. I.
Mason, Victor G. L. van Someren, John Ross, Michael
P. Power, David A. Evans, William J. H. Davies,
Ernest J. Fisher, Andrew Hegarty, James A. Hutchin¬
son, Satis Chandra Das, Harry C. Sutton, Frank D.
Johnson, and Gajanan J. Nahimtura ; and 6 passed
in physics, 9 in biology, and 2 in chemistry.

Second Examination ( four years' course). —Of 3 can¬
didates entered the following 2 passed the examina¬
tion : Michael J. O'Shea, and Richard B. Sephton.

Second Examination ( five years’ course). —Of 41
candidates entered, the following 18 passed the exa¬
mination : Ernest B. Keen, John W. Hitchcock (with
distinction), Charles B. Robinson, Thomas N. Usher
(with distinction), George F. Neill (with distinction),
Alfred K. Tughan, Rankin G. Walker (with distinc¬
tion), Ralph C. Fuller, Robert H. Jones, Harold H.
Field-Martell, Andrew D. Turnbull, Robert Massie,
MacWilliams Henry, William T. Torrance, Robert M.
M- Wilson, Syed Abdul Karim, Bertram Flack, and
Isaac J. McDonough ; and 4 passed in anatomy and 2
in physiology.

Third Examination ( five years’ course). Of 30 can¬
didates entered, the following 17 passed the examina¬
tion : John Young, Baldey Singh, Surendra Kumar
Sen, Albert R. H. Harrison, George F. Ford, Thomas J.
George, Edith Huff ton. Marguerite Alice C. Douglas,
Edmund Eccles, William Watson, Claude E. Watts,
Francis S. Crean, James Morham, Harold A. Higginson,
Lily Holt, Hormusji Jehangir Dadysett, and Gajanan
Jinabhai Mahimtura ; and 4 passed in materia medica.

Final Examination. —Of 54 candidates entered, the
following 17 passed the examination and were admitted

ized by Google

July 31.1907.

PASS LISTS.

The Medical Pees*. 131

L.P.C.P.E., L.R.C.S.E., and L.F.P. & S.G.: Ernest
Pielden Nivin, Dennis Cregan McCabe-Dallas, William
Alexander Huston, Lakshmi Narayan Ghosh, Richard
Howard La Barte Cummins, Francis Ernest Robert
Bartholomeusz, Thomas Richard McKenna, Samuel
Jay Aanji Kotak, John Scott Ward, Oliver Carlyle,
John Edmund Cox, John Arthur Cadman Tull. William
Clegg-Newton, Thomas McClure, Rajanja Robert
Williams, David Williamson Anderson, and Thirukamu
Sundara Reddy ; and 5 passed in medicine and thera¬
peutics, 3 in surgery and surgical anatomy, 8 in mid¬
wifery, and 10 in medical jurisprudence.

The Royal University of I reload. H

The Senate met on Friday, July 26th, at 11.30 o’clock
a.m. There were present: The Right Hon. Lord
Castletown, of Upper Ossory, C.M.G., Chancellor of the
University; Sir Christopher Nixon, Bart., M.D.,
LL.D., Vice-Chancellor, Rev. William Delany, LL.D,,
Edward Cuming, M.A., Rev. Thomas Hamilton, D.D.,
LL.D., John R. Leebody, M.A., D.Sc., Michael F.
Cox, M.D., Rev. William Nicholas, D.D., Sir Henry
Bellingham, Bart., M.A., Right Hon. Lord Killanin,
Sir William Thomson, C.B., M.A., M.D., Bertram
C. A. Windle, M.D., D.Sc., F.R.S., Right Rev. Mon¬
signor Mannix, D.D. Sir James C. Meredith, LL.D.
and Joseph McGrath, LL.D., Secretaries. Apologies
were received from SirThomas Moffett, LL.D., D. Litt,
Sir John Banks, K.C.B., M.D., LL.D., Right Hon.
John Young, M.A., Most Rev. Edward Thomas
O'Dwyer, D.D., Bishop of Limerick., Rev. Nathaniel
McA. Brown, J. Walton Browne, B.A., M.D., Richard
W. Leslie, M.D., M.Ch., Charles E. Martin. The
results of the recent examinations were considered
and Passes, Honours and Exhibitions were awarded
in connection therewith. The following returns,
which show the progress of the University, as measured
by the number of candidates for the Summer Examina¬
tions since 1902, were submitted :—

Summer,

1907.

Entered.

Retired.

Rejected.

Absent.

Deprived.

Poised.

Matriculation

1,127

1 7

6

4

420

680

First Arts ..

693

IO

I

I

253

428

Second Arts

513

9

I

2

123

378

B.A. Degree ..

179

10

3

-

68

98

First Engineering
Second Engineering

39

37

3

2

:

9

18

27

17

B.E. Degree ..

17

2

-

-

3

12

First Law

14

4

—

-

2

8

LL-B. Degree

6

-

-

2

4

LL.D. Degree

3

-

—

-

—

3

First Medical

Diploma in Public

93

4

6

25

58

Health .. ..

1

-

—

-

1

—

2,722

59

19

7

924

I » 7 I 3

Corresponding figures in former years :

—

1,670

1906 ..

2.515

70

20

6

749

1905 ..

2,313

7 1

24

I

732

1,485

T\ 1904 ••

2,184

67

19

3

636

L 359

1 , 1903 ••

2,012

55

14

3

567

1,473

1902 ..

1,902

55

17

5

589

i,2„6

It was unanimously agreed to confer the Degree of
LL.D. Honoris Causa upon Sir Otto Jaff6, Knight, J.P.,
Belfast, in recognition of his valuable public services,
especially in the cause of education ; and the Degree
of D.Mus.. Honoris Causa upon Mr. W. H. Grattan-
Flood, in consideration of his valuable musical com¬
positions and his contributions to Irish periodic litera¬
ture.

The following resolution was moved by Sir Chris¬
topher Nixon, Bart., Vice-Chancellor of the University,
seconded by Rev. Dr. Hamilton, and passed unani¬
mously :—

“That having regard to the injurious impressions
produced by the adverse comments on the working
of this University as a teaching and examining body,
made in the report of the Royal Commission on
University Education in Ireland (1903), and in that
of the Royal Commission on Trinity College, Dublin,

and the University of Dublin (1907), the Senate
earnestly desires to bring under the notice of the
Government the serious injury to higher education
in Ireland which will result from any further post¬
ponement of the settlement of a question so vitally
bound up with the intellectual and material progress
of the country.”

And the following were named as a deputation to
wait on the Chief Secretary in reference thereto :—
Pight Hon. Lord Castletown, of Upper Ossory, C.M.G.,
Sir Christopher Nixon, Bart., M.D., LL.D., Rev.
William Delany, LL.D., Rev. Thomas Hamilton, D.D.,
John R. Leebody, M.A., D.Sc., Alexander Anderson,
M.A., LL.D., Right Hon. Lord Killanin, Bertram
C. A. Windle, M.D.. D.Sc., F.R.S., Right Rev. Mon¬
signor Mannix, D.D.

It was agreed to fix October 22nd, 1907, at d.30
o’clock p.m. for the next Annual Meeting of Con¬
vocation.

A meeting of the University was subsequently
held at which the following Degrees were conferred :—
Degree of Doctor of Laws, Samuel James Diamond,
John Francis Butler Hogan, Charles James MacGarry.

The First Examination in Medicine. —Christopher
Barragry, Daniel J. Barrett, John L. Brown, Peter A.
Clearkin, Maurice J. Cogan, Ernest Colgan, Patrick
J. Corcoran, John F. Craig, Thomas P. Davy, Joseph
C. Denvir, Bernard Doyle, B.A., Gerald Fitzgerald,
Thomas F. S. Fulton, Michael J. Gallagher, Joseph
Gorman, M.A., Thomas D. Graham, Gerald S. Harvey,
James Hill, Joseph O. Hodnett, Norman L. Joynt,
Francis J. Keane, James J. Keirans, John L. Kilbride,
James Lafferty, Hugh T. S. M'Clintock, Robert J.
M‘Connell, Laurence J. J. M'Grath, Michael M'Guire,
Aloysius D. MacMahon, Robert C. M'Millan, Daniel
M'Sparron, Cornelius Martin, William Megaw, William
M. Millar, Alexander G. Mitchell, John J. H. Mitchell,
Henry H. Mulholland, Henry J. V. Mullane, Daniel
O’Brien, John P. O’Brien, James O’Connor, Thomas
F. O’Donoghue, William M. O’Farrell, Joseph A.
O’Flynn, latrick J. O’Grady, Oriel J. O. O’Hanlon,
Hugh O’Neill, Joseph Patrick, Joseph Porter, Joseph

H. Porter, James M. Rishworth, Walter N. Rish-
worth, Maurice J. Roche, John M. Rowe, Hugh A.
Skillen, Thomas Smyth, Francis J. D. Twigg, William
Wilson.

Honours in Botany, First Class. —James J. Keirans,
Ernest J. Colgan, Joseph H. Porter.

Second Class. —Michael M’Guire, John J. H. Mitchell,
Joseph O. Hodnett.

Honours in Zoology, First Class. —Ernest J. Colgan,
James J. Keirans.

Second Class. —John J. H. Mitchell.

Honours in Chemistry, First Class. —None.
Second Class. —James J. Keirans.

Honours in Experimental Physics, First C/ass.—
Joseph O. Hodnett.

Second Class. —Aloysius D. MacMahon, James J.
Keirans, Ernest J. Colgan, Hugh O’Neill.

Exhibitions. — First Class, £20. —James J. Keirans.
Second Class, £10.— Joseph O. Hodnett.

Diploma in Public Health Examinations.—Part I .—
Stephen B. Walsh, M.B., B.Ch., B.A.O.

L© ntfoo School of Tropical Modlcinc.

The following candidates have passed the examina¬
tions from May to July. 1907 :—

With Distinction. —Captain F. H. G. Hutchinson.

I. M.S., M.B., C.M. (Edin.), 1892. D.P.H. Camb., 1907 ;
Captain W. S. Willmore, I.M.S., M.R.C.S., L.R.C.P.,
1895 • Captain J. N. Walker, I.M.S., M.P.C.S.,

L. R.C.P., 1897 ; A. W. Balch, Surgeon U.S. Navy,

Ph.G. (Mass.) 1894, M.D. Harvard, 1898 ; C. A.
Godson, I.M.S., M.R.C.S., L.R.C.P., 1904; F.

Grenier (Colonial Service), M.B., C.M. (Edin.), 1891.

Ordinary Pass. —T. R. Beale Browne (Colonial
Service), M.R.C.S., L.R.C.P., 1901 ; J. C. C. Ford
(Colonial bervice), L.R.C.P. and S., L.F.P. and S.
(Glas.), 1900; G. Wilkinson, M.B., B.C. (Camb.),
T.S.A., 1892 ; E. Weatherhead, M.B. (Camb.), 1903.

M. R.C.S., L.R.C.P., 1903 (Colonial Service),

Google

DigitiZi

132 The Medical Press. NOTICES TO CORRESPONDENTS.

July 31,1937.

NOTICES TO
CORRESPONDENTS, ffc.

tSF Corrib pondmnts requiring a reply in this oolnmn are particu¬
larly requested to make use of * Distinctive Signature or Initial, end
to avoid tfie practice of signing themselves “ Reader," “ Subscriber,”
"Old Subscriber," Ac. Muoh confusion will be spared by attention to
this rule.

SUBSCRIPTIONS.

Subscriptions may commence at any date, but the two volumes
each year begin oo January 1st and July 1st respectively. Terms
per annum, 21s.; poet free at home or abroad. Foreign subscriptions
must be paid in advance. For India, Messrs. Thacker, Spink and Co.,
of Calcutta, are our officially-appointed agents. Indian subscrip¬
tions are R». 15.12.

ADVERTISEMENTS.

FOR One Insertion:— whole Page £5; Half Page, £2 10s.;

Quarter Page. £1 5s.; One-eighth, 12s. 6d.

The following reductions are made for a series:—Whole Page, 13
insertions, at £3 10*.; 26 at £3 3s.; 52 insertions at £3, and pro
rata for smaller spaces.

Small announcements of Practices, Assistsnciee. Vacancies, Books,
Ac.—Seven lines or under (70 words), 4s. 6d. per insertion ; 6d.
per line beyond.

Reprints.— Reprints of articles appearing in this Journal can be had
at a reduoed rate, providing authors give notice to the Publisher or
Printer before the type has been distributed. This should be done when
returning proofs.

Original Articles or Letters intended for publication should
be written on one side of the paper only and must be authenticated
with the name and address of the witter, not necessary for publica¬
tion but as evidence of identity.

Civil Surgeon. —The last tabulated figures available that
give the incidence of enterio fever in the army in South Africa
are those for 1905. The average strength of European troops in
South Africa for the year was 18,593 warrant officers, non¬
commissioned officers and men. Among this number there were
231 admissions for enterio fever, 17 deaths and a “ constant
sickness " of 43.60. The rate of admission was 12.4, the mortality
.91. and that of " constantly sick ” 2.35 per 1,000- These figures
showed a marked decrease from 1904, for then the figures were
admissions 29.5, deaths 3.79, and average "constantly sick” 6.2L
There is even a greater decrease when these figures are com¬
pared with average for the three years immediately following
the war, namely, 1902-1904. This average showed a decrease of
admissions 16.5, deaths 2.48, and average “constantly sick ” 3.35.
The enteric fever in the army in South Africa last year, as a
matter of fact, was less frequent and less fatal even than
influensa, for that disease caused 622 admissions and 25 deaths.

Inquibens. —The whole subject is fully explained in Dr. Shew-
Mackentie's book ’’ On the Nature and Treatment of Cancer"
(fourth edition), published by Messrs. Bailllere, Tindall and
Cox.

Optician. —We oannot publish our correspondent’s letter, inas¬
much as the oomplaints made do not appear to be well founded.

Db. A. B. J. Is thanked for his communication; we will look
into the matter, and give our opinion thereon in a private
letter.

Dr. J. O. C. will find his communication referred to in
another column.

Legend. —Our correspondent is thanked for his enclosure,
which, however, is scarcely suitable for this journal.

F. A. B. (Liverpool).—Dr. Munro's “Manual of Medicine,”
a second edition of which has reoently appeared, would answer
your requirements exactly.

L. F. P. 8.—We know of no official figures to show that
trachoma is actually increasing in the East End of London,
The disease is oertainly an alien one. and should be guarded
against bv the inspectors at porta, and we know that immigrants
are rejected on tnis score. The newspapers are breaking out
into alarmist articles on the subject, but we have not yet
seen evidence to show that there is more ground for alarm
iln n there has been for some years past.

the Treatment of hairy moles.

Iota writes: In reply to “ Query’s ’’ question about the treat¬
ment of moles, he may find painting the pigmented areas with
ethvlate of sodium effective. If carefully applied a scab forms
on ‘the area, which peels off without lenving much scar. Elec¬
trolysis will remove small moles and the hair-bulbs of hairy
moles. Rontgen rays are disappointing.

From the " Gentlewoman.” —A well-known physician (I can
vouch for the truth of the story) was called out late one night
to see a child. After entering into the minutest details with
regard to the neoessary poulticing and nursing, the doctor
explained his intention of calling early the following morning.
“Call, and will yer?” retorted the mother, arms akimbo, "and
ver don’t think our Willie’s ill enough for medicine, that yer
don’t! By gad, yer can go, for I'll have a man that ' oan
doctor.’ ”

ftaomdes.

Metropolitan Asyluraa Board.—Assistant Medical Offioers. Salary,
£180 per annum, with board, lodging, and washing. Applica¬
tions to The Clerk, Metropolitan Asylums Board, Embank¬
ment, London, E.C.

Devon County Asylum.—Assistant Medical Officer. 8alary, £140
per annum, with hoard, apartments, and laundry. Applica¬
tions to the Medical Superintendent, Exminster.

Zantibar Government.—Bacteriologist. Salary, £300 a year, with
free quarters, etc. Applications to Mr. A. W. Clarke,
Foreign Office.

County Asylnm, Micklcover, Derby.—Junior Assistant Medical
Officer. Salary, £120 per annum, with furnished apartments,
board, washing, and attendance. Applications to Dr. Legge.

Newport and Monmouthshire Hospital—Secretary and Superin¬
tendent. 8alary, £200 per annum. Applications to the
Chairman, Newport and Mon. Hospital, Newport, Mon.

Royal Lancaster Infirmary.—House Surgeon. 8alary, £100 per
annum, with residence, board, attendance, and washing.
Applications to the Secretary.

Stockport Infirmary.—House Surgeon. Salary, £100 per annum,
with board, washing, and residence. Applications to the
Secretary.

Whitehaven and West Cumberland Infirmary.—Resident House
Surgeon. Salary, £120 a year, with board and lodging.
Applications to Wm. H. Sands, Secretary.

Loughborough and District General Hospital and Dispensary.—
Resident House Burgeon. Salary, £100 a year, with fur¬
nished rooms, attendance, board, and washing. Applications
to Thos. J. -Webb, Secretary.

Taunton and Somerset Hospital.—House 8urgeon. Salary, £100
per annum, with board, lodging, and laundry. Applications
to Reginald A. Goodman, Secretary, Hammet Street,
Taunton.

Liverpool Royal Southern Hospital.—Resident Pathologist and
Registrar. Salary, £100 per annum, with board and residence.
Applications to the Superintendent.

Staffordshire County Asylum at Stafford.—Assistant Medical
Officer. 8alary, £150 per annum, with furnished apartments,
board, and washing. Applications to the Medical Super¬
intendent.

Plaistow Fever Hospital, London.—Second Assistant Medical
Officer. Salary, £100 per annum, with board, - etc. Applica¬
tions to the Medical Superintendent, Plaistow Hospital,
London, E.

The Cambridgeshire, etc., Asylnm.—8eoond Assistant Medical
Officer. 8alary, £120 per annum, with board, lodging, and
attendance in the Asylum. Applications To T. Musgrave
Francis, Clerk to the Visitors, 18 Emmanuel 8treet, Cam¬
bridge.

^Lppohttntema.

Boicott, A. E.. M.D., B.S.Oxon., Gordon Lecturer on Pathology
at Guy’s Hospital.

Collie. R. J., M.D., O.M.Aberd., a Medical Referee under the
Workmen's Compensation Act, 1906, to be attaohed to County
Court Circuit No. 43.

Cope, V. Zachart, M.D., B.S.Lond., Resident Medical Officer at
the British Lying-in Hospital.

Kerr. Harold, M.D., Ch.B.Edin., D.P.H.Camb., Assistant Medi¬
cal Officer of Health of the City of Newcastle-upon-Tyne.

Jones, Richard, M B., M.8.Edin., D.P.H.Camb., Medical Referee
under the Compensation Act for thS County Court Circuit
of Blaenau Festiniog and Portniadoo.

Leslie, W. Morrat, M.D., M.S.Edin., Medical Referee under the
Workmen’s Compensation Act in the City of London.

MacMtn, J., M.D., M.8.Edin., Certifying Surgeon under the
Factory and Workshop Act for the Kirkcudbright District of
the county of Kirkcudbright.

Paul, V. G. J., M.R.C.S.. L.R.C.P.Lond., Certifying Surgeon
under the Factory and Workshop Act for the Harwich Dis¬
trict of the oounty of Essex.

Frame, T. F., M.D.Brux., F.R.C.S.Eng., M.R.C.P.Lond., D.P.H.,
Health Officer to the Corporation of Calcutta.

firrihs.

Dbu Drort.—O n July 23rd, at Grahamstown, Cape Colony, the
wife of Edward Guy Dru Drury, M.D., B.S.Lond., of a son.
Rowe.—O n Julv 21st, at 260 Woodborough Road, Nottingham,
the wife of W. T. Rowe, M.D., B.8.Lond., of a daughter.

JHarriaa?0.

Archibald—Riddle. —On July 25th, at Holy Trinity, Cpper
Tooting, Richard James Archibald, M.R.C.8., L.R.C.P., of
Wandsworth Common, London, and Ramsgate, to Gertrude
Florence, eldest daughter of F. H. Brlmble-Rlddle, of Upper
Tooting. . _ .

Collinori doe—Klein. —On July 34th, at St. Stephen s. East
Twickenham, William Rex Collingridge, M.R.C.8., L.R.C-P-,
of Morland, Penrith, elder son of Dr. and Mrs. Collingridge,
to 8vbil Florence, elder daughter of Dr. and Mrs. E. Klein.
Jcler—Chambeblatne.— On July 26th. at Bt. Peter's, Witherley.
Frank Anderson, eldest son of H. Juler, Esq.. F.R.OA, of 23.
Cavendish Square. London, to Mabel Alicia, eldest daughter or
S. B. H. Chamberlayne. Esq., of Witherley Hall. Atherstone.
Lamolet—Rydrr.— On July 27tb, at Bt. Peter’s Church. Dulwien
Common. George Johnson Langley, M.D.Lon., eldest son or
George R. Langley,of Camberwell Green, to Mabel Rose, daughter
of the late Walter Greenway Ryder, and of Mrs. Ryder, or
Dulwich. _ .

Murray —Bott—O n July 24th, at 8t. John's, Paddington, Kenneth

G. V. Murray. P.W.D., Egypt, youngest son of 8urg.-Lt.Col. John
Murray. A.M.6. (retired), of 12 Astwood Road, London, to Muriel

H. H. Bott. daughter of the late John Bott and Mr*. Bott,
formerly of Cheltenham.

JJarths.

Fowler.— On July 20th, nt Enst Suffolk Hospital, Ipswich.
Charles Breame, M.R.C.S., L.R.C.P.. son of the late Lieut.-
Colonel B. W. Fowler, R.A.M.C., and of Mrs. Fowler, or

Moom.—On July 24th, at Branscombe, Guildford, Sarah, widow
of late W. H. Moor, M.D., aged 68
Watson. —On June 15th, at his residence, in Queenstown, Cape
Colonv, Alexander Lawrie Watson. M.A., M.B., Ch.B.. son of
George Watson, Esq., Alloway Park, Ayr.

zed by G00gk

The Medical Press and Circular.

“SALUS POPULI SUPREMA LEX.*

Vol. CXXXV. jWEDNESDAY, AUG. 7, 1907. No. 6

Notes and Comments.

The assembly in London of the
Second International Congress on
School Hygiene School Hygiene is an event of no
Congress. little importance, for it marks
in some degree the fact that the
British people who are credited with being poss¬
essed of a business-like faculty, consider that it is
worth their while finding out something about this
new science. Mr. MacKenna has given out that
many of the decisions of the Board of Education
are being reserved till he has ascertained the views
and experience of the medical educationalists
attending the Congress, and for this peculiarly
backward Board to have grasped that school
hygiene is not a mere fad for the delectation of
doctrinaires and busy old maids, but a practical
science on the development and application of which
much of the future of the country depends, is a
sign of hope for the rising generation or, at any
rate, for the next rising generation but one. More¬
over on the various Committees of the Congress
are to be found many excellent people who
already recognize that though school hygiene has
none of the glamour of politics nor the advertising
advantages of philanthropy—as frequently prac¬
tised—yet that it is in itself an object, and a
worthy one, of patriotism. And perhaps most
significant of all is the willingness of hard-headed
business men who have no immediate concern
with the public health as usually understood, to
give large sums to the expenses of the Congress,
in order that the industrial and commercial pros¬
perity of the country may be maintained, and their
own profits thereby kept up. Assuredly then,
when science, philanthropy, and commerce are
found coquetting under the bland aegis of the
Government, we may feel that the birth-right of
a fair healthy start in life is likely at some time to
become the possession of the proverbial happy
English child.

It is curious as showing the tend-
fl, ency of the public thought at the
Municipalised moment to notice which of the
Misical Mu— papers read at the British Medical
Association meeting at Exeter is
most extensively noticed and commented on in the
general press. Apart from the President’s excellent
address, this honour seems to have been accorded
to Dr. Arthur Newsholme’s communication to
the State Medicine Section, in which he spoke
of the whole trend of things at the present time
being towards the establishment of a municipal
medical service. That undoubtedly is true, and
it is a part of the municipalisation of many in¬

dustries which has been going on so rapidly of late
years to the alarm of the financiers, and to the com¬
fort of the poor and lower middle classes, whose
necessities were frequently exploited without com¬
punction. But it is a far cry from the municipal¬
isation of water and gas to the municipalisation of
the medical attendant, and though for attendance
on the poor such an official may eventually develope
out of the friendly society and club doctor of to-day,
it is not in human nature as at present constituted
to take the doctor that is forced on you by the
State when you can afford to pay for one of your
own choice. Dr. Newsholme thinks that the
increasing number of cases treated in voluntary
and rate-aided institutions is only a phase in a
movement which will end in the proper treatment
of all diseases at the expense of the community ;
and indeed the municipal fever hospital, which
was originally founded as a preventive measure,
is now used in some towns for the treatment of
consumptives, and the isolation hospital itself,
which was originally designed for paupers is now’
universally used for all classes, generally without
fee.

But, however much the municipal.
And the communal, or socialistic solution
Municipal might relieve the problem of
Hospital. medical attendance on the poor
of its worst features, such a system
would necessarily connote the annexation of the
hospitals as well, and it certainly is a question
whether the people generally are sufficiently edu¬
cated yet to run a hospital with all its varying
interests. Naturally, they w'ould insist, and
rightly insist, on the treatment of the patient being
the first consideration, but they would be exceed¬
ingly apt to overlook the educative and scientific
functions of a hospital. The facilities for both
these purposes at the present moment in all
popularly governed medical institutions, if
the pathological departments of some of the
asylums be excepted, are either very poor or non¬
existent, and unless democracy were much better
instructed in the value of pure learning than it is
now% there w’ould be great danger of its
overlooking the value to humanity of the clinical
laboratory, pathological research, and the criticism
of students.

As an example of the incapacity
A “Return "Case °* P eo Pl e to comprehend the un-
aad fortunate limitations of medical

its Result. practice, w’e may instance the
chronic troubles that rage about
fever hospitals and “ return ” cases. _ At the present

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134 The Medical Tress.

LEADING ARTICLES.

Aug. 7, 1907.

moment a wordy warfare is raging at Wolver¬
hampton, on account of one of these unlucky
events. One of the magistrates in that town,
Mr. C. Marston, is, in what he considers the public
interest, vigorously championing the case of one
of his employees who with his son caught scarlet
fever from a child discharged from the municipal
fever hospital. The discharged patient had been
detained six weeks in hospital and seems to have
undergone the usual preparation prior to leaving
the institution. He, however, developed nasal
discharge shortly afterwards and infected his
father and brother with the disease. Such un¬
fortunate mishaps are so common that all in¬
structed persons have learned to regard them
as normal and unavoidable features of fever hos¬
pital administration, but to the lay mind they
present the elements of unpleasant surprise and
the conviction that there must have been want
of proper care and supervision. Consequently
columns of the local paper are occupied with
polite recriminations between the Mayor, the
Medical Officer, and Mr. Marston, and public
sympathy seems to be on the side of the non¬
official. Such occurrences would be multiplied
a thousandfold were all hospitals and medical
services municipalised.

Last week William Rae, the
Death of “ bloodless surgeon,” died at the
William Rae. age of 67. It is only two years
since he sprang into fame in the
curious line he selected for him¬
self, and since the boom of the summer of 1905,
which converted his village of Blantyre into the
“ Lanarkshire Lourdes,” very little has been
heard of him and his doings. It is due to him,
however, to say that a large number of floral
offerings were sent to his funeral by “ grateful
patients,” although it seems from the accounts
that an almost equally large number of people
were disappointed at his death because they were
still “ awaiting cure.” We may at least charit¬
ably suppose that Rae himself believed in his own
powers, and that he became intoxicated with
the credulity and enthusiasm of his clients, but
it sounds rather curious to learn that ” Rae’s
practice, it is believed, will be taken up by his
son, a sturdy dairyman, who has shown some of
his father’s genius.” As a matter of fact the
force of personality is never better shown than
by the break down of the “ systems ” of quacks
as soon as the originator passes away. We
venture to predict but little success for the
“ sturdy dairyman ” unless he indeed possesses
the “ genius ” of the miner surgeon, his father.

LEADING ARTICLES.

ACCURACY OF THOUGHT IN MEDICINE.

The address in medicine at the Exeter meeting
of the British Medical Association was entitled
“A Plea for Accuracy of Thought in Medicine.”
The fact that it was delivered by Dr. Hale White
is sufficient guarantee of a wise and masterly treat¬
ment. At first sight it would appear that to plead
for greater accuracy of thought in medicine
would be simply to admit that the science in ques¬
tion has not yet reached finality. For in a certain
broad sense all progress in science depends strictly

upon greater accuracy in estimation, in com¬
parison, and in all other methods whereby adequate
knowledge of facts and of the relations of facts is
obtainable. Medicine is not an exact science, in¬
asmuch as it has to deal with many as yet im¬
perfectly understood laws and phenomena, and is
obliged to trust to many imperfect methods of
investigation. So that the medical man has to
be as accurate as he can in regard to many things
and to adopt as a working theory that which
appeals to his judgment as being most in confor-
formity with ascertained facts. Dr. Hale White
however, shows that medical men often deal
intellectually with many things daily before them
in a loose and slipshod intellectual fashion. He
instances gout, in which we know that urate of
sodium is deposited in some cartilages and other
structures, and that there is an excess of uric
acid in the blood. We speak of gout, bronchitis,
neuralgia, sciatica and so on, but where are our
proofs in the shape of a sufficient number
of accurate post-mortem observations ? Many
obscure symptoms are referred to irregular or
suppressed gout, whatever that may mean. Would
it not be better to speak out boldly and say we do
not know rather than beat the air with nebulous
phrases that serve to cloak our ignorance ? The
candour thus advocated is clearly an attribute of
the really scientific mind, but to advise a constant
assertion of nescience would be to most medical men
a counsel of perfection. It may be doubted whether
even a man so secure in professional eminence
as Dr. Hale White could carry out that attitude
for any length of time in his relations with students,
with the medical profession, and with his patients.
To inspire confidence is one of the first essentials
of practice and the man who lacks a certain amount
of dogmatism is apt to be a failure both as a teacher
and as a consultant, or as a practitioner, if he be
in general practice. Another illustration of in¬
accurate reasoning was taken from the treatment
of chronic osteo-arthritis, which being an affection
of the joints more or less resembling gout, is some¬
times treated with the restricted diet appropriate
for gouty patients. Then we are reminded that
peripheral neuritis due to alcohol is wont to.attack
the anterior tibial nerve in women. We accept the
statement of fact and for the rest we calm our in¬
tellectual activities into self-satisfied repose with
the blessed Mesopotamian w-ord “ selection.” Yet
it is difficult for a medical man who has been
pressed into a corner by the cross-examination of
*' intelligent ” patients to offer any truer explan¬
ation, because as yet none is known to science.
The doubt that may reasonably exist as to the exact
state of the cardiac muscle in a given case may
in future be "to a great extent avoidable by the
use of the ortho-diagraph. The introduction of
more accurate methods of investigation clearly
gives us the data of more accurate thinking, the
desirability of which must be evident to all who
cultivate science. One point raised by Dr. Hale
White is of considerable importance, namely,
the way many medical men have of dealing with
statistics, often laboriously collected, while they

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Aug 7.1907.

CURRENT TOPICS.

Thk Medical Pans. 135

have failed to grasp the fundamental principles of
statistical science. When trying to estimate the
surgical mortality after operation for impacted
gallstone for instance one must remember that
impacted gallstone rarely causes death. During
40 years at Guy’s Hospital there was only one death
in a case not operated on, the total number of
deaths from all causes being over 30,000. Mr.
Bland-Sutton taking statistics from various Lon¬
don and provincial hospitals finds that out of 35
cases operated upon ten died, or nearly 30 per cent.
Before we decide, therefore, that a patient should
be advised to seek relief in operation, we have to
consider carefully the high mortality that is en¬
tailed. Of this address it may be said that in itself
it constitutes a valuable and suggestive object
lesson in simple, clear and well-balanced reasoning.

CITY METHODS OF PHILANTHROPY-
The great world of medical philanthropy is
doubtless working out its salvation by a species
of evolution in which the struggle for existence
leads to a certain amount of wasteful rivalry and
of unfair competition. The hospital funds that
have come into existence throughout the King¬
dom bid fair sooner or later to establish some sort
of reasonable control over the medical charities
of which they are primarily the distributing and
collecting agents. At present the chief defect of
the funds, metropolitan and provincial, lies in the
fact that they are not representative, as they
should be, of subscribers, of the medical profession,
and of the public generally. The result is that
3 mall boards of management seek to thrust private
fads upon the charities that fall within the scheme
of their distribution of grants. To take a recent
instance, the Metropolitan Hospital Sunday and the
King Edward VII. Funds have insisted upon the
amalgamation of the orthopaedic hospitals, regard¬
less of the terms of existing charters or con¬
stitutions, or the sacrifice of valuable freehold
sites. A similar policy of amalgamation, however,
is not forced upon the ophthalmic or the throat
hospitals, which abound in London and which
are surely just as suited for amalgamation as the
orthopaedic institutions. But what have the Funds
to say to the cripples’ institutions ? Were there
not enough existing already in the Metropolis
without the addition of another by Sir William
Treloar ? Why should not the great sums he has
collected with indomitable vigour have been de¬
voted to the extension and consolidation of pre¬
existing charities of the kind ? But consistency
does not appear to be a guiding principle of the
Metropolitan Funds. There can be little doubt 1
that the large aunount collected by Sir William
Treloar during his year of office has diverted not
a few subscriptions from other medical charities,
so that in a sense his efforts are open to general
criticism. That his aims are noble and his en¬
thusiasm worthy of admiration may be at once
admitted, but in the great social world purity of
motive is not permitted to put a stop to criticism.
Now Sir William Treloar has again and again
stated that his institution is the only one in |

England in which tuberculous diseases of bone in
children are subjected to systematic surgical
treatment. That assertion has been naturally
called into question by those connected with the
Liverpool Country Hospital, which was founded
ten years ago for that very purpose. A corres¬
pondence between the Chairman of the Liverpool
Hospital and Sir William Treloar has been pub¬
lished. Notwithstanding that the facts were
brought to Sir William’s notice first on the 4th of
June, and subsequently affirmed again and again,
we nevertheless find a letter from the right honour¬
able gentleman was published on July 14th,
repeating the statement, which was reiterated at
the Queen’s Fete. Sir William Treloar, we feel
sure, cannot have meant to act ungenerously to
any institution, however much he may have been
carried away by the ardour and enthusiasm of
his own work. For all that the Funds if they are
to press forward their amalgamation schemes, will
do well to look into the question of the cripples’
homes.

CURRENT TOPICS.

Mr. Haffkine and the Indian Government.

We have had on several occasions to draw
attention to the treatment meted out by the
Government of India to Mr. Haffkine post or
propter the Mulkowal disaster. Whatever they
thought or suspected at the time, there is in
view of the evidence now before them nothing
left for an honourable body of men but to apolo¬
gise handsomely and unreservedly. In June
there was issued, as a Parliamentary paper, the
whole of the documents and reports relating to
that untoward affair, and those who are acquainted
with the value of evidence, especially if they
have a working knowledge of bacteriology, will
have no hesitation, we apprehend, in completely
exonerating Mr. Haffkine from any suspicion of
blame. In the Times, of July 29th, appeared a
letter signed by Professors Ronald Ross, Tanner
Hewlett, Albert Griinbaum, W. J. Simpson,
Leith, W. R. Smith, Sims Woodhead, Klein,
Simon Flexner (of New York), and Hunter
Stewart—surely as representative a body of patho -
logists as could be named—in which the opinion
was expressed that “ the whole charge against
Mr. Haffkine’s laboratory has collapsed, the
charge being not only not proven, but distinctly
disproven.” The signatories proceed to point
out the petulance of the conduct of the Indian
Government in evading this issue, and yet imput¬
ing blame to Mr. Haffkine for abandoning the
“ standard ” method of making the prophylactic
and substituting a new process “ on his own
authority.” The cynicism of this charge fades
away into most delicious impertinence when
it is remembered that Mr. Haffkine invented
the prophylactic himself, and taught the Indian
Government how to manufacture it, and was
continually improving it for their benefit. The
fact is that the Government have made a hideous
error by fastening on the wrong man when

D

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136 Thb Medical Puss.

CURRENT TOPICS.

Aug. 7, 1907.

wishing to fasten on to somebody ; now they have
done more, they have acted snarlishly as they
felt the ground slipping from under their feet.
Is it too late to hope that the officials who now
represent the Government will take the manly
or honourable course of making what reparation
and apology they can to Mr. Hafikine ?

Breathing Appliances in Mines.

The Royal Commission on mines, which has
been sitting for some time, has presented a
preliminary report dealing chiefly with breathing
appliances. It is discouraging to find that this
country, which depends for its prosperity so
largely on mineral wealth, is so far behind other
civilised nations that whereas in Austria and
France the use of breathing appliances is com¬
pulsory, and in Germany their employment is
general; yet in Great Britain, except at the
Tankersley Collieries in Yorkshire, they seem to
be regarded as mere scientific toys. It appears
from the report that in Westphalia these appli¬
ances have been shown to be so advantageous
to the employers in the case of fire and flooding
of mines, that they have been universally adopted,
and the workers themselves thus, through an
indirect channel, get the security they afford.
After testing a good many appliances the Com-
mission have come to the conclusion that though
there have been great improvements in the
latest patterns, no one type is to be recommended
for compulsory adoption, but they hope that
the mine owners will adopt some one of the
best patterns without delay. It is recommended
that neighbouring collieries should group them¬
selves into areas having a central rescue station,
and that special men should be trained by practice
in rescue work to use the appliances. It
seems not a little odd that whereas divers have
for years been supplied with air while they work
under the sea, an invention to preserve the life
of workers in foul gases is only just coming to
the fore. At any rate it may be hoped that
mine owners will not need any further stimulus
to adopt this means of protecting and rescuing
their workers, now that the Royal Commission
has shown its practicability.

Medical Arrangements on American Liners.

At this time of year the cross-Atlantic liners
are crowded with throngs of passengers. Each
year sees a considerable increase in this traffic,
which has now assumed such gigantic proportions
as to tax the resources of the shipping companies
to the utmost. On the other hand, considering
the golden harvest that is reaped from it, no
class of traffic paying steamships like their
passengers, it is a matter for some surprise that
the arrangements for the comfort and well-being
of their clients are not above suspicion. We
have heard of several complaints of a more or
less disquieting nature, but without better
evidence than has been forthcoming it has not
been advisable to notice them. However, last
week a correspondent of the Pall Mall Gazette
again drew attention to the subject, and we

gather from his article that the rush and scurry
on some of these liners is so great, and the medical
arrangements so haphazard, that great discontent
prevails among passengers. It surely is a serious
reproach to these great lines with their floating
palaces if this be indeed so. The tradition, of
course, at sea is that the doctor and his depart¬
ment are quite subordinate considerations, and
in the past when a comparatively small number
of passengers were carried, things were muddled
through somehow. But when three or four
thousand souls are on board a ship the medical 1
responsibility is very great, and we should have
thought that the medical officers would have
been provided with the amplest accommodation
for the reception of the sick, and with staffs
sufficient for all emergencies. No doubt it
would attract passengers greatly to know that
a highly efficient medical service was available
on a particular line, so that apart from humani¬
tarian reasons, it ought to pay any company
commercially to make such provision. But in
the meantime it is pitiful to learn that the Italian
Government are so dissatisfied with the arrange¬
ment made by the companies for their subjects
that they send an official medical man of their
own to see that things are properly looked after
on the voyage.

A Pharmacy Prosecution.

A recent prosecution in Glasgow under the
Pharmacy Acts revealed a curious state of affairs.
The defendant was accused of calling himself a
chemist and of keeping open shop and dispensing
poisons both personally and through an unqualified
assistant, although he was not a duly registered
pharmaceutical chemist. It appeared from the
evidence that he went to this shop 27 years ago,
and after five years of managership took over the
business on the death of the proprietor. During
those 22 years nobody had ever interfered with
him. On the passing of the Pharmacy A.ct in 1868
he had applied to be registered, but his appli¬
cation was refused. His lordship characterised the
offence as serious because the Act was passed
for the protection of the public, and he imposed
fines to the extent of {9 13 s. in all. This accident
suggests that it would be well to supervise the
qualifications of practising chemists periodic¬
ally in all parts of the United Kingdom. The
offence of “ covering ” is not unknown, neither is
that of personation. Indeed, mutatis mutandis r
much the same sort of evasion is probably practised
in the case of medical qualifications. In every
legally recognised profession it is necessary to
devise some efficient control with maintenance of a
register, but probably only the lawyers have
anything like proper machinery for the purpose.

Camphor Eating'.

There seems to be some remote prospect that
camphor eating may be added to the list of drug
habits that have been imported into the United
Kingdom. So far, however there is no particular
reason to dread the prevalence of so dangerous a
craze, any more than that of morphia, or Indian

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Apg. 7, 1907.

PERSONAL.

The Medical Pm». 137

hemp, or chloral, or other drugs that have figured
on the list for years past. In South America
camphor eating is said to be fashionable, its
victims exhibiting diminished will power and
shattered nervous and circulatory system
common to the prolonged abuse of narcotic drugs.
Camphor is credited with bringing a particular
disaster upon its victims in the shape of general
paralysis. The drug in question is prescribed
much more commonly in America than in our own
country, and it is possible that this fact to some
extent accounts for the greater frequency of cam¬
phor eating on that side of the Atlantic. At any
rate, we refuse to believe that the practice has
gained any real foothold in the United Kingdom.
It is always difficult to get direct evidence as to the
actual facts and figures of a particular drug, and
as a rule the investigator is forced to trust to the
reports of the markets to show that the consump¬
tion of some particular drug has undergone a
considerable increase.

Disinfecting Dangers.

A death from chlorine gas poisoning occurred
recently in Manchester under somewhat curious
circumstances. An elderly man was engaged by [
the Gorton District Council in Whitsuntide last j
to disinfect a house formerly occupied by a person
suffering from an infectious disease. He used for
the purpose chlorate of potash crystals, and hydro¬
chloric and carbolic acids. During the process
he inhaled some of the fumes, and developed an
illness which proved fatal some ten weeks later. j
Medical evidence showed that bronchitis and
laryngitis were present and that the condition was
primarily due to the inhalation of the fumes. The
incident points to the necessity of proper skill in
the application of gaseous disinfectants, of which j
chlorine is probably by far the most irritating and I
deadly. Sulphurous acid is not only safer, but I
easier to use and cheaper, facts which quite account |
for its popularity. The death above alluded to
took place before the new Compensation Act came
into operation otherwise the Council would have
been responsible for the occurrence. The possi¬
bility of death from disinfectant fumes should be
widely known, and most certainly work in con¬
nection with irritants and dangerous gases should
never be entrusted to anyone who does not possess
the requisite skill and special knowledge.

The Notification of Disease.

The article by Dr. McWalter, published in '
our issue of the 31st ult., contained *suggestions 1
deserving of serious consideration from those |
interested in questions of public health. It is
quite true, as Dr. McWalter points out, that
there is a general assumption that the only
diseases a medical officer of health is expected
to check are those known as zymotic. This is
a very narrow view of preventive medicine, but
one which is tacitly gaining the field. The fact
that it is only the zymotic diseases which are
officially brought to the notice of the health
authorities is doubtless one of the reasons for
this strange narrowing of vision. Dr. McWalter
suggests, therefore, a widening of the present
system of notification, or rather the adoption
of an entirely new method. His plan is that
every practitioner should at regular intervals
furnish the health authority of his district with
a full list of the diseases under treatment.
The list need not contain the names of the 1

patients, so that no question of breach of confi-
' dence could arise. As a result of such informa¬
tion the sanitary authorities would be in possession
of full knowledge as to the state of their districts
1 at any moment. It is of interest that a similar
system to that suggested is already at work irk
j Buenos Ayres and various other cities.

An Anti-Vaocinist Mare’s Nest.

His anti-vaccinist friends will hardly be very
grateful to Mr. Lupton for his question last week
to the President of the Local Government Board
! regarding an alleged death from vaccination at
I Groydon, since it gave Mr. Bums the opportunity
I of exposing another anti-vaccinist mare’s nest.
It has been stated, and Mr. Lupton repeated the
charge, that a child had died at Croydon, on
• 'April 29th, as a result of vaccination; that
the child had sores on the head, face, and arms,
and had lingered in agony for three months.
Fortunately, in the interests of truth, an investi¬
gation of the facts had been made by Dr. Copeman
of the Local Government Board, and, conse-
quentty, Mr. Bums was able to contradict Mr.
Lupton’s statement to the fullest extent. The
sores from which the child suffered had no
relation to its vaccination, but were in fact the
result of over-dosage with bromides, a drug
administered in large quantity by the child’s
mother, on account of fits from which it suffered.
Some twenty other children had been vaccinated
with the same lymph as this child, none of
whom had suffered from any untoward symptoms.
Moreover, it does not appear that there was
any foundation for the statement of the length
of the child’s illness, or even that the illness
had been fatal. We could wish that more of
the “platform facts” of the “anti-vacs”
could be brought to the test of question and
answer in the House of Commons.

PERSONAL.

Mr. Henry Morris, P.R.C.S., unveiled the Jubil.e
memorial window in Epsom College Chapel at the annual
celebration of Founders’ Day on July 27th.

Dr. R. P. Strong, of the American Bureau of
Science, ha; b?en exonerated after enquiry by a special
committee of the charge of inoculating Filipinos with
cholera virus.

Dr. T. Outterson Wood has been presented by
the staff and committee of management of the West-
End Hospital for Nervous Diseases with a handsome
silver bowl on the occasion of his retirement from the
post of Senior Physician. Dr. Outterson Wood has
been appointed Consulting Physician to the hospital.

H. S. H. Prince Alexander of Teck, G.C.V.O..
presided on July 20th at a general meeting of the
Special Appeal Committee of the Royal Waterloo
Hospital for Children and Women. He announced
that the building debt had during the last four years
been reduced from £30,000 to less than £1,000.

Dr. Hector Mackenzie will open a discussion
on the "Complications and Sequel® of Pneumonia and
the Treatment of Pneumococcal Affections by Serum
or Vaccine” at the Royal Society of Medicine, on October
22nd next.

Lord Selby has been able to resume his duties
as chairman of the Royal Commission on Vivisection.
The Commission has now adjourned for the summer
vacation.

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138 Thk Mkcicaz. Puss.

CLINICAL LECTURE.

Aug. 7, 1907.

A Clinical Lecture

ON

THE TREATMENT OF SUPPURATIVE OTITIS.

By R. H. WOODS, M.D., FJLCSJ.,

Surgeon {or Diseases of the Throat, Nose and Ear to Sir Patrick Dun's Hospital.

The obscurity which surrounds some diseases
of the ear and the neglect with which otology has
been treated by those responsible for medical
education in this country, have so deterred
medical men from paying proper attention to
the subject that many practitioners do not diffe¬
rentiate between those maladies that may be
easily understood by anyone with a surgical train¬
ing, and those that still puzzle the most advanced
otologists.

Now it so happens that pyogenic diseases, from
a public health point of view those of the greatest
importance, come under the former class ; and it
naturally follows that since they are better under¬
stood they can be better treated. A few words
on the subject of suppurative otitis media may,
therefore, not be out of place.

It will be convenient in the first place to draw
a picture of a typical case of purulent otitis, and
then see in what way the less typical ones vary
from it.

Suppurative otitis may have its origin in a
variety of ways. Among the more commonly
observed are the following :—

1. As a complication of febrile attacks, espe¬
cially where the fever is due to, or accompanied by
inflammation of the membrane of the throat and
nose, e.g., measles, scarlatina, influenza.

2. From a chill such as follows exposure to a
cold blast impinging on a small part of the body,
as happens, for instance, when sitting in a warm
room near an open window.

3. From mechanical violence such as a box on
the ear, or plunging into water from a height.

4. From using the nasal douche or blowing the
nose very hard, where, in addition to more or less
mechanical damage, septic or other irritating
material is forced into the tympanic cavity along
the Eustachian tube.

From whatever cause arising, the sequence of
events is the same in the vast majority of cases.
The patient is seized with severe, deep-seated
throbbing pain and a sense of fulness in the ear,
accompanied with some febrile disturbance. This
lasts in an untreated case from a few hours to
several days. During this time, fluid, dark-
coloured serum, is poured out from the swollen
mucous membrane into the tympanic and acces¬
sory cavities.

If the attack is mild the quantity will be small
and the swelling of the mucous membrane will
not be great enough to prevent the exudation
finding its way along the Eustachian tube. In all
but the mildest cases, however, the fluid is exuded
with increasing rapidity and the Eustachian tube
becomes more and more obstructed by the swelling
of its lining membrane, the pressure of the fluid
in the tympanic cavity increases until the mem-
brana tympani ruptures, and with the escape of
fluid into the external meatus the patient gets
relative relief. It will thus be seen that the in¬

terval of time between the onset of the attack and
the rupture of the drum is chiefly a question of
the severity of the attack.

From being at first reddish and serous, the
discharge after a day or two changes its character,
and becomes purulent or, more properly speaking,
mucopurulent.

Two courses are open to an ear in this condition.
The discharge may diminish and in a week or two
finally cease and the perforated drum heal up ; in
which event we call the case one of acute suppura¬
tive otitis media ; or the discharge becomes foetid
and continues indefinitely when it is called chronic
suppurative otitis media. What is the essential
difference between the two varieties, and what is
it that determines to which class the case is going
to belong ?

Some ten years ago, I undertook an investiga¬
tion to help to clear this point. In an epidemic
of measles and scarlatina lasting over five months
319 patients were admitted to the Hardwicke
Hospital. I daily examined the ears of each of
these patients. Many of them inflamed during
the course of the general disease, some already had
chronic purulent discharge.

I found that all the acute cases had this in
common, viz., that only one kind of organism was
present in the pus, while the pus from chronic
cases invariably contained a great variety. This
led to the generalisation that all cases of ear
suppuration are acute at first, and only become
chronic by being re-infected through accident, or
want of proper precautions.

That this is the essential difference between
acute and chronic middle-ear abscess is further
borne out by the fact that it is the rarest thing to
see a chronic otitis established in a case where
proper treatment is carried out from the onset.

The object of treatment in such cases should
then be to avoid this epi-infection by preventing
extraneous organisms from becoming implanted
in the tympanic cavity, or, to use a word suggested
by a medical man, himself a sufferer, to keep the
cavity monoseptic.

While it is probable that the external auditory
meatus is not sterile, yet it is more likely that this
secondary infection occurs when the tickling in¬
duces the patient to remove the discharge and
allay the irritation writh the tip of his finger
The pus thus becomes inoculated and as it decom¬
poses, the bacteria spread along it and gain
access to the drum and mastoid cells.

The first step in the prevention of this transition
from acute to chronic is the frequent removal of
discharge by syringing. To accomplish this
apparently easy task one or two points are worth
bearing in mind. In the first place, it is more
important that the fluid used should possess a
solvent action on the muco-pus than that its
germicidal power should be high. Therefore an
alkaline solution is indicated, and I am in the

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Aug. 7, 1907.

ORIGINAL PAPERS.

habit of advocating bicarbonate of soda solution
( 7 >ij. ad Oj.). This will emulsify and remove the
discharge better than an acid or neutral one, and
it has the great advantage in out-patient practice
that it is inexpensive and handy. The syringe
should have a fine nozzle, so that the size of the
stream is small as compared with the lumen of
the meatus. Only by this means can we be sure
that the fluid searches the inner end of the meatus.
It should be so easy to manipulate that the point
of the nozzle can be held in front of the posterior
wall of the cartilaginous meatus without risk of
its slipping inwards and injuring the drum. For
these reasons I have found an ordinary rubber
enema-syringe with a fine ear-nozzle, most suit¬
able, especially when, as is usually the case, the
treatment has to be carried out by someone with
no special training at the work. Glass syringes
are inefficient on account of their small capacity
and dangerous from the difficulty of holding them
properly. The only objection to the rubber
syringe is its price, which is sometimes prohibitive
to the very poor.

When the meatus is thoroughly cleared of dis¬
charge it should be dried. The next step consists
in introducing some drug into the meatus which
will have the effect of inhibiting the growth of
bacteria in the meatus. It matters very little
what form this takes ; an insufflation of boric
acid is very good, but it needs an insufflator,
and even then the powder may not go as far as it
is intended to go. My own practice has been to
put the patient lying on the opposite side, and to
fill the ear with a saturated solution of boric acid
in equal parts of rectified spirit and water, and
allow a quarter of an hour to elapse before letting
the drops run out. A little of the solution will
remain behind, and even after the spirit and water
evaporate, the boric acid has crystallised out and
mixes with the fresh discharge, when it again
begins to flow.

Neglecting tuberculous otitis, which is, of course,
chronic from the first, if we want to prevent a
chronic otorrhoea from being established, it is
therefore only necessary to ensure that the ear
be attended to once or twice daily by removing
the discharge and impregnating the meatus with
some unirritating drug having an inhibitory effect
on the growth of bacteria.

For the prevention of acute otitis, it is most
important that adenoids, when present, should be
removed, as from their low vitality they favour
inflammatory attacks which may spread to the
car along the Eustachian tube. Nasal douching
should be avoided whenever possible, and under
no circumstances carried out in any but the
gentlest manner.

Note.— A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture
for next week will be by G. H. Savage, M.D., F.R.C.P.,
Consulting Physician for, and Lecturer on. Mental
Diseases, Guy’s Hospital ; Examiner in Mental Patho¬
logy, University of London. Subject : “ The More

Recent Treatment of the Insane.”

Probably the oldest medical man in the United
Kingdom on- the list of consulting physicians to a
hospital is Sir Henry Pitman, who has passed his
ninety-ninth birthday this month. Sir Henry grad¬
uated M.B. sixty-seven years ago, and commenced
his long connection with St. George’s Hospital half a
century ago.

The Medical Pris». 139

ORIGINAL PAPERS.

A PLEA FOR ACCURACY OF
THOUGHT IN MEDICINE, (a)

By \V. HALE WHITE, M.D.Lond., F.R.C.P.

Senior Physician Guy’* Hospital, Ao., &e.

It seems to me that sometimes we retard the pro¬
gress oi our science by being afraid to say we do not
Know. All human bemgs desire to lind explanations,
i his is laudable, but it snould not lead us to such hasty
greed that we swallow false explanations which do
us more harm than good, for then we resemble the
unreasoning thirsty child who drinks salt water.
Wrong explanations may be worse than none, because
many people accept them comfortably without stop¬
ping to enquire 11 they are reasonable; but if no
explanation was in the held, some thinkers would
devote themselves to the problem which they now
pass by, being soothed by the false interpretation, as,
indeed, physicians were for the centuries during which
the humoral doctrines prevailed.

It might be thought that, in the present scientific
age, the habit oi being content with rubbish in place
ot an explanation was a mental malady that had left
us, just as the dancing mania of the middle ages has
departed ; but I am afraid we sometimes show symp¬
toms of it. Accumulated observation and ex¬
perience have taught us a great deal about gout, but
all we really know of its pathology is that urate of
sodium is deposited in some cartilages and other
structures, and that there is an excess of uric acid
in the blood. Nevertheless, often, instead of boldly
saying to ourselves we do not know the cause of
many cases of neuralgia, sciatica, bronchitis, and
several other diseases, we set them down to gout;
but where are the figures from the post-mortem room
showing that urate of sodium is excessively frequently
found in the cartilages or fibrous structures of, for
example, people suffering from sciatica, or that they
have an excess of uric acid in their blood ? If we think
accurately, we ought not to say a person has gouty
sciatica unless we believe that he has urate of sodium
in some of his cartilaginous or fibrous structures, or
an excess of uric acid in his blood, and that these
facts are etiologically related to his sciatica. Further,
we ought, as a result of the experience of ourselves or
others in the post-mortem room, to have such good
evidence in support of our belief that we should not
feel our reputation for skill in diagnosis seriously
damaged if the patient were killed on the spot and
no urate of sodium or excess of uric acid were found.
Some, perhaps, feeling the impropriety of calling these
conditions gouty on such slender evidence as others
deem sufficient, and yet susceptible to the Mesopo¬
tamia-like soothing influence of words', irrespective of
their meaning, have said : Here are a number of
symptoms we cannot explain ; we do not think they
arc due to gout, but let us imagine that the gout is
irregular, or atonic, or undeveloped, or suppressed,
and then we can ascribe them to it. In passing, the
thought arises, if gout is undeveloped or suppressed,
how can it cause symptoms? This method of nomen¬
clature is worthy of Gilbert and Sullivan, but, seriously,
is it creditable ? As Sir Dyce Duckworth says:
“ Without doubt, many morbid states have often been
flippantly or erroneously set down to irregular gout
which owned no such designation, and thus a cloak
for ignorance has always been at hand to throw over
careless observation, ignorance, or wilful misinterpre¬
tation of symptoms.” But others have gone further
on the slippery downward path reached by the habit
of jumping to conclusions, instead of saying we do
not know, for they have not onlv declared that patients
have irregular gout, but have linked it to one of the
only certain pathological facts we know about true
gout, and so have ascribed the symptoms of irregular

la) Abstract of Address In Medicine, delivered at the Exeter
Meeting; of the British Medical Aiaoeiatlon, 1907.

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140 Thx Midical Pkiss.

ORIGINAL PAPERS.

Aug. 7, 1907.

gout to an excess in the blood of uric acid or bodies
allied to it. Some do this without knowing the
amount of uric acid present in the blood of 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 leukemia there is an
excess of uric acid in the blood without the symptoms
supposed to indicate suppressed gout. This doctrine
has become so widespread that even the public tell
us that their symptoms are caused by an excess of
acid. Having assumed, ndt proved, that the symp¬
toms 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 assumption made is that
certain foods cause an excess of uric acid—some say
carbo-hydrates, 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 ostco-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.

Sometimes we attempt to pacify this dislike to
acknowledge that wc do not know, by words which
do not really help us at all—in fact, by lulling us into
the belief that they explain facts when they do not.
they lead us to imagine that our knowledge has rock
for its foundation, when in truth it is built upon sand.
For example, a teacher tells his students that alcohol
is the cause of the peripheral neuritis from which the
woman before him is suffering ; but in saying this he
fails to explain the remarkable facts that the disease
is commoner in women than in men, and picks out
the anterior tibial nerves before any others. There
must be something different in the nerves of women
from those of men and of the nerves in women the
anterior tibials must be different from the others.
Now, is the opportunity for the soothing influence of
words ; instead of being helped to face these facts
as inexplicable in the present state of our knowledge,
wc are told that alcohol has a selective action upon
these nerves especially in women, just as lead is said
to have a selective influence on the musculo-spinal
nerves. But does this help us ? Surely not. It
merely restates the fact that is evident to everybody ;
it is no explanation, but only an attempt to befog us
with words and so possibly to retard the true ex¬
planation.

One of the greatest discoveries ever made in medicine
will come to pass on the day when the mysteries now
concealed by the phrase “ selective action,” are made
plain, and we understand why, for example, the rash
of measles comes first on the forehead ; that of the
scarlet fever on the chest ; that of typhoid fever
chiefly on the abdomen ; and why, of all nerves in the

body, the poison of diphtheria is specially harmful
to those supplying the palate and the ciliary muscle.

Want of time prevents my bringing forward other
instances of the years of delay in arriving at a truthful
diagnosis that follow from cowardice in acknowledging
that we do not know the cause of many symptoms ;
but it would not be difficult to do so, especially from
among chronic diseases of the joints and diseases of
the heart. I notice at the present time an increasing
tendency to consider the muscle of the heart to be at
fault; I believe that in the past we have not consi¬
dered this nearly as much as we ought, and probably
we have often overlooked disease of the cardiac muscle,
but, unless we check our clinical work by histology,
we run great danger of believing disease of the cardiac
muscle to be present when it does not exist. I think
I could show that the heart has often been said to be
feeble or dilated on insufficient grounds, and the ortho¬
diagraph will, I think, teach us that we have frequently
been in error when we have thought the heart altered
in size, just as the clinical use of the manometer has
taught us that the estimation of the arterial tension
by the finger is not so accurate as we have been inclined
to believe.

He is the best physician who spends much of his
time in the post-mortem rooms, and is not afraid to
say he does not know. But the inability to make this
confession is not peculiar to our profession. Since I
drew up this address I have come across the following
from the pen of Sir Alfred Wills :—" A constant source
of difficulty in judicial investigations lies in what seems
almost like an ineradicable tendency of human nature—
an impulse to appear to know everything about occur¬
rences of which the witness in reality knows but a part,
and often a small part. ... It seems to require some
moral courage to say, “ I don’t know.” It is not that
the witnesses mean to deceive, but they have reasoned
out what they never really observed, and confound
the impressions so produced with those of actual obser¬
vation.” With doctors the temptation not to acknow¬
ledge they do not know is particularly strong, for
patients are often so insistent upon an explanation
that they thrust one upon the unfortunate doctor.
Let us hope that they will do this the less as general
education improves.

Talking of unwillingness to confess our ignorance,
leads us to think of instances in which, while trying to
treat medicine scientifically, we are woefully in¬
accurate, because we make excursions into sciences in
which our training is inadequate. For example, the
light and airy way in which some of us play with
figures, as though there were no science of statistics,
is astounding. Professor Karl Pearson truly says:
“ Approaching pathological inheritance from the
modern statistical standpoint, it is almost heart¬
rending to notice the great amount of effort and energy
wasted in the collection of data bearing on the in¬
heritance of disease, but, unfortunately, much effort
and energy have been thrown away upon other medical
statistics, besides those connected with inheritance.”

It must be left to expert statisticians to reform
technical errors, but it is easy to indicate a few that
are obvious. Frequently the mistake is made of deal¬
ing with far too few figures; often the very data
are wrong, as we have just seen in connection
with the hflematemesis. Allowance is rarely
made for the number of persons alive at different
ages ; it is very common to sec figures published be¬
lieved to prove the effect of this or that treatment
without any allusion to the rapidity of recovery if no
treatment had been adopted, and often the figures
do not tell us what we desire to know. For example,
statistics are published showing the frequency of re¬
covery after some difficult operation. In the first
place, for these to be of any practical use, we want to
be able to contrast them with figures showing the mor¬
tality among those not submitted to operation. W e
ought to compare the expectancy of life among T those
who are not operated upon with that of those who
submit to operation, for it is clear that if the operation
considerably shortens the life of many, the total harm

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1 O

Aug. 7, 1907.

ORIGINAL PAPERS.

done by the operation may be more than the total
good. Then, again, although it is interesting to know
the degree of perfection to which any particular
surgeon can carry the difficult art of operating, and so
lower the mortality, yet, as all the patients cannot
possibly go to the one skilful man, it is far more im¬
portant to know the usual mortality among operating
surgeons. These are only some of the points we have
to consider, but let us take as an illustration the opera¬
tion for a gall-stone impacted in the common duct.
When trying to estimate the propriety of this we
must bear in mind that when impacted in the common
duct a gall-stone rarely causes death. From the years
1854 to 1894, only one patient not operated upon died
in Guy’s Hospital from an impacted gall-stone, the
total number of deaths from all causes having been
over 20,000. Naunyn has only once known the con¬
dition fatal. Some distinguished surgeons have
operated upon several cases with complete success,
but on the other hand, Mr. Bland-Sutton, doing the
right thing and taking the figures not only of an in¬
dividual surgeon, but from the chief London hospitals,
and the I.eeds and Newcastle Infirmaries, finds that
out of 35 cases operated upon, 10 died, or nearly
30 per cent. But it might be urged that, bearing in
mind the risk of fatal cholangitis and the tediousness
and discomfort of passing an impacted gall-stone natur¬
ally, it is worth while to submit to operation, but
before coming to this conclusion we must proceed very
carefully, considering the high mortality following
operation. Further, it is notoriously difficult to dis¬
tinguish between an impacted gall-stone and malig¬
nant disease, so that in estimating the benefit that
follows operation, we must take into account the
shortening of life, owing to operation, among those who
are operated upon in the belief that they have a gall¬
stone, although they really have malignant disease.

Flease let it be understood that I am not in any old-
fashioned way objecting to the advances of surgery.
Far from it. The debt that physicians owe to modern
surgery is very great; every year hundreds of people
whom we physicians are powerless to help have their
health restored to them by surgeons, and my surgical
friends know well that not a week goes by but that I
seek their aid. Nor am I here attempting to decide
whether gall-stones should be excised from the common
duct. The sole reason why I have taken an example
of an operation upon medical cases to illustrate the care
which must be exercised before arriving at a conclusion
derived from figures, is that it is easier to see the result
of a surgical operation than that of other modes of
treatment ; but I can readily take an instance from
medicine, namely, the treatment of typhoid fever by
bathing. Many large collections of cases have been
published showing that if all the patients whose tem¬
perature exceeds a certain point are bathed, the mor¬
tality is lowered, and from that fact it is argued that
all patients whose temperature exceeds that point
should be bathed. But this does not follow, for sup¬
posing the bathing killed some who would otherwise
not have died, but saved more who would have died
if they had not been bathed, the mortality would be
lowered, although the treatment would have killed
some. Surely the right thing to do is not to bathe all,
but to select to the best of our judgment those who
should be bathed.

But when we have got our figures, the problem is
often much more obscure than any of those just quoted,
and demands a special training in the use of statistics
that few doctors possess. A good illustration of the
extreme difficulty of dealing with medical statistical
problems is the question whether tubercular disease is
hereditary. Often the evidence is fallacious, as, for
example, when the writer forgets that all experience
gained in the post-mortem room shows that many
have tubercular disease who, as far as wc know, gave
no evidence of it during their life. Even figures from
life insurance societies dealt with by actuaries are not
free from fallacies of evidence, for they can take no
account of those who are born of tubercular parents
and die of tubercular disease without coming up for
examination for life insurance. Often the reasoning

Thi Mxdical Pum, 141

is fallacious also, as. for instance, it is stated that such
and such a proportion of sufferers from phthisis have
consumptive parents, forgetful of the fact that this is
worth little, unless we know what proportion of people
who have not got phthisis have consumptive parents,
and, beyond obvious pitfalls such as these, there are
others that only the expert statistician can avoid. A
few years ago, when it was discovered that there could
be no phthisis without infection by tubercular bacilli,
many of the medical profession, without any careful
consideration, threw overboard the belief that in¬
heritance played any part, and it was maintained that
the children of tubercular parents were not more
liable than others to phthisis, but Prof. Karl Pearson
has recently published a paper in which he states that
the inheritance of a special liability to infection bv
tubercle bacilli plays a very important part. Much
has been made of cases in which it appeared that
phthisis has been transmitted from husband to wife
or vice versa, but as a rule, no attempt is made to
calculate the probability that both might have such a
common disease quite apart from infection from one
to the other, and, therefore, it is interesting to read
that Prof. Karl Pearson says : “ There is clearly no
need in such cases to appeal to infection from husband
or wife to account for the small number of cases in
which both parents suffered.” I am afraid that fre¬
quently we describe conditions as having a special
association without any endeavour to determine
whether they are more frequently associated than
might he expected as a matter of chance. The statis¬
tics about insanity and cancer also show the extreme
difficulty of a proper use of medical figures. I have
often urged what I am glad to see he urges that, as to
deal with figures requires a special training, which is
enjoyed but by few of us, we should not draw conclu¬
sions from statistics unless we obtain the help of
those specially educated to their use. But statistics
are only part of a larger matter, namely, the extra¬
ordinary width of knowledge required for our science
of medicine.

Yet another hinderance to the advance of medical
knowledge is the acceptance of facts upon authority.
Thus the haemoptysis of phthisis was often ascribed to
vicarious menstruation, although it occurs equally in
men and women ; it may be met with in females who
are of such an age that menstruation does not take
place, and it has no monthly periodicity ; but perhaps
the most striking instance of subservience to authority
was the almost universal habit of bleeding solely
because the teaching of the day said that people should
be bled. Often patients were actually bled to death ;
yet those who did it were so blinded that they ascribed
the death to the illness and not to the bleeding.

Not so very long ago, that extremely powerful
poison, antimony, was given for many diseases because
it was stated by authorities to do good. No one would
now contend that any considerable proportion of the
thousands of patients who took antimony were one
whit the better for it. When a student begins his work
he must for a little while accept some statements upon
the authority of his teacher ; but with every dav of
his career the necessity for this becomes less and less,
for medicine is a science in which nature performs on
every patient, experiments that those who have eyes
to see can watch and so observe for themselves if the
statements commonly made are correct.

Speaking of the use of antimony and venesection, as
illustrating the harmful effect of authority, reminds
us that no department of medicine shows this better
than that which deals with treatment. Sometimes
authority in one country advises different treatment
from that employed in another. Thus, whilst in Eng¬
land we often give strychnine when the pulse is feeble,
in Germany camphor is used for the same condition.
This seems absurd, one or the other must be the better.
Often little attention is paid to the natural course of
the disease towards recovery; for example, many
methods of treatment by drugs, electricity, scrums or
operation are said to benefit exophthalmic goitre, re¬
gardless of the fact that if the patient is put to bed and

1+2 Thk Medical Press.

ORIGINAL PAPERS.

Aug. 7. 1907.

kept quiet, she will usually recover without any other
treatment. With many diseases the natural tendency
to get well is so great that, unless there is a strong con¬
sensus of opinion as to the efficacy of one particular
mode of treatment, e.p., iron for chlorosis, mercury for
syphilis, thyroid for myxevdema, probably no special
treatment by drugs docs any good. It may be laid
down that when more than two drugs are praised as
benefiting any disease, probably no one that we know
does so.

Unreflecting adhesion to authority has a particularly
serious effect in keeping back the advent of correct
knowledge, for, in the first place, when the authority
is found to be wrong, much energy that might be uti¬
lised in the search for truth is expended in demolishing
that which is false, and, in the second place it seems
almost a law that we should rush to extremes of thought,
so that having been for years wrong in one direction,
we travel for years wrongly in another course, before
attaining the true position. For example, for many
years after it was shown that bleeding had been fre¬
quently practised for diseases in which it did harm, it
was very rarely done, and many patients were, there¬
fore, deprived of the relief it would have given them,
and it is only now that we have learnt to correctly
know when to employ it. “It is almost always the
unhappiness of a victorious disputant to destroy his
own authority by claiming too many consequences or
diffusing his proposition to an indefensible extent.”

Much of this excessive zeal for treatment by drugs
arises not only from an unwise adhesion to so-called
authority, but from a lack of appreciation that patho¬
logy is the basis of all medicine. The primary duty of
a physician is to find out what is the matter with his
patient; proper treatment can only be secondary to
that. Another reason for incorrect treatment is that
many say, “ You must do something.” I can never
see the reasonableness of this. The very fact that the
doctor does not know what to do is actually used as a
reason why he should do something ; surely it is the
very reason why he should do nothing, for he may
well do more harm than good. To know when to
interfere and when not to interfere with Nature is a
fine test of the sagacity of a clinical physician. Do
not, however, imagine I am urging that treatment is
rarely of use. Far from it. Never at any period in
the history of medicine has treatment been more skilful
than now, and never did out art save more lives than
now.

The last point to which I have time to draw your
attention is that it usually requires considerable trouble
to train ourselves to receive new ideas properly, and
by failing in this respect we retard the progress of
medical thought. In this matter there are three kinds
of mind. Those having the one usually claim that
they are critical, but they arc obstructive rather than
fair critics. For the most part, thc> are extremely
slow to assimilate anything new, strange to say they
frequently pride themselves on this, and take great
comfort from the sad fact that many suggestions which,
when first promulgated, appeared fruitful have turned
out to be barren. Those having the other are easily
enticed away by new notions just because they are
new; they absorb new ideas too rapidly without
digesting them ; in popular language they are ready
to swallow anything. Fortunately, our profession
contains many who fall into neither of these classes
because they have an evenly balanced mind, trained
to estimate the value of novel suggestions.

Pardon me for having in these fragmentary remarks
only stated what you all know, and what many have
taught at various times during several centuries. My
excuse for urging a plea for accurate thinking is that
the more accurately we think the more rapidly will
medicine progress.

The Board of Governors of the Foyal Hospital,
Kilmainham, have selected Lieutenant-Colonel R. J.
Windle, Royal Army Medical Corps, for the appoint¬
ment of physician and surgeon to that Institution in
succession to Lieutenant-Colonel F. S. Heuston,
C.M.G., whose tenure will expire on September 30th.

THE CARE OF TUBERCULOUS
CHILDREN, (a)

By T. N. KELYNACK, M.D., M.R.C.P.

Honorary Physician and Medical AdvUer to the Children'* Hose
and Orphanage ; Honorary Physician to the Mount Vernon Hospital
for Consumption.

Tuberculosis still remains one of the greatest
scourges of child life. In the Anti-Tuberculosis
Campaign it is essential for success that adequate
provision should be made for the protection of
infants and children from a tuberculous invasion
and adequate means secured for the early detection
and prompt treatment of all forms of tuberculous
disease originating during the all-important
initial years of life.

In the study of this question pathological con¬
siderations should receive attention. More than
one-third of all deaths at the ages of 15 to 35 are
from phthisis. Much of this mortality is the
harvest of the tuberculous seed sowing in infancy
and childhood. It is said that tuberculosis has
increased about 20 per cent, among London
children during the last fifty years. Of the
1,200,000 new lives added every year to the
population of the United Kingdom from one-
fourth to one-third are bom to want and squalor,
conditions making for tuberculosis. Tubercu¬
lous lesions are found in children under 15 years
of age dying from all maladies in about 40 per cent,
of the cases. Tuberculosis may be contracted
during [intra-uterine life, but is rare. An in¬
herited predisposition of soil is certainly trans¬
mitted. Milk is probably an unimportant source
of tuberculous infection. While agitating for
hygienic control of our milk supply it is essential
that the personal responsibility of parents and
others in maintaining a healthy environment for
the child should be insisted on. Von Behring’s
contention that tuberculosis is commonly acquired
from tuberculous milk in France has not been
substantiated, but his views regarding infection
by tuberculosis in early life, its long latency in
the glands of the abdomen and thorax, and its
development when childhood’s days have passed,
are being supported by recent investigations
and will go far to revolutionise theoretical con¬
ceptions and reform practical prophylactic
measures.

Pulmonary tuberculosis occurs much more
frequently in children than is usually believed.
Professor Emmett Holt states that in nineteen
months sixty-seven cases of pulmonary tuber¬
culosis were under treatment in the New York
Babies’ Hospital, sixty-two under two years and
fifteen under six months of age. By adopting
a new method he was able to demonstrate the
presence of tubercle bacilli in the pulmonary
secretion in over 80 per cent, of the cases : the
possibility of infection at home was known to
have existed in at least 40 per cent.

Tuberculosis is met with among school children
to an extent which demands serious attention.
The promised medical inspection for public
elementary schools should do much, if conducted
by skilled examiners, in detecting the early evi¬
dences of commencing tuberculosis and in recog¬
nising children predisposed to tuberculous disease
Among the inmates of our Children’s Home and
Orphanage 25 per cent, are said to be the offspring
of consumptive parents. Dr. Leslie Mackenzie states

Thursday, August 1st, 1907.

zedbyC.OOgle

\VG 7, 1907.

ORIGINAL PAPERS.

The Medical Peess. 143

that 14 cases of pulmonary tuberculosis were noted
among six hundredEdinburgh school children ;
and in three cases among Aberdeen children.
Dr. William Robertson, of Leith, detected six
cases of tubercle of the lungs among eight hundred
and six school children. Dr. Alfred Greenwood,
among one thousand and twenty-eight Black-
bum children, specially selected by school attend¬
ance officers for medical examination, found that
6.2 per cent, were phthisical. Dr. Wilkinson,
among seven hundred and nine Oldham children,
found seventeen with pulmonary involvement, a
percentage of 2.3. Dr. J. E. Squire, after an
examination of nine hundred London children
in one school in a very poor neighbourhood,
places " the proportion of cases of possible tuber¬
culosis of the lungs at about 1.5 per cent.”

The late Professor Grancher found evidences
of predisposition to tuberculosis in something
like 17 per cent, of the Paris school children.

All schools should arrange for thorough medical
examination with a view to the early recognition
of tuberculosis and the detection of all tuber-
culously disposed children. The French plan
of removing children from tuberculously con¬
taminated homes has proved advantageous.
There is need for an extension to this and other
countries of the German Forest Schools for
consumptive and tuberculously disposed children.
This country is miserably poor in its provision
for sanatoria for children. Urban hospitals for
tuberculous cases are to be condemned. In¬
stitutions taking adult consumptives are not
suitable places for children. Many of the sup¬
posed advantages of a marine situation for tuber¬
culous children are in a great measure imaginary.
Consumptive cases are certainly best dealt with
at high and dry and sheltered inland stations.
There is urgent need for co-ordination of know¬
ledge and co-operation of practical effort. In¬
dividual benefit and national advantage would
accrue from the founding of a National Society
for the Study and Care of Tuberculous Children.

OBSERVATIONS ON THE

DETERMINING CAUSE OF THE
FORMATION OF NASAL POLYPL (a)

By EUGENE S. YONGE, M.D. (Ed.).

Honorary Assistant Physician, Manchester Hospital for Consumption
and Diseases of the Throat.

The author's conclusions, which refer exclusively
to mucous polypus of the nose, may be summarised
as follows :—

(1) Mucous polypus may be regarded as a patho¬
logical condition possessing certain definite char¬
acteristics which distinguish it from other swell¬
ings and new formations that may occur in the
nasal cavity. (2) Mucous polypus is essentially,
and in its earliest stage, a patch of mucous mem¬
brane, which has become aedematous, the pedun¬
culated appearance, which polypi commonly as¬
sume, being chiefly the result of physical causes
acting on the primary patch of swollen cedematous
mucosa. This tendency to become pedunculated
is of course not peculiar to the condition in ques¬
tion, but is shared by many other intra-nasal
new formations. (3) In the majority of instances
the condition appears in both nasal cavities with-

(a) Abstract of Paper read before the 8ection of Laryngology and
Otology at the Annual Meeting of the British Medical Association,
Aogait 1st, 1907.

out any apparent local cause, which is sufficient
to account for it. This circumstance, combined
with other considerations, leads to the supposi¬
tion that there is usually a constitutional element
in its production which, together with certain local
influences, is capable of setting in action that which
is considered, by the author to be the proximate
cause. (4) In a minority of instances there is
present a condition ( accessory sinus suppuration )
which is a presumptive local cause of polypus-
formation. But since this process does not neces¬
sarily lead to the production of the disease, and
since the disease may occur without its interven¬
tion, it is reasonable to conclude that the process
is instrumental in causing polypus-formation only
when it sets in action the factor which is the actual
proximate cause. (5) In a certain number of
instances there have been observed changes of an
inflammatory nature in the bone and periosteum,
which would presumably be sufficient, if they were
shown to be primary to the changes in the mucous
membrane, to account for the incidence of cedema
in that structure. But in view of the facts that in
numerous specimens of bone, underlying polypi,
no bone disease has been found ; that polypi have
been demonstrated to occur on a mucous membrane
which shows only a superficial inflammation and
in which the deeper parts are not diseased, and that
the lesions in the bone, when present, have been
shown by several observers to be secondary to the
specific process in the mucous membrane, it may
reasonably be inferred that bone-disease is not
essential to the production of mucous polypi and
that the primary cedema of the mucous membrane
must ordinarily be referable to some other factor.
(6) The proximate cause of the cedematous infil¬
tration of the mucous membrane, which represents
the primary and essential process of polypus-form¬
ation is in the author's opinion, the obstruction
of certain definite capillaries and veins, brought
about by a circumstance (dilatation of the ducts of
the mucous glands, and, to a lesser extent, of their
acini) which produces its specific effect by causing
pressure on, and, probably, obliteration of the
vessels, which surround the structures in question
in the form of close networks. (7) An inflamma¬
tory process in the mucous membrane is a very
common antecedent and accompaniment of
polypus-formation, but since the former condition
is obviously present in varying degrees of intensity
and persistence, in a great number of cases which
do not at any time give evidence of polypus-form¬
ation, it appears reasonable to suppose that in¬
flammation of the mucous membrane does not of
itself, lead to polypus-formation, but only does
so by securing the intervention of another factor.
The presence or absence of this factor (glandular
dilatation) determines, in the author’s opinion,
whether an inflamed mucous membrane undergoes
oedema and subsequent polypoid changes or
whether it escapes such changes. (8) The evid¬
ence in favour of the contention that this particular
factor sets in action the proximate cause which
leads to the primary oedema, is derived from
pathological, clinical and experimental observa¬
tions.

Pathological. —(1) The frequent observation of
distension and cystic dilatation of the glands in
mucous polypi, and the almost invariable (a) pres¬
ence of the condition (in the specimens examined)

(a) It is of course not necessary, from a logical point of view, that
two circumstances should be in invajuablb association in order that
an etiological relationship may be assumed, a fbbquxnt conjunction
being sufficient.

zed by G00gk

144 Thx Mkdical Pun.

ORIGINAL PAPERS.

Aug. 7, 1907.

in the underlying and contiguous mucous mem¬
brane wherever this was oedematous. (2) The
absence of the glandular changes in those
instances of inflammation in which polypoid
changes were not present. (3) The fact that an
inflamed mucous membrane and one in a state
of polypoid change appeared to show all residual
circumstances in common except one — the
glandular changes.

Experimental. —(1) The fact that the production
of an inflammatory process in the nasal cavity, in
suitable animals, was not followed by any indica¬
tion of polypoid change or of any distension of
the glands. (2) That the production of an in¬
flammatory process in similar animals, produced
in the same manner, by similar agents and lasting
for the same period of time, but combined with
measures calculated to cause overloading and dis¬
tension of the mucous glands, was followed by
polypoid change in the mucous membrane, the
latter showing marked distension and cystic
dilatation of the glands on histological examin¬
ation.

Clinical .—The author’s hypothesis appears to
offer an adequate explanation of the incidence of
mucous polypi occurring under dissimilar circum¬
stances and conditions. It is capable also of ren¬
dering intelligible the constitutional element that
is evident in many instances; the common occur¬
rence of polypi in cases where glandular disturb¬
ances are known to exist, and, at least in some in¬
stances, it helps to solve the question of recurrence.
Moreover, the theory assists, in the presence of
other known factors, in explaining the age-incid¬
ence ; in reconciling the discrepancy between the
incidence as observed post mortem, and the incid¬
ence as observed clinically, and lastly in explain¬
ing the localisation of polypi in special areas of the
nasal cavity and in certain of the accessory sinuses.

THE CO-ORDINATION OF THE
PUBLIC MEDICAL SERVICES, (a)

By ARTHUR NEWSHOLME, M.D., D.P.H.

Medical Officer of Health, Brighton, Ac.

The following is a summary of Dr. Newsholme’s
paper in introducing the discussion :—The scope
of preventive medicine is no longer confined to
germ-born diseases, but extends to such early
treatment of any disease as will secure a less severe
or less protracted later stage of disease.

The community as well as the individual is in¬
terested in this wider definition of preventive
medicine, though, as shown by the serious loss of
life and health still due to avoidable causes, this
is only partially realised. Poverty and disease
act in a vicious circle, and the practical problem
considered in this paper is the means by which
people may be prevented from becoming poor by
preventing them from becoming sick.

Official and voluntary agencies now at work show
how much is already being done in the communal
treatment and prevention of sickness. The list
of these agencies given in the paper shows that the
distinction between prevention and treatment has
never been maintained. A rapidly-increasing pro¬
portion of total sickness is being treated in volun¬
tary and in State or rate-supported institutions.

Axe we getting a satisfactory return for this
increasing burden on rates, taxes, and charity ?

(a) Abstract of Paper read before the Section of State Medicine at
the Annual Meeting of the British Medical Association, Exeter,
August 1st, 1907.

Whether viewed from the standpoint of patients,
doctors, or of the public health, the present state
of the medical service must be condemned as
unsatisfactory.

The conditions of private medical practice among
the poor are admittedly most harassing and unsat¬
isfactory to the doctor. To the patient they are
equally unsatisfactory, for (1) diagnosis is belated,
and (2) treatment is curtailed owing to expense.
(3) In dispensaries, etc., there is a serious waste
of time. (4) There are no co-ordinated arrange¬
ments for medical consultations. (5) Valuable in¬
formation as to the incidence of disease is wasted.
(6) There is a great waste of information as to the
existence of conditions conducing to disease.

These defects can be overcome, as is seen in the
co-ordinated arrangements where the notification
of consumption is successfully at work. Thus the
visit of an officer to the notified patients sets in
operation all the prophylactic, curative and
sanitary measures which are needed, equally for
the welfare of the patient and of the public. Un¬
detected cases are recommended for diagnosis
and treatment. Sanatorium training and treat¬
ment are secured.

These defects are not overcome, for instance,
when the organisation for the medical supervision
of scholars is separate from the general public
health administration of a district. Much of the
medical inspection of scholars, if it is to be efficient,
must be done by interviewing parents, and much
of it involves home visits. The home is the point
from which many of the evils discovered by medical
school inspection will have to be attacked and
controlled. In actual fact parents will not tolerate
dual medical examinations for school purposes,
and on the other hand neither school doctor nor
medical officer of health fulfil the complete needs
of the case. These will only be met when district
doctors are appointed by each municipality,
and these doctors are co-ordinated with the
mechanism of preventive medicine, enabling us to
secure the early systematic and unstinted diag¬
nosis and treatment of all disease before, even
more than at, school ages.

The present state of medical service is evid¬
ently transitional. Neither provident dispensaries
nor cries against “ hospital abuse ” and “ under
cutting ” practice have been able to hinder the
steady progress towards the treatment of disease
at the expense of the community ; nor is it possible
to arrest this trend. What has hitherto been
done in the collective treatment of disease is merely
a phase in the evolution of the system which will
effectually ensure the early recognition and proper
treatment of all diseases. Such a system would
justify itself economically by the corresponding
reduction of sickness and of inefficieny ; in short,
the justification of a municipal medical service
both economically and medically consists in its
being a branch of a general system of preventive
medicine. By this means information of preventive
value will no longer be allowed to run into culs-de-
sac and be lost, preventive medicine being regarded
as a whole, and its many fragmentary portions
being no longer allowed to continue relatively
impotent by being detached from single executive
control.

A smallpox case has been notified to the health
authorities of Surderland. The patient is a well-known
merchant, who has just returned from a visit to Den¬
mark, where he contracted the disease. He has been
removed to the borough sanatorium.

y Google

Aug. 7, 1907.

ORIGINAL PAPERS.

MILK IN RELATION TO HUMAN
TUBERCULOSIS, (a)

By HENRY E. ARMSTRONG. D.Hy., Durh., M.R.C.S.,
L.S.A.

Medical Officer of Health, Newcastle-upon-Tyne.

The Vehicles of Media by which the Bacillus of
Tuberculosis gains entrance into the bodies of pre¬
viously healthy human beings are the following,
viz.:—

(a) The milk and milk-products (1), consumed as food,
of tuberculous cows ; (b) The milk of a tuberculous
human mother; (c) The flesh of tuberculous animals
consumed as food ; {d) Dried expectorated matters
and other infectious discharges of consumptive persons
inhaled or swallowed as atmospheric dust, etc ; (e)
Heredity ; (/) Marriage of the tuberculous ; other
vehicles, etc.

This division of the subject may be considered under
the following heads, viz. :—

(1) .—THE PREVALENCE OF TUBERCULOSIS AMONG

DAIRY COWS.

The Report of the Royal Commission on Tuber¬
culosis issued in 1898 states that “ of all the animals
slaughtered for food in Great Britain and Ireland
those of the bovine race seem to be more largely
aflected with tuberculosis than any other.” In the
absence of statistical information as regards our own
country the Report proceeds to show that in Leipzig,
of 9.303 cows slaughtered, 4,048 or 43.51 per cent.,
were tuberculous. The proportion of such diseased
cattle in the English cow-houses, which has been
publicly and authoritatively stated at about 30 per
cent. (MacFadyean) (2) may not be excessive. In the
year 1901 there were 1,887,414 milch cows in England,
and 4,102,061 in the United Kingdom.(3) Thirty per
cent, of these means upwards of 560,000 tuberculous
milch cows for England alone, and nearly ij- millions
for the United Kingdom. The bare idea of the amount
of possible human tuberculosis from the milk of so
immense a number of diseased cows is appalling.
Notwithstanding this truly dreadful possibility
the Report above quoted gives prominence to the
following statement. “ It is not proved to our satis¬
faction that tubercle bacilli has ever been detected
in milk unless drawn from a cow with tuberculosis
of the mammary gland. ”(4)

(2) .—THE ENTRANCE OF TUBERCLE BACILLI INTO

MILK, AND THE STATE OF MILK SUPPLIES IN RELA¬
TION TO TUBERCULOSIS.

In a well-known work(5) the means of entrance of
uberculosis into healthy cowsis described, and may
be| summarised as follows :—(a) Tuberculous excre¬
tions and discharges conveyed to soil, air, water,
fodder, and general surroundings (premises, stables,
straw, stable refuse, utensils); (b) The milk of a
tuberculous animal may be consumed by other animals ;
(c) The bacilli may be distributed by the cough of a
tuberculous cow (Ravenel) or (d) by the saliva of a
cow in licking In this way she may also infect the
surface of her udder, and thereby the milk, by means
of the hands of the milker.

Each or all of these ways may lead to the con¬
tamination of the milk after yield. By the repulsive
habit of spitting on the hands before milking, or by
dried expectoration in a cowhouse, a consumptive
milker may infect the milk after it has left the teats
of the cow.

The foul state of many cow-houses, both in town and
country is only too well known, and ample illustration
of this is on record.(6) It is right to add that of late
y^ars great improvement has taken place in many

(«) Extract from the Report of the Medical Officer of Health, New-
«MUe-upoD-Tjne, IS07.

U) The term “ milk products” Includes, of course, butter, butter¬
milk, whey, and cheese.

(2) Tran*. Brit. Cong, on Tuberculosis, 1901.

(3) Report of Royal Commission, p. 4.

(J) P 13”*. 28.

(5) “ The Bacteriology of Milk,” Harold Swithlnbank and George
Newman, M.D, London, 1903.

'*! Rsport of Roy. Cota, on Tuberculoals, 1898, as. 45, 48.

The Medical P r ess. 1 45

towD cow-houses—but most of those in rural districts
are as insanitary as ever. Dr. Hope, of Liverpool,
has shewn that in town-yielded samples of milk
the tubercle bacillus was found in 2.8 per cent., whereas
in supplies sent from the country 29.1 per cent, were
found to be tuberculous. Speaking from personal
experience, the writer affirms that the cow-houses
in Newcastle and the surrounding country districts
are in much the same condition as in other places ;
and he has every reason to believe that a bacterio¬
logical examination of the different urban and rural
milk supplies sold in the city would disclose results
similar to those found in Liverpool and elsewhere.
Even accepting the untenable hypothesis that cow’s
milk is only rendered infectious when the udder
becomes diseased—the difficulty of diagnosing such
disease at an early stage in time to prevent the use of
the milk for food is so great as to put beyond the range
of practical utility most of the apparent value of the
suggestion.

( 3 ).—THE EXTENT OF THE DISEASE CAUSED OR CAUS-
ABLE BY MILK AND ITS PRODUCTS.

The milk trade is one of the most complex of organi¬
sations. Under defective management it may become
a most elaborate means for the spread of different
infectious diseases, and of none more frequently
than tuberculosis. The fact that milk as sold to
customers is the mixed yield of perhaps from 10
to 50 different cows—a certain proportion (perhaps
a large one) of which are possibly tuberculous, renders
the entire product, if so infected, a most potent agent
of evil. As milk is distributed night and morning
to the houses of dairy customers, by many of whom—
especially the children—it is consumed raw, the
opportunities of the dissemination broadcast of the
virus of tuberculosis or other disease are far beyond
comparison greater than with any other article of
diet. The spread of infection from a diseased cow
may go on for many months without detection, whilst
her milk is being consumed without suspicion. That
the many forms of tuberculosis among the young,
and indeed among all ages, are not oftener traced to the
milk-supply is the consequence not of the harm*
lessness of the milk itself, but of the complexity of the
circumstances attending its distribution, together with
the very nature of the disease and the conditions
of its development. In the case of an outbreak of
scarlet or enteric fever, of which there have been several
hundreds within the last twenty years or so, the
suddenness of the outburst, the nature of the ailment,
the common routine of inquiry invariably made by the
special inspector, and a host of other circumstances,
point at the outset to the milk-supply as the possible,
if not probable, cause. But, with tuberculosis this
is not so. This disease is insidious in its approach ;
its period of incubation is unknown; the signs of its
presence are for a considerable time indistinguishable
from those of other ailments ; and the means of tracing
its probably remote origin are not available. Hence
the impossibility in the present state of our knowledge
of presenting evidence of the extent to which the
disease may be attributed to milk or any other in¬
dividual cause. This circumstance has led to the idea
on the part of some that “ if there had been anything
like the danger from the meat and milk of tuber¬
culous cattle that medical officers of health say there
is, we should all have been dead of tuberculosis long
ago 1 ” Such an idea, if true, would apply to all in¬
fectious diseases, which would never cease until they
had exterminated the entire human race. But they
do not spread in this way for several well-known
reasons which it is unnecessary here to state ; and the
same applies to tuberculosis, with respect to which
it may be added that special predisposition on the
part of some persons and exactly the opposite condition
on the part of others, are special characteristics of
that disease. It is stated on good authority that
about 90 per cent, of the cases of tuberculosis among
calves and swine have been proved to originate ; n
feeding with infected milk.(i)

(1) L. Rablnowltsch. Trans. Brit. Cods, of Tuberculosis, 1901
Vol HI., p. 508.

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146 The Medical Press.

ORIGINAL PAPERS.

Aug. 7, 1907.

(4) -—THE DIFFICULTY OF RECOGNISING TUBERCULOSIS

IN DAIRY CATTLE BY ORDINARY MEANS.

The difficulty of diagnosing tuberculosis by ordinary
physical means at any but the most advanced stages
of the disease is universally recognised ; but this very
fact is an element of the greatest mischief in the
possibility it allows for the continuous spread of in¬
fection for a long period, from a diseased cow. Daily
visitations at cow-houses afford but little information
to the inspectors of the sanitary authority as to the
health of dairy cattle.

(5) .—THE TUBERCULIN TEST AS A MEANS OF DIAG¬

NOSING TUBERCULOSIS OF CATTLE.

The Royal Commission of 1898 in their Report,
s. 15, “recommended that funds be placed at the
disposal of the Board of Agriculture in England and
Scotland, and of the Veterinary Department of the
Privy Council in Ireland, for the preparation of com¬
mercial tuberculin, and that stock-owners be en¬
couraged to test their animals by the offer of a gratuitous
supply of tuberculin and the gratuitous services of a
veterinary surgeon on certain conditions.”

“ These conditions shall be:—(a) That the test be
applied by a veterinary surgeon ; (b) That tuberculin
be supplied only to such owners as will undertake
to isolate reacting animals from healthy ones ; (c)
That the stock to be tested shall be kept under satis¬
factory sanitary conditions, and more especially
that sufficient air-space, ventilation, and light be
provided in the buildings occupied by the animals.”

The Commission further recommended the circula¬
tion among agricultural societies of instructions for
the proper use of the tuberculin test, with explanation
of the significance of reaction, and direction for effective
isolation of re-acting animals.

The above recommendations are sufficient proof of
confidence in the value of the tuberculin test. Although
made eight years ago, so far as is known to the writer
they have led to no practical result whatever on the part
of the British Government. For this reason, and seeing
the well known disinclination of farmers to speculation,
and their not unnatural hesitation to experiment
with the object of discovering disease in their herds,
i t is perhaps not surprising that the test has not become
popular among them. The responsibility incidental
to such a discovery may not be unconnected with
their failure to adopt it. The magnitude of the task,
and the claims for compensation involved have doubt¬
less deterred the Government from pushing the subject
forward on their part. Hence little or no progress
has been made in England toward the elimination
of bovine tuberculosis as a commercial project. Its
compulsory extinction as a source of the greatest
danger to human life has never yet, it is believed,
beer seriously proposed. What is the reason ? "If
preventable, why not prevented ?"

(6) POSSIBILITY OF ELIMINATING TUBERCULOSIS OF

CATTLE.

In reviewing the pros and cons of this momentous
question the chief points for consideration appear
to be the following :— (a) The tuberculin test is ad¬
mittedly reliable as a means of detecting the disease ;

( b ) Voluntary attempts to eliminate tuberculosis
have been freely tried in Denmark and have met with
a very large measure of success. To ensure complete
success of the process compulsory and universally
complete application of the principle is necessary ;

( c) The process of elimination should involve the
immediate slaughter of all re-acters and the destruction
of their carcases. Stock-owners should not be respon¬
sible for the carrying out of this great work for the
public benefit; neither should they be at any pecuniary
loss ir its execution.

Fair compensation should be granted on compliance
with requirements during a stated period whilst the
process is in operation. Doubtless the knowledge
of the sum of money that would be required for this
purpose is the main objection to the enforcement
of the measure by Government. Such an objection
would not hold in the case of an acute and widespread

epizootic or other disease, say of cattle plague, an
outbreak of which in this country in 1865-b involved
the death of upwards of 233,000 head of stock. Here
the first consideration was the stamping out of the
disease as quickly as possible, and at any cost.
Tuberculosis of animals is more widely spread than
cattle plague has ever been ; it is always chronically
prevalent in our herds and dairies ; whereas visitations
of cattle plague are few and far between ; and what is
worst of all, it causes a vast amount of human sick¬
ness and death, which cattle plague does not do.
Hence its distinction, both on hygieric and economic
grounds, is more urgently called for than would
be that of an epizootic disease of different kind. It
is estimated that the disease in animals may be elimi¬
nated in a single year. It might be attacked in single
counties or districts in successive years to diff use over
a longer period the cost of dealing with it. All fresh
importations of cattle into a district after a given
date should be subject to the test. If all stock-
owners and butchers were required to purchase
subject to guarantee against tuberculosis, as proved
either by the tuberculin test or by inspection after
slaughter, the test would rapidly become general.
Owners would only be too glad to adopt it in self-
defence, and other action necessary for the extinction
of the disease would soon follow.

( 7 ).—THE CONTROL OF THE MILK-SUPPLY BY SANITARY
AUTHORITIES.

The control of the milk-supply of any district, to
be satisfactory or complete, involves the necessity
of frequent bacteriological examination of speci¬
mens drawn from the udders of each and all of the
cows yielding milk for the supply of that district.
This means that such examination should apply to the
produce of dairies within the district and others
sending supplies to it from without. A sanitary
authority may take power to obtain the required
specimens, and may carry it into effect in its own
district; but to do so in the case of districts at a
distance would be difficult and troublesome unless
through the co-operation of the sanitary authorities
of such districts. But under present conditions
such co-operation is scarcely to be expected. For
example : a large amount of milk is sent daily to
London from Cheshire. Are the different rural authori¬
ties of the latter county to be expected to bestir
themselves vigorously in order to condemn, in the
interest of the distant metropolis, the cowsheds and
milk-supplies of their own farmers, many of whom
may be members of these same authorities ? And
how can London supervise the Cheshire dairies
for itself ?

The necessity for the regular and frequently repeated
bacteriological examination of the milk-supply from
every dairy cannot be too strongly insisted on. Tuber¬
culosis of the udder is a well-known, though not by
any means a common, form of the disease in cows,
and the great danger in such cases of spreading the
disease to consumers of the milk is admitted, ever by
the late Royal Commission, who cannot justly be charged
with undue severity—at least to the dairy-trade—
in their proposals for dealing with the milk of tuber¬
culous cows, seeing that their protective recommenda¬
tions extend only to animals with obvious disease of the
udder, notwithstanding the fact that the milk of
cows without visible sign of tuberculosis of the udder
has been shown by many bacteriologists to be in-
fectious.(i)

This systematic and general bacteriological examina¬
tion of milk is all the more urgently required by the
fact that dairy farmers are not yet compelled by law
to take steps to ascertain whether their milch-cattle
are all tubercle-free. The possibilities of spreading
tuberculosis through the milk-supply are very great*
inasmuch as in the case of one cow only having|the
disease in a large dairy-herd, her milk, mixed with that
of the other cows, will contaminate the entire supply,
which, being distributed twice a day for a lengthened

(1) L. Rablnowiteoh, 1901, and Swlthlnbank and Newman, 1903.

by Google

Aug. 7, 1907.

ORIGINAL PAPERS.

The Medical Fun. ' 147

period, and consumed largely by children and princi¬
pally uncooked—whether in its natural state or in the
form of butter or cheese—has thus greater possi¬
bilities for conveying infection than any other article
of food. The ramifications of the milk trade throughout
the United Kingdom are so complex and so intricate
that no proper supervision in the interest of the
consumer is at present practicable. Such supervision
is possible only by the union of representatives of
county councils and district authorities, both urban
and rural, in one general body, with power to organise
and cause to be carried out all such measures for the
regulation of the production and distribution of milk
as are required for the protection of the health of
the consumers. The action of such a body need not
by any means be limited to the control of the milk
supply. In the national interest it might extend to
the extinction of bovine tuberculosis, and other
matters relating to public hygiene. The work for
such an organisation is abundant, and if taken in
hand will be found to increase year by year.

A sanitary authority should have power to collect
at the place of production samples of any milk intended
for sale within their district. No power is given to
deal with any form of tuberculosis in a dairy, no
matter how extensive, other than the comparatively
rare one in which the udder is affected ; and how is
the dairyman to be proved to know that a disease
of his cow’s udder is tuberculosis ? The application
of the tuberculin test to dairy cattle, even in cases of
suspected tuberculosis of the udder, is not provided
for. The Liverpool milk clauses also fail to afford
the protection against, and means of detection of,
tuberculosis among the dairy cattle yielding the milk-
supply for the city, which the public health demands.
The medical officer of health may, it is true, by a very
tedious and roundabout process, obtain an order to
prohibit the sale of milk at any dairy, but not unless
he is of opinion that such milk has caused, or is likely
to cause, tuberculosis to its consumers t How, without
previous application of the tuberculin test, is he to
obtain the information on which to form such opinion ?
How long may the distribution of such milk have to
continue to cause tuberculosis before the medical
officer can possibly feel justified in concluding that
it has done so ? As it stands, the supposed “ power ”
is a pure delusion.

(8 ).—Action Desirable.

Every sanitary authority should have the power
to enforce, and should be required to enforce, the
following provisions, viz. :—(1) to apply the tuber¬
culin test to, and (2) to take such specimens as may
be required of the milk of any cow, the yield of which
is intended for sale in the district of such authority ;
(3) to prevent the sale of milk of any cow re-acting
to the tuberculin test, or found to be affected with
tuberculosis in any form whatever ; (4) To destroy
any dairy cow re-acting to the tuberculin test and to
compensate the owner, in the event of his compliance
with the requirements being approved by the sanitary
authority; (5) to require that no fresh cow shall
be brought into any dairy for the production of milk
for sale that has not previously been recently tested
with tuberculin and failed to re-act thereto.

The administration in detail of the foregoing and
other requirements for the regulation of the milk
trade ought, in the national interest, to be directed
by a combination of sanitary authorities, as else¬
where indicated in the present report.

(9)-—THE ATTITUDE OF THE LATE ROYAL COMMISSION
IN RESPECT TO THE MILK OF TUBERCULOUS COWS,
AND ITS CONSEQUENCES.

Among much that is valuable in the report of the
Royal Commission of 1898, there is also much that
is grievously disappointing. The observations on
milk-supply (ss. 39 and 42) and recommendations 7 and
8 on the same subject are, as already stated, directed
against the milk of cows with diseased udders only.
The sale of the milk of other tuberculous animals
'» not condemned and therefore, by inference,

is sanctioned by the Commissioners. In view of the
abundance of proof as to the deadly nature of such
milk, this is a lamentable fault in the report. As a
whole, the sections of the report above referred to may,
not inaptly, be characterised as milk and water.

The effect of the pronouncement of the late Royal
Commission on their want of evidence as to the danger
from the milk of a tuberculous cow, unless her udder
was diseased, has naturally been to convey the general
impression that the Commission did not regard such
milk as dangerous, no matter how extensive the dis¬
ease of the cow in the rest of her body—an admission
only too likely to be taken as a rule for universal
guidance. This opinion of the Commission is con¬
firmed by subsequent sections (1) of the report, in
which the protective measures recommended relate
only to milk from cows with udder disease. That
the conclusion of the Commission is absolutely in¬
correct and the doctrine advanced upon it dangerous
to the highest degree, is proved by scientific evidence,
part of which was before the world long before the
sitting of the Commission, but of which they appear
to have had no knowledge, and part of which was
published subsequently. Thus Bollinger, in 1880,
produced tuberculosis by innoculation with the milk
of a cow whose udder was not tuberculous ; Hirsch-
berger (1889) found milk infective from a cow affected
with slight tuberculosis of the lung only Ernst
found in 114 samples of milk from 36 tuberculous
cows, showing no udder lesion, that 28.57 P er cent,
were infective; Smith and Schroeder found the
milk infective in two cases out of six ; and Del6pine
found the same in five out of twenty-four tuberculous
cows with no udder lesion.(2)

'• -Again : . The presence of tubercle bacilli

in the milk of cows that respond to the tuberculin
test without showing clinical evidence of tuber¬
culosis was proved in the same year (1899) by the
thorough experiments of Adami and Martin. A
further proof in support of this theory was furnished
by my last year’s observations on milk supplied to
infants in Berlin. . . The supply of milk taken
from animals . . . contained tubercle bacilli

though they showed no clinical symptoms of tuber¬
culosis.” (3)

(IO).—LAW IN RELATION TO TUBERCULOUS MILK.

Special powers for dealing with tuberculosis and
milk have been obtained by the authorities of Glasgow.
Manchester, Liverpool (4) and many other English
towns. Most of these powers, as ultimately granted,
are based on the findings and recommendations of
the Royal Commission of 1898, and for that reason
alone, and others also, fall far short of requirements.
The Corporations of Manchester and several other
towns “ sought limited power of inspection of the cows
on all farms supplying them respectively with milk ;
and of exclusion of milk of cows with any form of udder
disease or suffering from advanced (5) tuberculosis.”
These proposals were modified considerably by the
Local Government Board, the Board of Agriculture,
and the Associated Chambers of Agriculture and
finally, the Corporations in question obtained the
very limited power (1) to fine a dairyman who sold
milk from a cow with a tuberculous udder, or continued
to keep a diseased cow among other dairy cattle ;
(2) to require dairymen to notify tuberculosis of the
udder.

Recommendations :

1. —With regard to Milk every sanitary authority
should arrange for the systematic bacterial examina¬
tion, and, as far as possible, the control, of the milk
supply of its district.

2. —Every dairy farmer or producer of milk for
sale should, before offering such milk for sale in any

(1) 81 . 39,42, end 43.

(2) Lancet, January 20th, 1900.

(3) Dr. T. Reblnowitsch, Trans. Brit. Cong. on Tuberculosis, 1901.
Yol. III., pages 508-9.

(4) The Liverpool Clauses are given in extenso In the Appendix to
this Report. P. 61.

( 6 ) The Sanitary Committee of Neweastle-apon-Tyne are of opinion
hat the word “advanced” should be omitted from the list of powers
a o be sought for the city.

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D

OPERATING THEATRES.

Aug. 7, 1907.

148 The Medical Press.

district, and whenever required by the sanitary au¬
thority of such district, satisfy such sanitary authority
that the cattle yielding such milk are, each and all
of them, free from tuberculous disease, as proved,
after the application of the tuberculin test, by the
certificate of the veterinary inspector of the district
in which such milk is produced.

3. —With or without suspicion of any milk or milk-
product having caused or being likely to cause infec¬
tious disease, every sanitary authority should have
full power:—(a) To inspect the cowsheds and dairy
premises of any farm or dairy supplying the district
of such authority with milk or a milk-product, and
prevent the sale of such milk or its product in their
district unless and until they are satisfied as to the
sanitary condition and regulation of the cows&ed
and dairy premises generally in which such milk is
produced ; (6) To inspect, examine, and apply the
tuberculin test to any cow ; (c) To collect at the
place of production or elsewhere such samples as they
may require of the milk of any cow, the yield of
which is intended for sale within the district of such
authority: dairymen should be required to render
assistance, and any person obstructing should be
liable to penalty ; (d) To prevent under penalty the
sale of the milk of any cow re-acting to the tuberculin
test, or found to be effected with any form of tuber¬
culosis whatsoever, or any other disease of the udder;
( e) To brand and cause to be destroyed any dairy
cow re-acting to the tuberculin test; the State to
compensate the owner in the event of his compliance
with the requirements being approved by the sanitary
authority ; (/) To require under penalty that a cow
shall not merely be brought into any sanitary district
or allowed to remain therein for the production of
milk for sale unless and until such cow has been
recently, and within a specified time, officially tested
with tuberculin and failed to re-act thereto.

4. —The limitation of the prohibition of the use of
milk or milk-products of tuberculous cows to such
cows only as have disease of the udder should be
abandoned as mischievous.

5. —It should be the duty of every sanitary authority
(medical officer of health) of a district in which milk
sent there for sale from an outlying district is found
to be tuberculous, without delay to report the fact
to the sanitary authority (medical officer of health)
of such outlying district, or the county council in
which such district is situated. On receipt of such
information by the sanitary authority (medical officer
of health) of such outlying district it shall be their
(his) duty without delay to cause the tuberculin test
to be applied to each cow of the dairy at which such
tuberculous milk was produced, and to cause all such
steps to be taken as are indicated in the preceding
par. 13, sections (d) and (e). Until the completion
of such testing, they (he) should prevent the sale of
any milk from the dairy in question, and should without
delay inform the sanitary authority of every district
ordinarily supplied with such milk, that they have
(he has) done so. It should be the duty of the county
council to see to the carrying out of all of the fore¬
going requirements, and any farmer, dairyman,
etc., who, after prohibition as above indicated, sends
milk or its products to any district for sale, should be
liable to penalty.

Every sanitary authority should be empowered
and required to license for a stated period every
dairy and cowshed in their district or in any outlying
district in which milk is produced and sent to their
district for sale ; and to require as one of the conditions
of every such license or its renewal that all cows
of such dairy, including new additions, be proved
by official veterinary certificate, after applical ion of
the tuberculin test, to be free from tuberculosis before
their milk shall be offered for sale. Any unlicensed
milk dealer selling or offering milk for sale should be
liable to penalty.

All sanitary authorities should be encouraged to
promote, by means of lectures and addresses, the
education of the inhabitants of their respective dis¬
tricts as to the nature and causes of tuberculosis, the

measures for its prevention, and the duty of private
persons and the public generally in respect thereto.
The sanitary authorities of Great Britain should unite
to establish a Board of Representatives as a supreme
national health authority, to deal with tuberculosis
and other national disease, physical degeneration,
and the various matters relating to public health.

A special Council of Representatives should be
appointed to consider and report on the foregoing
recommendations, and the action desirable to give
effect thereto.

As all sanitary authorities are equally interested
in this great question, they are earnestly requested
to consider and as far as possible to co-operate in
carrying out the foregoing proposals.

OPERATING THEATRES.

ST. PETER’S HOSPITAL.

Partial Excision of the Bladder for Malignant
Growth. —Mr. Swinford Edwards operated on a
man, aet. 54 (who looked his age), who had presented
himself with the following history : Two years ago he
had an attack of haematuria which lasted two days;
he had no further symptoms until April of this year,
when on getting up in the morning he passed a large
amount of blood and many clots. Since theD he had
been troubled with increased frequency of micturition
(.12 by day, 4 by night), and with difficulty iD passing
water. On admission, and up to the present time, there
was always a little blood at the end of micturition.
He has not complained of much pain, though there
was sometimes slight pain during micturition. He did
not think he was losing flesh. Cystoscopy had been
performed in the out-patient department by Mr.
Pardoe, when a typical epithelioma of the bladder was
seen occupying apparently an area of a two-florin
piece. It was situated on the anterior wall, and did
not seem to involve the vesical orifice of the urethra.
Urinary analysis was as follows : Cloudy ; light colour ;
slight reddish deposit; acid; specific gravity, 1013;
some albumen ; no sugar ; urea 1.2 per cert. ; micro¬
scopical examination showed crystals of urates;
there were no enlarged glands to be felt either in the
groin or abdomen. The patient having been anaes¬
thetised, supra-pubic cystotomy was performed. It
was found that the incision into the bladder went
right through the growth. On inserting a finger into
the viscus, the extent of the epithelioma could be made
out by palpation between the finger and thumb.
It was found to have an area of about three inches
square, and to be confined to the anterior wall and
fundus of the bladder, not extending to the lateral
walls. Upwards, it did not go as far as the peritoneal
reflection, though there were inflammatory adhesiors
between the peritoneum and bladder-wall, rendering
stripping very difficult- The growth itself, Mr.
Edwards said, promised to remove easily. In stripping
the peritoneum, the membrane was torn and was
stitched up at once with a silk suture. The ircision in
the bladder wall was then continued upwards urtil
clear of the growth, which last was next gradually
excised by means of a pair of scissors, one blade of
which was inserted into the bladder through the
primary incision. The bladder wall was cut through
well clear of the growth (about three-quarters of an
inch) on the right side, the cut edge being clamped by
a succession of artery forceps, this being repeated on
the left side and in this way the growth was completely
removed. There was not much bleeding, only a few
vessels having to be tied with catgut ligatures The
cut edges were brought into apposition before the
forceps were removed, and stitched together with

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APg. 3 . T 9 Q 7 -

CORRESPONDENCE.

stout catgut which did not penetrate the mucous
membrane. An aperture was left at the anterior part
just big enough to admit a full-sized tube, and the
skin incision was closed in the ordinary way, a smaller
tube being inserted as far as the bladder-wall. The
cuts necessary to remove the portions of bladder ex¬
tended to within an inch and a half of the vesical
orifice of the urethra. Mr. Edwards pointed out that
the naked eye appearance of the growth was that of a
typical epithelioma. It was a hard nodular ulcerated
mass with infiltrated edges, but the extent of growth
in the bladder wall did not seem to be much greater
than the area of ulceration. No evidences of lym¬
phatic infection were found during the operation.
Mr. Edwards remarked that this operation was a very
rare one on account of the inaccessibility generally of
malignant growths of the bladder. It would be found,
he said, that in the vast majority of these the disease
was situated around one of the three orifices of the
bladder, namely, the two ureteric openings and the
orifice of the urethra, so that, as a rule, in malignant
cases, the fundus of the bladder was chiefly involved.
He had only had one previous case in which
a small carcinomatous nodule was excised from the
anterior wall of the bladder. In the present patient
he had found the growth larger than he had anticipated
would be the case judging from its cystoscopic appear¬
ance. It practically necessitated the removal of the
whole anterior bladder-wall from the apex to within
an inch and a half of the urethra. With regard to
the operation, the patient was placed in the TredeleD-
berg position, as soon as the bladder contents had been
evacuated. The usual supra-pubic incision was made,
but in order to give sufficient access to the field of
operation, it was found necessary to divide the inner
fibres of the recti on each side. He regretted having
inadvertently opened the peritoneal cavity whilst
stripping the serous membrane off the bladder, but
owing to the peritoneum being tightly bound down in
the neighbourhood of the tumour, it was unavoidable.
However, it was fortunate he at once recognised this
contretemps, and took care to repair it before incising
the bladder. At the end of the operation a small tube
was inserted down to, but not into, the bladder. Mr.
Edwards said that there were very few cases of excision
of portions of the bladder for malignant growth on
record, and he believed that recurrence had taken
place in a considerable proportion of the small number
recorded In the present case, he hoped for a better
result, owing to the free removal of bladder-wall with
the [tumour, and also because of the fact that there
was no apparent enlargement of glands or lymphatics.

A month aftert he operation the patient is passing
all his urine per urethram, and the supra-pubic wound
18 firmly closed. The man himself is in a very satis¬
factory condition.

CORRESPONDENCE.

Fkdll OUR SPECIAL CORRESPONDENTS
ABROAD.

GERMANY.

.. ,, „ . , , Berlin. Am. 4tb. 1*07.

At the German Society for Surgery, Hr. Thorkild
Kovsing read a paper on

Total Extirpation of the Urinary Bladder with
Bilateral Lumbar Ureteral Openings.

Be observed that total extirpation of the bladde r
was only rarely performed, although it was frequently
‘“dicated with propriety, this was on account of its
a Ppalling immediate mortality. Of 31 cases operated

Th» Medical Pun. 149 ,

on 51 died—a mortality of about 50 per cent. (17 males
with 11 deaths—64.7 per cent.; 11 females with 4
deaths—36 per cent.). This high mortality could not
be dependent on the dangerous nature of the operation
itself, as it could be mostly performed without much
haemorrhage, and without any special difficulties, but
the difficulty lay rather in treating the severed ureters
iu such a way that infiltration of urine and infection
ot the large, deep wound was avoided. Hitherto the
ureters had been chiefly treated in three different
ways: (1) opening freely into the wound (Barden-
heuer, Kuemmell) ; (2) into the rectum or the sigmoid
flexure (Maydl, Tuffier, Modlinsky, Kuemmell, Krause,
Hogge, Wilms) ; (3) in females by implantation into
the vagina with subsequent colpocleisis (Pawlick).

By. the first method infiltration of urine was of course
unavoidable, with the second, opening into the rectum
always gave rise to danger of infection. If the sutures
cut through, urine mixed with fecces emptied into the
wound, and even where the case ran an ideal course
the danger of secondary ascending infection was always
to be feared. Vaginal implantation involved castrat-
tion, incontinence generally resulted and there was also
a danger of ascending infection. The speaker had there¬
fore hit upon another way, as he came upon a case of
bladder tumour where total extirpation seemed the
only way of saving the patient. At the one sitting he
performed bilateral lumbar ureterostomy. As his success
in this as well as in two later cases exceeded his ex¬
pectations he believed he was justified in describing
his method and recommending further trials.

Under aether and in the Trendelenburg position a
wide semi-circular incision with the convex part down¬
wards was made just above the symphysis with partial
Separation of the insertions of the recti muscles, and
the bladder was reached. This which was previously
filled with a 1 per cent solution of phenosalyl was now
opened, separated from its surroundings like a cystic
tumour — in males along with the prostate—and
finally removed, after the urethra had been drawn out
like a pedicle, and cut through between two pairs of
clamp forceps. In two cases he succeeded in enuc¬
leating extra-peritoneally, in one the peritoneum was
attached and infiltrated with carcinoma. Here the
whole peritoneal covering was also removed, and after
the completion of the extirpation the large peritoneal
wound was closed by a running Kuerschner suture.
The wound cavity was tamponnaded with gauze
moistened with a 1 per cent, solution of silver nitrate.
The recti muscles were again attached, the skin wound
was sutured with aluminium bronze, up to the middle
line where a strip of gauze was left in. The ureters
were then sought through small oblique lumbar in¬
cisions, freed as far as the ligatures and drawn out com¬
pletely so that they hung out of the lumbar openings
like two earth worms. The lumbar wounds were then
at once closed and covered with collodion and lint.
The ureters were then placed in a symmetrical position
in the trigonum Petiti, conducted into a sterilised
glass container after a No. 12 catheter had been intro¬
duced into the ureter beyond the abdominal walls.
Outside the ureter was drawn through a perforated
rubber cap and protected by it. The ureter now healed
in and necrosed up to 2-3 cm. and projected above
the skin as a small beakshaped urethra when the
necrosed part was cut off in about a week. When the
lumbar incisions were healed the catheters were re¬
moved from the ureters and from then the urine was
cared for by dressings. These dressings (made by
Svenscn and Hagen, Copenhagen) consisted of a wide
elastic binder into which two plates of silver were sewn,
each provided with an opening into which the flat
silver flasks that collected the urine accurately fitted
Flattened silver tubes ran from these to which india-
rubber tubes were attached which conduct the urine
into a urinal hung below the symphysis. On the under
surface of the silver capsule is a rubber ring filled with
air which is pressed on bv the girdle round the loins.
The apparatus had proved its usefulness as the patient
first operated on had been able to keep dry day and
night for a period of eleven months. The speaker

Digitized by GoOgle

150 Thb Medical Press.

CORRESPONDENCE.

Aug. 7, 1907.

demonstrated the apparatus and also the three malig¬
nant tumours removed. He also related the cases in
detail, and claimed that the operation could be per¬
formed without danger of sepsis or of dangerous
infiltration of urine.

AUSTRIA.

Vleam. An*. 4th. 1907.

Experimental Cirrhosis and Tubercle.

Stoerk reported a few experiments he has made
with tubercle to the Gesellschaft. He found that all
the animals which were infected withtuberculous matter
produced changes in the liver resembling cirrhosis.
This transition took place irrespective of virulence or
nature of the bacilli. The changes usually commence in
the remote or finer ramifications of the blood-vessels
in fibrous bands that increased in the opposite direction
to the blood current, i.e., from the capillaries towards
the larger arteries. The specific epithelial tissue is
first changed into a cellular tissue that subsequently
passes in to a hard fibrous tissue traversed by the gall
ducts. He believes that many cases of cirrhosis are
due in the first instance to tubercle and not always to
external poisons from excess, &c.

Inguinal Glands and Tubercle.

Bartel demonstrated from a few preparations taken
from guinea-pigs into which he had injected tubercle.
The first example was a right-sided inguinal lymphatic
after subcutaneous tuberculous infection by vaccination
The gland was seen to be hard and fibrous with a few
isolated giant cells. The second animal had large cica¬
trices in the lung with bronchiectasis. Three and four
animals had been fed, one with infected food, the
other with pure food, but vaccinated copiously. The
former suffered severely from tuberculosis and was
treated for the disease while the vaccinated animal
suffered very little. From this he reasoned that there
was more danger from food than'even vaccination,
while breathing was inoffensive. Number five animal
by vaccination showed a large quantity of eosinophile
cells, enclosed in hard centres in the lungs.

Tar and Nephritis.

Swoboda showed a young girl, set. 4, who had suf¬
fered from nephritis, the result of using a tar ointment
for a troublesome eczema. This case seems to be one.
peculiarly averse to the drug as not more than 30 or 40
grammes at the very outside was used in the treatment
of the eczema. The ointment used contained 3 per
cent, of the tar product. In the ordinary text-books
we are taught to apply large quantities of this sub¬
stance without any qualifying restraint, not less than
5 or 10 per cent, when administered to young children.
This is a mistake. Prescribers should be warned of
the danger that lurks in the drug when freely used.

Escherich presumed that the active principle, tere-
bene, was copiously absorbed by the open eczematous
wound, which speedily produced the toxic effects
recorded.

Schessinger thought the disposition of the patient
had more to do with the toxic results in these cases as
large quantities of the tar products can be used in open
wounds without the slightest symptom of any malaise.

Physiological Lines on Nails.

Schick treated the members to an exhaustive history
of the lines on the nails of children. Besides the in¬
flammatory paronychia of syphilitic infants there
were physiological lines, due probably to gastric or
intestinal catarrh ; but such transverse lines are also
found in perfectly healthy children where no catarrh
exists. About the end of the fifth week a wavy trans¬
verse line may be observed on the thumb of the infant,
but sometimes appearing first on the fingers, with the
convex margin towards the point of the digit, from
which it recedes about the 90th day. As a rule these
lines appear first in the thumb, and pass along to the
little finger in regular sequence. This change has been
designated a physiological one, but correctly speaking
it is just as pathological as the syphilitic marking.

It would appear that this so-called physiological mark¬

ing of the nails is due to the injury done to the organism
when it is passing from the intra to the extra-uterine
life. This is supported by the fact that the weight of
the child falls during the first week with the well-known
physiological desquamation.

Hochsinger said he had often observed this pheno¬
menon when looking for the syphilitic marking during
the exanthematous period. Schick’s physiological
marking was quite distinct from the syphilitic in point
of time, the latter being|always later than the former.

Swoboda had long observed this linear pathological
change in scarlet fever, he said, as well as in other severe
diseases.

Escherich thought this marking was due to the
disturbed balance in the metabolism after birth.

LETTERS TO THE EDITOR.

THE GENERAL PRACTITIONER.

To the Editor of The Medical Press and Circular.

Sir,—A t the recent annual meeting of the Parents’
Union I was much impressed by some passages in
an address by the Hon. E. Lyttleton, Head Master
of Eton. He described as really tremendous the
fact that the three great altruistic professions, the
ministry of the gospel, the medical, and the teaching
professions “ are all being starved.” He declared
it as his conviction that this is principally because
we are passing through a phase of believing that
excitement, and amusement, and comfort are ends
of living instead of very dubious concomitants. He
said that thousands of men outgrow the belief; but
by the time they do, their professional career in life
is fixed, and it is not altruistic or social, because
another amazing lie has been somehow stamped
upon the minds of the youth of to-day, viz., that
social service is dull. If I quote the substance of
these passages it is not to express agreement with
the idea that the medical profession is being * ‘ starved ’’
in the sense that Mr. Lyttleton uses the word. Every
general practitioner, at any rate, knows that there
are more doctors than are called for. What I want
to bring forward and emphasise is the fact that no
one should take up the calling of medicine unless he
has more than the average of capacity for self-sacri¬
fice. He ought to love science, to love his profession,
and have an unlimited amount of sympathy with
suffering humanity. If he has a keen sense of humour,
and an optimistic temperament, the outcome of
sound physique and health, so much the better;
and if, along with these intrinsic endowments he
possesses at the outset so much of the world’s goods
as puts him beyond the risk of grinding poverty, his
life as a doctor in whatever rank he may find himself
ought to leave little real cause for complaint. To
practise medicine as a trade, as a mere money-making
routine employment, must be always more or less
degrading ; whilst to pursue such a trade with the
sole aim of money grabbing, with the aim first of all
of getting as much money as possible out of every
patient instead of subordinating every thought to
consideration of the welfare of the patient, is to
demoralise oneself below the level of the lowest
trade trickster of tho day. An unqualified quack
may sometimes plead ignorance, but no such excuse
can be urged by an educated professional man.
Men who make money in such a way are not to be
envied, they themselves probably always come to
recognise that peace and happiness are not to be
achieved by such methods. Whilst a doctor must
be prepared for a hard life there seems no reason
why he should not demand from the State the privileges
and the protection, which are his just due. To gain
these, I agree with your correspondent G. P., he
must combine, and with one voice demand and insist
upon his rights. The general practitioner at present
seems sadly in want of leaders to guide him in this
direction.

I am. Sir, yours truly,

August 1st, 1907. G. P. No. 2.

by Google

Diqitizi

Aug. 7, 1907.

SPECIAL ARTICLE.

The Medical Pims. 151

To the Editor of The Medical Press and Circular.

Sir, —I am much interested in the correspondence
now going on in your esteemed columns with regard
to that despised individual, the G.P. The general
practitioner doubtless has his misfortunes and makes
his mistakes—like a few consultants—but he has,
be it remembered, about ten specialties to keep going
all at once, which is rather a strain on a “ ranker,”
when the “ officer ” finds one as much as he can
manage. I have had in twenty-four hours to go from
a placenta pr.xvia case (with which I was up all night,
and saved the mother, but not the child) to an accident
in a mine, and deal with five cases of various kinds of
fractures and severe wounds ; then drive on to a bad
prostatic case with retention of urine in an important
county gentleman, and from there to consult with a
brother practitioner in a doubtful case of small-pox !
Thank heaven, I don’t have such days every day, but
it shows what we G.P.’s may have to do. Happily, I
do not know a tubercle bacillus by sight from a cod¬
fish, and I have, I confess, a bit of Mr. Bernard Shaw’s
contempt for the opsonic index, and I think most of
my assistants soon get that stuff knocked out of their
heads when they find themselves with their first
shoulder presentation, or strangulated hernia. If our
” pastors and masters ” would come down to a rough
colliery practice for six months, the medical curri¬
culum would soon be chopped up into something very
different.

I am, Sir, yours truly,

Collier.

P.S.—I never read The Medical Press and Cir¬
cular without finding something in my line, though
I always skip the opsonic index, and all that.

To the Editor of the Medical Press and Circular.

Sir, —I have been much interested in the two letters
published iD this week’s issue of your paper and am
obliged to the writers of both for their kindly refer¬
ences to me. The works which Dr. Edwards alludes
to show that he has given much thought to ODe need
that I emphasised, namely, good text books written to
supply particular information for the general prac¬
titioner, and with his remarks I am in complete sym¬
pathy. But the other aspect of the problem that
G.P. draws attention to is a rot less important one.
How are we to overcome the apathy of the general
practitiorer, so that he may realise more clearly what
is required to improve his own position ?

My aim has beer to point out that it is for the good
of the medical profession as a whole that the ordinary
medical man should be better represented. That there
are many aspects of health and disease of which he
alone has experience, and that he cannot be expected
to make use of his research opportunities till he is
better supplied with literature, has greater leisure, and
some pecuniary compensation offered to him for
labour honestly expended. It is this whole outlook
I would ask other medical men to bear in mind. There
Is widespread discontent felt with the unsatisfactory
stateof general practice. Thefault is.asG. P. remarks,
largely our own. When the apprenticeship system
was abolished the student lost touch with the condi¬
tions of ordinary medical experience, and the improve¬
ment in the skill of the practitioner himself caused the
consultant to cease his, at one time, customary super¬
visory control. These two developmental factors
have almost separated the general practitioner’s out¬
look from the consultant’s and the specialist's, and it
rests with him to show how a return to medical unity
on a higher plane can be brought about.

I would personally welcome any suggestions or
criticisms of real or apparent weaknesses in the position
here laid down.—I am. Sir, yours truly,

J Lionel Tayler.

Willesden Green, N. August 2nd. 1907

Mr. A. Pearce Gould, F.F.C.S., has received a
donation of one hundred guineas for the Cancer Re¬
search Fund of the Middlesex Hospital from Mr. A.
J- B. Carl ill.

OBITUARY.

JOHN PIRIE, M.A., M.B.AbeRD.. F.F.P.S.Gi.asg.

We regret to record the death of Dr. John Pirie,
late of Glasgow. Some years ago. Dr. Pirie retired
from the practice of his profession in that city, and
went to reside at Courthrll, Campbeltown, where he
passed away on July 24th. Dr. Pirie, who had reached
his 81st year, was a native of Ross-shire. He was
educated medically at Aberdeen University, where
he took the full Arts course, graduating M.A., and
afterwards hisM.B. degree in 1851. In 1868, he became a
Fellow of the Glasgow Faculty of Physicians and
Surgeons. His first appointment was as house-surgeon
in the Aberdeen Royal Infirmary, and about the year
1852 he went to Campbeltown, where he remained till
1867, when he came to Glasgow, and there the rest of
his active life was spent. Dr. Pirie was a fine repre¬
sentative of the physician of the old school, genial,
kindly, and generous, with a rich fund of wit and
humour. By his professional brethren he was held in
the highest respect, he had the confidence, in many
instances the warm affection, of his patients, while he
had the regard and esteem of all who had the privilege
of his acquaintance. From the time he came to
Glasgow he took a great interest in the necessitous
poor, and, along with Dr. W. L. Reid and a few kindred
spirits, he founded the Glasgow Medical Mission, one
of the most beneficent of the institutions of the city.
He took a warm interest in everything connected with
the Highland counties, and he was at different times
president of the Kintyre Club, the Ross and Cromarty
Society, and the Northern Highland Benevolent
Society. He is survived by three sons and one daugh¬
ter.

SPECIAL ARTICLE.

ANNUAL MEETING OF THE BRITISH
MEDICAL ASSOCIATION.

Exeter. July 27th to August 3rd, 1907.

F * , [From Our Special Correspondent].

The Exeter Meeting has proved an unqualified
success. Good weather, numerous visitors, un¬
bounded hospitality, well-ordered meetings, interesting
sectional discussions, an exceptionally excellent
pathological museum, a good trade exhibition, and
many attractive entertainments, social gatherings
and wisely selected excursions have all united t»
crown this year’s great Conference of Medicos with
distinction. To the President and his confreres
and many friends and helpers, and also to the per¬
manent officials of the Association, congratulations
and thanks are due.

Next year’s gathering in the smoke-laden city of
Sheffield will not easily surpass the success of the
quiet and quaint cathedral centre of the West.

The Business of the Association.

The scientific visitor and the mere perfunctory
medico know little of the strenuous work of the
Council and representatives. Under its new constitu¬
tion the Association is slowly finding its feet and
testing its powers. As yet. however, it can hardly be
said that this large and influential body has come
into its kingdom. This year, however, good progress-
has been made. In the near future important ad¬
vance will be made in several directions. The rapidly
progressing new Central Offices in the Strand will
prove of much service in aiding the fit and proper
evolution of the Society.

Dr. H. Radcliffe Crocker, has tendered his resig¬
nation of the important position of treasurer, and
Dr. Edwin Rayner, of Stockport, has been elected
his successor. Dr. Smith Whitaker, the indefatigable
Medical Secretary, is to receive further assistance*

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152 The Medical Press.

SPECIAL ARTICLE.

Aug. 7, 1907.

so that the work of his department may be more
adequately dealt with. The financial position of
the Association received much consideration, and
steps are to be taken to extend and consolidate this
essential factor. Much time was also devoted to
the old perplexities and ever recurring puzzles relating
to the relationships of patients, practitioners and
consultants, hospital abuse, and medico-political
procedure and legislative action touching medical
practice and the interests of the sick, and the progress
of sanitary science.

Official Addresses.

The President’s Address on “ Science in its Applica¬
tion to National Health ” was received with general
approval, and was certainly timely in its strong
expression of the need for a national awakening
to the importance of physical culture and the urgent
necessity for a Government inquiry into the wide¬
spread scourge of tuberculosis which is working such
loss to us as a people.

Dr. W. Hale White’s address on “ Medicine ” was
an eloquent plea for accuracy of thought and a worthy
sermon on the righteousness of confession of ignorance,
limitation of knowledge and the wisdom of recognising
an effort-making agnosticism in matters medical.

Mr. Henry T. Butler’s address on surgery was an
able and impressive oration on the contagiousness
of human cancer, in which he presented evidence that
auto-inoculation, though rare, did occur, and thus
opened a view to the pathology of malignant disease
which had far-reaching practical bearings.

Sir John William Moore’s popular lecture on
“ Weather, Climate and Health ’’ was a well-ordered
exposition of man’s relationship to various natural
conditions which exercise profound influence on the
maintenance of health and the production of disease.

The Work of the Sections.

The chief work of the meeting was conducted in
the Sections, thirteen in number. Most of these
were attended by comparatively only a few enthusiasts,
but many valuable and interesting discussions took
place, and not a few suggestive papers were presented.
The present arrangements for the conduct of the
work of the sections leave much to be desired and,
evidently, if the scientific value of the annual meeting
is to be maintained, close attention should be given
to this most important matter. As a first step a
time-table should be arranged for each section and
rigorously adhered to. Communications should, as
far as possible, be of the nature of demonstrations,
and all papers should be printed in full or in abstract
iorm before presentation. By these and other
improvements in selection and procedure the scientific
work and service of the sections would be considerably
increased and enhanced.

Among the numerous discussions which took place,
and papers which were presented, it is, in the limits
-of space at our disposal, impossible to refer to any
in particular. We are, however, arranging to give
abstracts of the more important in our pages during
the next few weeks.

Entertainments.

Carping critics are wont to sneer at an annual gather¬
ing such as this as little more than a proceeding of
“ picnicking,” and for not a few of the visitors this,
t must be admitted, is the most manifest feature.
But even a general practitioner is worthy of a holiday,
and there seems no adequate objection to associating
social pleasures with scientific pursuits. Exeter has,
at all events, succeeded in accomplishing this pleasing
UnioD. During this week numerous attractive enter¬
tainments have taken place. The Mayor and the
"Sheriff (Dr. Picard) extended a civic welcome to the
visitors and received them in the ancient Guildhall.
The Mayor and Mayoress (Alderman and Mrs. W. H.
Reed) also gave a garden party in the pleasant grounds
■of Northcoutray. The President and membeis of
the South-Western branch gave an Evening Fete.
A particularly attractive garden party was given by

the Lord Bishop of Exeter and Mrs. Robertson in
the charming garden of the Palace.

Numerous garden parties, receptions, entertain¬
ments, were given, and many most enjoyable private
luncheons and dinner parties held, and much courtesy
and kindness displayed by many in guiding to local
features of interest.

During the week a number of excursions were
arranged for to some of the many charming places
in the neighbourhood.

On Saturday, the closing “ off ” day, loDg excur*
sions took place to Plymouth, Falmouth, Endsleigh,'
Ilfracombe, and Bideford and Clovefly, after which
many visitors continued their delights by extending
their holiday and touring into Devon and Cornwall.

The Annual Exhibition.

The •* Trade Show” is always an interesting and
instructive adjunct, and this year it was excellently
housed in the convenient and readily accessible Victoria
Hall in Queen Street, near to the Central Reception
Rooms. The organizers had succeeded in presenting
a thoroughly representative and well-arranged display
of all varieties of “ material ” required for hospital
equipment and the conduct of the healing art. The
exhibition was well patronised and exhibitors appeared
satisfied with the interest evinced by the numerous
medical visitors, who, on their part, seemed pleased
with the courtesy shown to them and the many and
excellent arrangements which had been made for their
comfort.

Ninety-one different firms had stands, and many
were large and elaborate. Old favourites were con¬
spicuous and many familiar faces were to be seen.
Surgical appliances and hospital equipments were par¬
ticularly well represented.

Down Brothers, Ltd., showed new and original
designs for operatiDg-tables, and a large selection of
surgical instruments and anaesthetic apparatus and
medical accessories. The Holborn Surgical In¬
strument Company exhibited various admirable
sterilizers and several ward and instrument tables and
a large collection of goods of excellent workmanship
at remarkably low prices. Messrs. Arnold and Sons
had a large and inspiring show, including the high
pressure steam sterilizers, as suggested by Mr. W.
Bruce Clarke. Also a large assortment of modern
instruments employed in surgery, gynaecology, and
the surgical specialities. S. Maw, Son, and Sons
displayed representative types of their aseptic furni¬
ture, ard of their many special surgical instruments
and medical sundries. John Weiss and Son, Ltd..
had a large collection of ophthalmic instruments and
selections of their most recent general instruments.
Thomas Hawksley had a very attractive stall at
which were demonstrated the use of blood pressure
apparatus and other physiological instruments em¬
ployed in clinical investigations. Mayer and Metzler
were well represented, and exhibited many forms of
instruments used in the practice of laryngology,
rhinology, and otology, which well demonstrated the
favour in which this firm is held for this most important
and delicate class of surgical inventions. The Equi¬
poise Couch Company gave practical evidence of the
serviceability of their ingenious and admirable equi¬
poise beds, lounges, and chairs. By the adoption of
this system, patients may be placed in any position
without trouble or exertion. This method of con¬
struction should have wide application to the needs
of patients both in hospital and private practice.
Geo. Gale and Sons had a good display of their

Lawson Tait ” bedsteads, wire mattresses, and well-
designed and strongly constructed hospital furniture.

Allen and Hanbury, Ltd., as usual, had a par¬
ticularly attractive stand, with many new forms of
instruments, transfusion apparatus, operating tables,
sterilizing apparatus, and such novelties as Stack’s
portable dressing sterilizer and Dr. F. C. Eve’s cerebro¬
spinal manometer. The Liverpool Lint Company
and the Sanitary Wood-Wool Company, Ltd., had
useful displays of their well-established antiseptic

Aug. 7, 1907.

SPECIAL ARTICLE.

The Medical Pmw. 153

dressings and other preparations. Philip Harris and
Co., Ltd., exhibited several forms of drug, bacterio¬
logical and urinary cabinets, and a particularly ser¬
viceable and cheap form of surgery couch. Reynolds
and Branson, Ltd., showed ambulance requisites, a
new form of apparatus for the administration of
oxygen and many ingenious appliances for clinical
work. Messrs. Browne and Sayer displayed their
ideal inhaler, and other hospital requisites. The Ajax
Sanitary Company’s exhibit attracted much atten¬
tion, being a simple and effective device for lavatory
basins, sinks and baths, consisting of a sliding valve
or shutter which can be made of any shape and of a
variety of materials in a recess at the back of the basin,
forming a moveable weir, over the top of which the
waste water may run away faster than it can flow into
the basin. The Medical Supply Association pre¬
sented an elaborate display of their hospital furniture,
surgical instruments and dressings, anaesthetic appa¬
ratus and electrical appliances. The Dowsing Ra¬
diant Heat Company demonstrated their now familiar
appliances for radiant heat and light treatment.
G. H. Neal showed his well-known “ Repello” and
other forms of clinical thermometers..

Electro-medical apparatus was well represented and
admirable exhibits of thoroughly up-to-date X-ray
high-frequency and electro-therapeutic outfits were
tnaie by such well-known firms as Messrs. Harry \V.
Cox, Ltd., W. Watson and Sons, Marconi’s Wireless
Telegraph Company, Ltd., Alfred E. Dean, the Sanitas
Electrical Company, Ltd.

Drugs, of varying therapeutical value and in almost
infinite pharmaceutical form, were exhibited by a large
number of firms.

The Denver Chemical Manufacturing Co.
made a prominent show of their useful local applic¬
ation Autiphlogistine. The Bayer Company. Ltd.,
reminded us of the value of such well-established agents
as asperin, neroni, tannigen, veronal, and somatose.
Fairchild Bros, and Foster made a good display of
their “ Fairchild Products ”—peptogenic milk powder,
pepsenica, panopepton, trypsin, noladin, &c. Parkes,
Davis and Co., as usual, were well to the front, show¬
ing elegant preparations used in modern therapy, in¬
cluding adrenalin, eudrenine, formidine, veratrone,
and specimens of their admirable “Glaseptic ” nebulisers
and sprays. Meister, Lucius and Bruning, Ltd.,
exhibited a selection of antitoxins, serums, &c., includ¬
ing the various tuberculin preparations, and a large
assortment of their many synthetical preparations.
Novocain and the demonstrations of its methods of
employment for anaesthesia attracted considerable
attention. TheMaltina Manufacturing Co., Ltd.,
made a bold show with their many and varied
" Maltine ” preparations. Oppenheim, Son and Com¬
pany, Ltd., showed their ingenious and acceptable
“aseptules.” '■ coccoids,” and other specialities includ¬
ing their well-known vaporiser and aeriser. The
Angier Chemical Company, Ltd., again reminded us
of the benefits of their petroleum emulsion, and their
more recently introduced throat tablets. The Charles
H. Phillips Chemical Company exhibited their
famous antacid “ Milk of Magnesia,” a preparation
we have long approved and recommended.

Armour and Company, Ltd., well known for their
reliable preparations of digestive ferments showed
samples of their animal products. Stovaine, one of
the new local anaesthetics, was shown byLES Etab-
L1SSEMENTS POULEINE FRERES.

Evans. Gadd and Company, Ltd., made an elegant
display of their standardised products, including their
Liq. Violae Glucosidi, Tinct. Digitalis, and Liq. Thymo-
Antiseptic Co.

The Sanitas Company, Ltd., had a large show of
their ever growing “Sanitas” preparations. Jeyes’
Sanitary Compounds Co., Ltd., also displayed their
"Cyllin” preparations. Wyleys, Ltd. exhibited a
election of their Neroin compound, liquors, medicinal
syrups amd other well-established and much valued
preparations. Knoll and Co. showed bromural.

styptol, santyl, styracol, and diuretin. The Miol
Manufacturing Co., Ltd. made a particularly
attractive show with their new “Miol,” a prepairation of
olive oil and malt, which we have found of much
value as a nutrient, particularly for children.

B. Kuhn and Company exhibited the well-known
disinfectant, “ Chicnosol,” papain and the now popular
local anaesthetic ethyl chloride. C. J. Hewlett and
Son displayed their elegant pharmaceutical prepara¬
tions and several useful forms of antiseptics.

Foods and dietetic preparations, both for the healthy
and the sick, the infant and the adult, this year, as in
former exhibitions, bulked largely, and their represent¬
atives showed no lack of enterprise in advocating the
merits of their particular products.

The Aylesbury Dairy Co., ltd., exhibited their
new preparations, pollyta and humanoid and also
showed various preparations of humanised milk,
poumiss and keptin.

Mellin’s dietetic preparations for infants and in¬
valids were much in evidence, including their “ Lacto,”
food biscuits, and chocolate.

Nestle’s and Anglo-Swiss Condensed Milk Com¬
pany displayed specimens of their milk and milk-
chocolate preparations. Cadbury Brothers, Ltd.,
and J. S. Fry and Sons, Ltd., furnished liberal sam¬
ples of their world-famed chocolate and cocoa pre¬
parations. International Plasmon, Ltd., furnished
evidence of the manifold advantages and varied forms
in which Plasmon can be advantageously employed.
Horlick’s Malted Milk also found a place. “ Virol ”
was prominent, and the Liebig Extract of Malt
Company, Ltd., had a specially attractive exhibit of
Lemco, Oxo, and other meat preparations.

Keen, Robinson and Co., Ltd., presented the far-
famed and old-established Robinson’s Patent Barley
and Patent Groats and Colman’s Sinapisms and other
mustard preparations.

A new casein preparation was exhibited by the well-
known biscuit manufacturers, Messrs. Peek, Frean
and Co., Ltd., called “ Tilia,” in the form of biscuits,
which is likely to become very popular in the near
future.

Callard and Co. presented their starchless and
sugarless preparations which have done so much to
simplify and render palatable the dietary of diabetic
and other cases. The Manhu Food Company, Ltd.,
also showed their diabetic foods. G. Van Abbott
and Sons exhibited preparations of their Gluten bread
and other foods for diabetics and obesity cases.

Ihemhardt’s Food Company, Ltd., showed their
useful soluble food for infants and their palatable and
nutritious “ Hygienia.” Reynolds’ Pure Digestive
Wheatmeal and Wheatmeal Bread was prominently
displayed. Virogen, Ltd., exhibited their “ Virogen ”
and other foods. Broomfield and Co. again showed
the useful vegetable fat “ Albene.”

Ronuk, Ltd., had a stand on which were set out
their various wood stains and sanitary polishes.

The Cellular Clothing Company, Ltd., showed
their excellent “ Aertax ” clothing, which we can
thoroughly recommend from personal experience.

Beverages found a prominent place. Such favourite
waters as Perrier, Apenta. Apollinaris, Johannis.
Alexander Riddle and Co., Ltd., and Feltoe and
Smith, Ltd., presented their lime-juice and lemon
preparations. Camwal, Ltd., reminded medical visi¬
tors of its numerous aerated mineral waters, which are
particularly fine and palatable.

Friedrichshall, the old-fashioned but valuable
natural aperient mineral water, made a praiseworthy
bid for a renewal of its ancient and well-merited
popularity.

Ingram and Royle, importers of many forms of
natural mineral waters, supplied useful information
concerning their particular specialities. Several health
stations availed themselves of the opportunity of
making known their special climatic and other advan¬
tages. Buxton furnished information concerning its
mineral waters and baths. Harrogate furnished

DiaitizedbvGoOQle

Aug. 7, 1907.

154 The Medical Press. REVIEWS OF BOOKS.

attractive literature .concerning its many means of pro¬
viding all forms of. hydro-therapy in its Royal Baths.

The Borough of Royal Leamington Spa also furnished
a stall with literature concerning its special climatic
advantages and bathing establishment.

Several medical publishers wisely gave opportunities
to country and busy practitioners to examine ttfeir
books. Among those exhibiting were H. K. Lewis,
W. B. Saunders Company, Rebman Ltd.

The Pathological Museum.

All concerned in the preparation of this year’s patho¬
logical collection merit congratulation. The selection
and arrangement of preparations were excellent.
Unfortunately, the Barnfield Hall, in which the speci¬
mens were laid out, was somewhat out of the way and
was not visited, we fear, by many except those specially
interested. An excellent catalogue made the collec¬
tion one of the most valuable and instructive features
of the meeting. It consisted of 139 pages of descriptive
letter-press, giving descriptions of over 900 specimens,
photographs, drawings, &c. A particularly praiseworthy
feature were the demonstrations given on three morn¬
ings by Mr. Ernest N. Shaw, Dr. F. W. Mott, and Dr.
W. F. Bashford.

Where almost every exhibit is worthy of thorough
study, it is difficult and appears invidious to particu¬
larise. Special interest, however, centred about the
extensive collection of specimens illustrating diseases
of the breast, lent by St Bartholomew’s Hospital;
preparations illustrating the researches carried out by
the Imperial Cancer Research fund under the direction
of Dr. Bashford ; the diagrams of Professor Ehrlich,
illustrating experimental tumour production, and the
very extensive collection of specimens illustrating
tropical medicine and parasilology.

The preparations of cerebro-spinal meningitis, sert
by Professor Muir from Glasgow,were of special interest
and value.

Professor Strassmann, of Berlin, furnished a par¬
ticularly beautiful series of gynaecological preparations,
the mounting of which were beyond praise and admir¬
ably adapted for teaching purposes.

Among the special exhibits were series of specimens
exemplifying lesions of the Brain and Spinal Cord,
and the Liver and Gall-bladder. The large collection
of X-ray photographs of fractures near joints and dis¬
locations were of great value to surgeons.

Dentists found a special section devoted to prepara¬
tions illustrating dental pathology, arranged and classi¬
fied by Mr. W. H. Yeo.

A department which might well be developed to
larger dimensions in future was that displaying
instruments for pathological investigation. We should
like to see every year a complete exhibit of all new
instruments for clinical research.

It seems lamentable that a collection so valuable,
and entailing the expenditure of so much time and
trouble should be available for so short a time, and
should be seen and studied by so few.

It is certainly worth considering whether it would not
be of greater service to medical science if the annual
pathological museum could not be held in London,
and allowed to remain open for at least a month.

This year’s collection is so excellent that we think
it should support the suggestion which we have ven¬
tured to make.

REVIEWS OF BOOKS.

JONES’ MEDICAL ELECTRICITY, (a)

The rapid issue of edition after edition of Lewis
Jones’ “Medical Electricity” proves that the work
is found useful by medical readers. The present
edition contains new matter, such as the use of
mechanical means for obtaining interrupted currents
of measured duration ; the introduction of drugs by
, (a) •' Medical Electricity." By H. Lewis Jones, M.A., M.D., In
charge of the Electrical Department in St. Bartholomew's Hospital, 4 c.
Fifth Edition. London: H. K. Lewis. 1906.

electrolysis ; the treatment of rodent ulcer by zinc,
ions ; the treatment of skin diseases by X-rays, and
so on. The mere recapitulation of these additions
reminds us of the rapid strides that are being made
in electrical therapeutics. Perhaps one of the most
interesting things to note in this connection is the
number of skin conditions that are invaluable to
modern methods. Lupus of the nasal cavity, for
instance, may be attacked with a high frequency
electrode ; warts may be cataphoresed with mag¬
nesium sulphate ; xanthelasma of the lids speedily
cured by electrolysis, while mycosis fungoides often
disappear beneath the X-rays. Dr. Lewis Jones’
book contains a great amount of material, which
is conveyed to the reader in good literary style. A
vast deal of accurate and condensed knowledge is
contained therein, and we have every confidence in
recommending this work. There is an ample X-ray
section and many illustrations.

M:CONNELL’S PATHOLOGY, (a)

This little manual fills a useful position in the
literature of the subject. A wide range of knowledge
is covered by the author, who presents his infor¬
mation, in some instances, in the shape of a series
of short notes, and in others by a fuller description.
The matter, so far as we have tested it, is accurate
and up-to-date, such as one would expect from a
teacher of the author’s experience. There are many
excellent illustrations and several coloured plates.
In this unpretending volume Dr. McConnell has-
provided the busy practitioner with an excellent
condensed reference book on pathology.

THE GEM CUTTER’S CRAFT. ( b)

This work, from its title, might appear to be
of too technical a charater to be interesting to
the ordinary reader apart from those actually in¬
terested in gems from a business point of view. A
careful perusal has, however, convinced us that it
will appeal to very many, both at home and abroad,
on account of the highly interesting and attractive
manner in which the author has handled his subject.
Although a master of his craft he has contrived to
make a most readable book and one, too. that while
not burdened with over-many technical minuti®
seems to contain most of the information that can
be required even by those who make the discovery,
mining, and preparation of gems their particular
business. In his brief preface the author says, “ 1
do not address myself especially to the jeweller, the
miner, the collector, the lapidary’, or the amateur,
but that my book may prove of interest and assis¬
tance to some of these I sincerely trust.”

There is no doubt whatever that the author’s
expectation will be fulfilled, and we hope also that
the book will find a place in the libraries of many
who do not come into the classes he enumerates.
The history of certain famous gems and of gems
generally is given, and the curious fancies and super¬
stitions of the ancients regarding some of them.
The methods employed for their recognition and the
details relating to their preparation (cutting, polishing,
etc.), are given in detail. The wealth of illustrations
and the excellent manner in which they are repro¬
duced add an interest which could hardly have been
conveyed by words alone. Although there are so
many (almost as many as there are pages in the book)
no one of them can be regarded as “ padding,” and
the letterpress and the illustrations separately are
each well worth the price charged for the book.

The publishers have done their share well, tbe
print, paper and binding combine to make the work
a creditable addition to any library.

(а) A Manual of Pathology," By Guthrie McConnell, M.D,
Pathologist to the St. Louis Skin and Cancer Hospital, 4 c., 4 c. Phila¬
delphia and London: W. B. Saunders and Co. 1906.

(б) “ The Gem-Cutter's Craft." By Leopold Claremont. Author «
" A Tabular Arrangement of the Distinguishing Characteristics and
Localities of Precious Stones,” in the .Wining Journal. London
George Bell and Sons. ijs. net. 296 pp. 259 illustrations.

Digitized by G00gle

Aug. 7. 1907.

WEEKLY SUMMARY.

The Medical Puss. 1 53 "

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT PATHOLOGICAL LITERATURE.

Treatment by Bacterial Inoculation.— Whereas
the “ boom ” in vaccine treatment which followed
on the publication of Wright’s discoveries some two
years ago has undoubtedly died down, and vaccines
are not used as widely as they were a year ago, never¬
theless signs are not wanting that the vaccine method
is taking its legitimate place in treatment, and that
physicians and surgeons recognise better than they
did the kind of cases to which it is suitable. One
need of the present situation is that practical workers
should regularly make their results known—whether
successful or the reverse, and that thus the profession
should be put in the way of estimating the true value
of the treatment, and of learning the rules which
govern its applicability. A particularly valuable
paper in this respect is that of Von Eberts and Hill
(American Journal of the Medical Sciences, July, 1907).
In other respects it will be of use to practical workers
in that it furnishes many hints on technique, and on
the fallacies which may interfere with accurate opsonic
estimation. (1) Full instructions are given as to the
preparation, standardisation and dilution of vaccines for
inoculation purposes. The authors advise that if the
best results are to be obtained, the vaccine should be
derived from the actual infecting organism of the
individual case. This rule, however, does not always
apply. Thus, they hold that in streptococcic in¬
fections, the personal vaccine is a necessity, and in
acne a personal vaccine gives the best results. On
the other hand, in furunculosis and carbuncle hetero¬
genous vaccines are often satisfactory, and in gono-
coccol and meningococcol infections the authors look
for the best results with heterogenous vaccines. In
working with tubercle, they are in the habit of
using Koch’s T. K., carefully diluted, but they
have devised a method of preparation of personal
tuberculin. (2) They furnish notes of fourteen cases
treated—tuberculous ulceration of bladder, lupus,
tuberculous arthr.tis, tuberculous adenitis, furuncu¬
losis, carbuncle (two), suppurative periostitis, multiple
abscess, acne, gonorrhoeal polyarthritis, epidemic
cerebro-spinal meningitis (three). In all the cases except
one of meningitis, which ended fatally, there was
either a complete cure or a marked improvement.
The notes on the cases emphasise the authors’ re¬
marks on the respective value of personal and hetero¬
genous vaccines; (3) The authors state their views
as to the supposed necessity for constant estimation
of the opsonic index during treatment. They say :
“ While the opsonic index is a most valuable guide
in regulating the amount and time of dosage, we are
of opinion that excellent results may be obtained,
especially in the treatment of localised tuberculous
lesions, without the use of the “ Immunity Ther¬
mometer ” ; success in the vast majority of cases
attending the employment of minute doses at long
intervals. Generally speaking, the feelings of the
patient are a safe guide.” This opinion of experienced
workers, borne out as it is by many others, is of the
utmost importance. The main objection to the wide
adoption of the vaccine treatment up to the present
has been the trouble and expense of maintaining the
opsonic control which was supposed to be necessary ;
if this control can be done without, then the greatest
obstacle to vaccine treatment vanishes. F.

Bacteriology of Summer Diarrhoea of Infants.—

Morgan publishes (British Medical Journal, July 6th,
1907) the results of a bacterioscopic examination of
a large number of cases of summer diarrhoea of in¬
fants. Cultures were made from the faeces, intestines,
mesenteric glands, or spleen in each case. In a small

proportion of cases the B. Gaertner was found, and
m a few others organisms resembling but not identical
with the B. Flexner and B. Shiga. The preponderat¬
ing organism was one which Morgan believes has not
been previously described. It was isolated from 28
out of 58 cases of diarrhoea ip 1905, and from 15 out
of 34 in 1906. In its general characters it closely
resembles the bacillus of hog cholera of MacFadyean,
but differs from it in its action on litmus milk, in the
production of a larger amount of indol, and in its
failure to produce acid and gas in maltose and dextrin.
It is pathogenic for animals, producing diarrhoea and
death in young rabbits, rats, and monkeys when
these animals are fed on cultures. The condition
produced in monkeys closely resembled infective
diarrhoea in children. Morgan concludes that the
type of summer diarrhoea observed in this country
differs clinically and bacteriologically from the type
seen in America. It.

Anti-rabic Treatment at the Pasteur Institute.—

Viala publishes yAnnales de l' I ns tit ut Pasteur, June
25th, 1907) a statistical abstract of the cases treated
for rabies in 1906 at the Pasteur Institute. During
the year 773 persons submitted themselves to the
vaccine treatment ; two died of hydrophobia. In one
of the fatal cases, however, the disease showed itself
less than fifteen days after the end of the treatment.
Omitting this case, the mortality would be 0.13 per
cent. This is the lowest mortality rate in the history
of the Institute, the nearest to it being 0.18 in 1902.
The number of persons treated is slightly greater
than in any year since 1902. The great diminution
from the years earlier than that is due to the establish¬
ment of ’ several other anti-rabic institutes in the
provinces of France. At present, there are no less
than five, situated respectively at Marseilles, Lille.
Montpellier, Lyons, and Bordeaux. Of the per¬
sons treated at the Pasteur Institute last year, 22
came from Holland. 1 from England, 1 from Russia,
and 1 from Greece, the rest being French. In the
two cases which ended fatally, the patient was bitten
in the face. |j R.

Pathology of Ben-oeri. —Hewlett and De Kort6
publish (British Medical Journal, July 27th, 1907)
some observations on men and monkeys which
justify a suggestion as to the causation of beri¬
beri. They obtained several monkeys suffering from
a disease closely resembling beri-beri; the animals
were very ill, most of them having oedema of the face
and genitals; the urine never contained albumin,
and the knee-jerks were either increased, diminished
or absent. They all died, and the only constant
lesion found was congestion of the kidney, accom¬
panied by cloudy swelling, and in scattered areas
haemorrhages into the convoluted tubes. Hyaline
casts were constantly found in the urine, which also
in some cases contained highly refractile cells of an
unknown nature (? protogoa). Attempts to infect
healthy monkeys from the sick were not very successful,
but in two animals the eyelids became puffy, and
the knee-jerks exaggerated. The authors next fed
monkeys on urine from human beri-beri patients,
a somewhat similar form of illness being produced.
The urine of patients suffering from beri-beri was
carefully examined. Granular and hyaline casts
were present in abundance. In addition, three peculiar
forms of body were seen : (1) Small spherical refractile,
bodies 2 to 3 m. in diameter, apparently possessing
a thick capsule and hyaline contents. They dkGnot

zed by Google

MEDICAL NEWS IN BRIEF.

156 The Medical Fees*.

give the reactions for fat; (2) large, globular cells,
20 m. in diameter, containing a cytoplasm studded
with very refractile granules, and with a single nucleus ;
( 3 ) large cells, 30 m. in diameter, enclosed in thick
capsules, with a finely granular oval nucleus with
rounded nucleoseus. These bodies the authors regard
as possibly protozoa. Finally, the kidneys of subjects
dead of beri-beri were examined ; the lesions found
were similar to those present in the monkeys' kidneys
described, but more intense in degree. As’a working
hypothesis, the authors suggest, that beri-beri is a
protogoan infection, that the infective agent is elimin¬
ated in the urine, and that the urine is the source of
infection. r.

Preparation of Homologous Tubercle Vaccine.—Allen
describes (Journal of the American Medical Association,
July 20th, 1907) a method of preparing personal or
homologous vaccine from tubercular sputum. (1)
Fresh sputum was carefully washed in six changes of
normal salt solution. (2) The sputum was thoroughly
beaten up with an ordinary egg-whisk for ten to
fifteen minutes. (3) The foam was collected and
liquefied by placing it under an exhaust pump. This
was found to be the best means of obtaining bacteria
free from pus cells (4) The resulting emulsion was
concentrated by centrifuging. (5) The fluid was stan¬
dardised by a modification of Wright’s method for
other bacteria. The modification consisted in counting
the red blood corpuscles in a given number of marked
squares before staining, then staining, and counting
the tubercle bacilli in the same squares. (6) The pre¬
paration was sterilised by heating on two successive
days for two hours at 60 deg. C., and an antiseptic
added. (7) That the fluid might possess the various
toxins and ferments which would be destroyed by heat,
a portion of the emulsion before sterilisation was
passed through a Beakefeld filter. This filtrate, which
was difficult to standardise, was added to the vaccine
before injection, or injected separately at the same time.
The obvious objection to this elaborate method is that
equally good results could be got by making cultures
from the sputum, and making emulsions therefrom in
the ordinary way. Allen argues, but is hardly convinc¬
ing, that bacteria grown in culture should differ in their
biological effects from bacteria direct from the lung.
The author recalls the interesting historical fact that
“in 1638, an English professor, Dr. Robert Fludd, ad¬
vised sputum injections as a cure for phthisis.”

R.

Histogenesis of Cancer.—Oertel (New York Medical
Journal , July 6, 1907) describes the changes in a case
of cancer of the liver in which he believes he was able
to trace the metamorphosis of liver cells into cancer
cells. He noticed these stages: (1) The liver cell has
lost much of its protoplasm by granular degeneration.
The nucleus has lost most of its chromatin, and its
nucleolus has disappeared. (2) Regeneration is begin¬
ning. The nucleus is enlarged, showing more chroma¬
tin granules, and a faint nucleolus. (3) The chromatin
granules have coalesced, and the nucleolus is distinct.
At the same time there is an accumulation of proto¬
plasm around the nucleus. The metamorphosis is now
complete, a cancer cell having been produced. These
cells still maintain their lobular arrangement, but when
they reproduce they break away from this, and the
typical cancer growth is formed. R.

Medical News in Brief.

The Metropolitan Hospital.

At a meeting of the Metropolitan Hospital Fund,
held on Thursday last at the Mansion House, it was
reported that the executors of the late Mr. George
Herring would pay to the treasurer of the fund £30,000
on accourt of the legacy bequeathed to the Hospital
Sunday Fund, and it was decided that this should
be included ir the total amount of the fund which
would thus amount to £74. 165. The distribution
committee recommended that disbursements of

Aug. 7, 1907.

! ^68,134 3 s - 4d., to 159 hospitals and institutions, 7
; dispersaries aDd 27 nursing associations, and this
| was ordered. After considerable discussion, in the
course of which it was stated that over 1,000 beds
in the hospitals were at present unoccupied, and
that 62 hospitals in London owed £150,000 to their
tradesmer and bankers for current accounts, it was
resolved, “ That any hospital or institution at present
receiving a grant from this fund be invited to consult
the council of this fund before incurring further expense
in providing additional accommodation for patients.”

Tragic Death of a Medical Man.

We regret to state that Dr. Rynne, of Cheltenham,
was found dead on July 20th, at his house. He was
about as usual on the previous day, and attended his
patients. He rose at the usual hour in the morning,
and, according to custom, went to the bath-room. As
unusual delay occurred in his making his appearance,
the bath-room was entered, and Dr. Rynne was found
dead near the bath. He was about 38 vears of age,
and leaves a widow and three children.

At deceased’s residence, on July 22nd, the
Divisional Coroner conducted the official inquiry.
The Coroner said that the facts were " very
simple and very sad,” and he was sure would
elicit the sympathy of the jury with the widow and
relatives of deceased. Mary Rynne, widow of
deceased, stated that her husband enjoved fairly
good health. About five years ago he had something
in the nature of a fit. On Friday last, he was about
attending to his practice as usual. He retired to bed
that night with witness about 12.30. Awaking in the
morning, witness missed him from her side. On in¬
quiries being made, he was found by witness’s brother.
Mr. OMara, inside the lavatory. The door was locked
on the inside, and had to be forced open.—Stephen
O’Mara, brother-in-law of deceased, said he arrived at
Osborne Villas on a visit on Friday night. Deceased
was then in good health and spirits’ Witness corrobo¬
rated the wife’s testimony, adding that deceased was
lying on the floor, attired in pyjamas and slippers.
Witness raised him, and he seemed then to be dead.
John Francis Johns, M.D., practising in Cheltenham,
who knew deceased personally, gave the result of a
post-mortem examination made by him, which showed
that deceased had suffered from fatty degeneration of
the heart. Death was due to syncope.—The jury
returned a verdict accordingly.

The Royal Army Medical Colleffe.

The Royal Army Medical Corps Staff have taken
possession of the fine new Medical College, with facades
to the river, next to the Tate Art Gallery, and Museum
in Atterbury Street, erected by the Government at a
cost of £80.000. The lower course of the college is
built of grey granite, and the upper stories of brick,
with stone dressing. The Grosvenor Road frontage is
very imposing, the roof being supported by Ionic
columns, resting on a granite portico base, over which
is the Royal monogram. There are two blocks, one
residential, to accommodate about eighty students,
and the other contains the laboratory and museum.
The college is equipped on the latest scientific model,
and contains lecture and class-rooms, reading room,
billiard-room, and officers’ mess and quarters. The
building comprises lower and upper ground floors,
together with first, second and third floors.

It is expected that the college will become a centre
for the study of scientific research and tropical medicine.
Students who join the college will be young officers
who are already qualified, but they will have to pass
an entrance examination. There are two courses, senior
and junior, which last respectively six and two months.
The senior course will be taken by captains who have
returned from their first foreign service, and they will
undergo at the cost of the Government a special course
of Army training by the professors of the college and
certain physicians and surgeons of the London hos¬
pitals. Lieut.-Colonel H. E. R. James of the Royal
Army Medical Corps, is commandant and director

Aug. 7, 1907.

PASS LISTS.

The Medical Pres*. 157

of studies, The professors, all of the Royal Army Medical
Corps, are:—Military surgery, Major C. G. Spencer,
M.B. ; tropical medicine. Lieutenant Colonel R. J. S.
Simpson, M.B. ; hygiene, Lieutenant-Colonel A. M.
Davies, A.M. ; assistant professor, Major C. E. P
Fowler ; pathology, Lieutenant-Colonel W. B. Leish-
man, M.B. ; assistant professors. Major W. S. Harrison
M.B. and Colonel F. J. Lambkin. The clinical teachers
in medicine are Mr. H. M. Murray, M.D., and Mr.

B. P. Hawkins, M.D. ; in surgery, Mr. G. H. Makins,

C. B., and Mr. H. F. Waterhouse, M.B., together with
seven other teachers in special branches. The college
will be ready for the formal opening in the autumn,
and it is hoped that the King may be pleased to per¬
form the ceremony.

The Mid wives Act, 1903 .

The Local Government Board has issued to Boards
of Guardians a circular directing attention to Sec¬
tion E of the new rules of the Central Midwives’ Board
recently approved by the Privy Council, the section
in question relating to “ regulating, supervising, and
restricting within due limits the practice of midwives.”

PASS LISTS.

University of Aberdeen.

At the graduation ceremonial held July 25th, the
folowing degrees were conferred on candidates who
had previously passed the examination :—

Degree of Doctor of Medicine ( M.D. ).—William
Campbell Anderson, B.Sc., M.B., Ch.B.; Robert
Brown, M.B., Ch.B. ; James Clark, M.B., Ch.B. ;
Frederick William Ellis, M.B., Ch.B. Maurice
Buchan Johnson, M.B., Ch.B. ; Peter Macdonald,
M.A., M.B., C.M. ; William Mitchell Smith, M.B.,
C.M.

Degree of Master of Surgery ( Ch.M .).—Alexander
Mitchell, M.A., M.B., Ch.B.

Degrees (M.B) and (Ch.B.) New Ordinances (with
Second Class Honours).—' 'Walter J. Dilling, *David
Horn, B.A., George H. C. Lumsden, *James M.
M'Queen, M.A., B.Sc ; Andrew M'Kay Niven.

Ordinary Degree. —Ernest W. Allaway, John W.
Archibald. Thomas P. Clapperton, John Ferries,
William I. Gordon, M.A., Alexander Horn, John
Elrick Kesson, Benjamin Knowles, James Leask,
Margaret C. Macdonald, Dalziel B. M'Grigor, William
I. Mackintosh, James M. Mathieson, James A. Milne,
Benjamin Mitchell, James Mitchell, John K. O’Neil
Murray, Algernon Edgar C. Myers, Patrick Nicol,
Arthur Shepherd, ‘Alexander Stewart, William T.
Stewart, John MTntosh Wilson, M.A.

• Passed Final Examination with Distinction.

The John Murray Medal and Scholarship to the
most distinguished Graduate (M.B.) of i 9°7 was
awarded to David Horn, B.A., Queensland.

The Diploma in Public Health was granted to
Arthur G. Troup, M.B., Ch.B. (Aberd.).

The'Conjoint Board of tho Royal Colleges of Physicians
and Surgeons of Edinburgh and Faculty of Physicians
and Surgeons of Qlasgow.

The following candidates passed their respective
examinations in July, viz. :—

First Examination (five years' course). —Francis
William Grant (with distinction); James Grant
Morrin; Morris William Rees (with distinction);
Francis Patrick Quirk; James Douglas Wright;
William Millerick ; John Boyd Michie.

Second Examination (five years' course). —Surcudra
Kumar Sen (with distinction), Edith Huflton, Robert
John Helsby (with distinction), Harold Hope Scott.

Four years’ course. —Thomas Mitchell Jamieson.

Third Examination (five years' course). —Richard
B. M. Sullivan, Osmonde Rusleigh Belcher, Thomas
Sholto Douglas, Isaac Flack, Henry Frank Collins,
Alexander Baxendale, Robert McConnell Blair.

Final Examination, and Admitted Licentiates of
the Co-operating Bodies. —John David Jones, James
Finbair Jefferies, John Robert Dunn Holtby (with

honours), Hugh Clement de Souza, Walter Riddell,
Isaac Flack, George Ernest Nash, Walter Ernest
Barrett, Gilbert Elliot Aitken, Robert Kay Nisbet,
David Williamson Morison, Cuverji Ruttonji Vevai,
Jitendra Nath Pai, Clare Annis Langmaid, Bhair&wn-
ath Donanath Khote, Edwin George Hodgson,
Charles Jacobs Tillekeratne.

Army Medical Service.

The following is a list of successful candidates for
Commissions in the Royal Army Medical Corps at the
recent examination in London for which 59 candidates
entered. The names are arranged in the order of
merit:—

T. McC. Phillips, B.A., M.B., B.Ch., R.Univ.Irel. ;
H. S. Dickson, B.A.Cantab., M.R.C.S.Eng., L.R.C.P.
Lond. ; G. F. Dawson, M.A., M.B., B.Ch., Univ.
Aberdeen ; H. V. B. Byatt, M.R.C.S.Eng., L.R.C.P.
Lond. ; R. E. Todd, M.B., B.S.Lond., M.R.C.S.Eng.,
L.R.C.P.Lond. ; T. F. I.umb, M.R.C.S.Eng., L.R.C.P.
Lond. ; H. Gibson, M.R.C.S.Eng., L.R.C.P.Lond. ;
C. P. O’Brien Butler, L.R.C.P.& S.Irel. ; G. Petit,
L.R.C.P.&S.Irel. ; J. B. Hanafin, L.R.C.P.&S. Irel. ;
J. A. Renshaw, M.R.C.S.Eng., L.R.C.P.Lond. ; R. F.
O’T. Dickinson, L.R.C.P.& S.Irel. ; \V. R. O'Farrell,
L.R.C.P.& S.Irel. ; R. De V. King, M.R.C.S.Eng.,
L.R.C.P.Lond. ; D. B. McGrigor, M.B., B.Ch., Univ.
Aberdeen ; C. T. Conyngham, B.A., M.B., B.Ch.,
B.A.O., Univ. Dub. ; H. McC. Hanschell, M.R.C.S.
Eng., L.R.C.P.Lond. ; J. R. Lloyd, M.R.C.S.Eng.,
L.R.C.P.Lond. ; FI. W. Carson, M.B., B.Ch., B.A.O.,
R.Univ.Irel. ; R. G. S. Gregg. B.A., M.B., B.Ch.,
B.A.O., Univ.Dub. ; H. T. Treves, M.R.C.S.Eng.,
L.R.C.P.Lond. ; F. T. Dowling, M.B., B.Ch., B.A.O.,
B.A., R.Univ.Irel. ; J. C. L. Hingston, M.R.C.S.Eng.,

L. R.C.P.Lond. ; F. J. Stuart, K.B., B.Ch., Univ.
Aberdeen ; B. A. Odium, L.R.C.P.& S.Irel. ; W. R.
Spong, B.A., M.B., B.Ch., B.A.O.. Univ.Dublin ;
J. F. Grant, M.B.,. B.Ch., Univ. Aberdeen ; P. H.
Hart, B.A., M.B., B.Ch., B.A.O., Univ.Dub. ; A. E. B.
Jones, M.D., M.B., B.Ch., Univ.Dublin; A. Hendry,

M. B., B.Ch., Univ. Aberdeen.

Indian Medical Service,

The competitive examination for commissions in
the Indian Medical Service was held on July 23rd,
24th, 25th, 26th, and 27th. The subjects of exami¬
nation were medicine and therapeutics, surgery and
eye diseases, applied anatomy and physiology, patho¬
logy and bacteriology, midwifery and diseases of
women and children, materia medica, pharmacology
and toxicology. Thirty-three candidates presented
themselves for 14 vacancies. The following is a list
of the successful candidates arranged in the order of
merit:—Hugh William Acton, L.R.C.P., M.R.C.S.;
Vivian Bartley Green-Armytage, L.R.C.P., M.R.C.S. ;
Arthur Norman Dickson, M.B., Cantab., L.R.C.P.,
M.R.C.S. ; Arthur Norman Dickson, M.B.Cantab.,
M.R.C.S. ; Arthur Batoum Zorab, M.B., B.S.Lond.,

L. R.C.P., M.R.C.S. ; Alexander Glover Coullie, M.B.,
Ch.B., F.R.C.S.Ed. ; Robert Ernest Wright, M.B.,
B.Ch., B.A.O.Dub. ; William Hunter Riddell, M.B.,
Ch.B.Ed. ; Alexander James Hutchison Russell,

M. A., M.B., B.Ch., St. Andrews ; Dewan Hakumat

Rai, M.A., M.B., Ch.B.Ed. ; Francis Shingleton-
Smith, B.A., B.C.Cantab. ; L.R.C.P., M.R.C.S. ;

Arnold Thomas Densham, B.C.Cantab., L.R.C.P.,
M.R.C.S. ; Arthur Waltham Howlett, M.B., Ch.B.
Viet. ; Frederic Allan Barker, B.A.. B.C.Cantab. ;
Arnold Newall Thomas, L.R.C. P., M.R.C.S. _

PlagUE haTmade its appearance at Liverpool. At
a meeting of the City Council or July 31st, Dr. Utting,
chairman of the Port Sanitary Committee, stated that
this week they had one case of plague in hospital, and
twenty-four cases of suspected contact. Most of the
suspected cases are those of foreign sailors shipped at
Indian ports

The late Miss Emilv Rebecca Leon has left legacies
to the amount of £2,000 to the various medical and
homoe'pathic institutions.

Digitized by Google

Aug. 7, 1907.

158 _The Medical Press. NOTICES TO CORRESPONDENTS.

NOTICES TO
CORRESPONDENTS, ffc.

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“Old Subscriber,” Ac. Much confusion will be spared by attention to
this rule.

SUBSCRIPTIONS.

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each year begin on January 1st and July 1st respectively. Terms
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must be paid In advance. For India, Messrs. Thacker, Spink and Co.,
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The following reductions are made for a series:—Whole Page, 13
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rata for smaller spaces. ~

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Ac.—Seven lines or under (70 words), 4s. 6 d. per insertion : 6 d.
per line beyond.

Contributors are kindly requested to send their communications*
If resident In England or the Colonies, to the Editor at the London
office : If resident in Ireland to the Dublin office, In order to save time
In reforwarding from office to office. When sending subscriptions
the same role applies ae to office; these should be addressed to the
Publisher.

Ha prints.—R eprints of arttoles appearing In this Journal can be had
at a reduced rate, providing authors give notice to the Publisher or
Printer before the type has been distributed. This should be done when
returning proofs.

Original Articles or Letters intended for publication should
be written on one side of the psperonly and must be authenticated
with the name and address of the writer, rot necessary for publica¬
tion but as evldsnce of Identity.

Urban District Councillor.— Inquiries tend to show that
our correspondent's statements are not confirmed.

C. O. C. P.—It does not belong to the province of a medical
journal to discuss a personal matter of the nature mentioned
by our correspondent.

House Phtsician.—A pply to the Agent-General of Ooltmy
named, who will doubtless give every detail required* We
have not heard of a vacancy for the post having been declared.

Spe 8.—Wherever possible a patient requiring the high fre¬
quency treatment should always be sent to a medical man who
has special knowledge of the subject.

M.R.C.S., L.R.C.P. (Leeds).—Our correspondent is ndvised to
write for a catalogue of the latest works and to ask for a list
of those upon the subject named which are being most reoom-
mended.

Dens.—Y es, it is a recognised fact that the teeth of girls
decay sooner than those of boys. The cause seems to be
related to the fact that girls are more precocious than boys,
and that, as they attain full development sooner, they begin
correspondingly sooner to show signs of retrogression.

DOCTOR OR CABDRIVER.

A medical man in a certain small town was rung up about
one o’clock in the morning and asked what he would charge
to accompany the caller to a country house some three miles away.
" Is it a serious case?” inquired the sleepy doctor. “Very
serious.” “All right; I’ll come. I shall have to charge you
a guinea." The doctor got dressed, and, having harnessed his
horse, they set off. Arrived at their destination, his companion
handed over a guinea, and jumped out of the trap, thanking
the doctor very profusely for his service. “But—the patient?”
“ I’m the patient,” cut in the other. “ You see, doctor, I
arrived by the last train, and the people at the inn would not
drive me here under 30s. I thought it too much, so 1 called
on you. You offered to do it for a guinea—so here we are.”

Distona.— The method originated, we believe, at the Hudders¬
field Infirmary, and decalcified or cancellous bone oertainly
seems very useful in some cases of chronic ulcer. You would
probably have to prepare it yourself, or make speolal arrange¬
ments with a firm.

Lex.—W e have not made up our minds whether the case
calls for comment. Such, of course, could only be adverse, and
the facts we have are too meagre to justify us in entering the
fray. Could you give us ampler details from the spot? If so,
we "may be able to take the question up in earnest.

Delegate. —We fear you will be much too late, but you
might write direct to one of the General Secretaries.

Glaswegian. —We cannot enter into private correspondence
in the matter. There is no reason why your letter should not
be published, and we should be happy to do so if you wish.
We can hardly be expected to advise under the oircumstanoes,
though we shall be happy, as we say, to publish your com¬
plaint.

W. R. 8 .—Your letter on “ The Collection of Debts owing to Medical
Men ” Is unavoidably held over to our next.

Our Parib Correspondent's weekly letter was undelivered In
time for press, owing to tbe Bank Holiday. It will appear next week.

£ppointment0.

Dk Souza, D. H., M.B., B.S., B.So.Lond., Demonstrator in
Physiology at the University of Sheffield.

8wann. W. F. G., B. 8 c.Lond., Assistant Lecturer and Demon¬
strator in Phvtics at the University of Sheffield.

Bowman, G. F„ M.B., M.Ch.Vict., Medical Offloer of Health by
the Limehurst Rural District Council.

Got7 , L ?’ J 1 ', U ” M B-. B.S.Cantab., Certifying Surgeon under
the Factory and Workshop Act for the Shaftesbury District
of the oountv of Dorset.

HAWI ? L n«’ W ‘ Ch B ’ D.P.H.Liverp., Assistant Medi-

«vl Officer at the New City Hospital for Infectious Diseases,
rarakerley, Liverpool.

Hollice, B 8-, M.R.C.S., L.R.CP.Lond., Certifying Surgeon
under the Factory and Workshop Act for the 8tunninater
Newton District of the oountv of Dorset.

LKW T 8 i. ^ , JamE8 > L.R.C.P. and 8., L.M.Edin.,

L.F.P.S.Glasg., Medical Offloer of Health by the Pontardawe
(Glamorganshire) Rural District Counoil.

Baomms.

Royal Victoria Hospital, Bournemouth.—House Surgeon.

"* la ,'7’ 100 P er annum, with board, lodging, and lsuudrv.

Applications to the Secretory on or before August 14th. "

Grimsby and District Hospital.—Resident House Surgeon.
Safary, £ 10 ° per annum, with board, lodging, and washing.
Applications to S. M. Forrester, Secretary, Victoria Cham¬
bers, Grimsby.

North Lonsdale" Hospital, Barrow-in-Furness.—House Surgeon.
Salary, £100 per annum, with board and lodging. Applica¬
tions to the Secretary, North Lonsdale Hospital, Barrow-in-
Furness.

Bailbrook House, Bath.—Medical Superintendent. Salary, £450
per annum, with board for self and wife if married, fur¬
nished quarters, laundry, attendance. Applications to
Herbert Coates, Secretary, 49 Broad Street, Bristol.

Bridgnorth and South Shropshire Infirmary.—House Surgeon.
Salary, £100 per annum, with board and lodgings in the
Infirmary. Applications to the Hon. Secretary, the Infirm¬
ary, Bridgnorth.

R°yaJ South Hants and Southampton Hospital.—House

Physician. 8 alary, £100 per annum, with rooms, board,
and washing. Applications to T. A. Fisher Hall, Secretary.

Brighton, Hove, and Preston Dispensary.—House 8 urgeo"n.
Salary £160 per annum, with furnished rooms, coals, gas,
and attendance. Applications to C. Somers Clarke, Hon.
Secretary, 113 Qneen’s Road, Brighton.

Manchester, Corporation of.—Monsall Fever Hospital.—Fourth
Medical Assistant. Salary, £100 per annum, with board,
lodgings, and washing. Applications to the Chairman of the
Sanitary Committee, Publio Health Offloe, Town Hall, Man¬
chester.

Burgh of Paisley.—Infectious Diseases Hospital.—Assistant Medi-
oal Offloer. Salary, £100 per annum, with board, waahing.
and attendance. Applications to Fra Martin, Town Clerk,
Municipal Buildings, Paisley.

Egyptian Government.—Kasr El Ainy Hospital.—Resident Medi¬
cal Officer. Salary, £250 a year, with quarters, servants,
washing, ooal, and light. Applications to The Director-
General, Publio Health Department, Cairo.

Egyptian Government.—Ministry of Eduoation.—School of Medi¬
cine, Cairo.—Assistant to the Professor of Pathology.
Salary, £E.330 per annum. Applications to The Director,
Government School of Medicine, Cairo, Egypt.

Northampton, County Borough of.—Medical Offloer of Health.
Salary, £400 per annum. Applications to Herbert Han-
kinson. Town Clerk, Guildhall, Northampton.

County Asylum, Mioklcover, Derby.—Junior Assistant Medical
Offloer. Salary, £130 per annnm, with furnished apartments,
board, washing, and attendance. Applications to Dr. Legge.

Newport and Monmouthshire Hospital-Secretary and Superin¬
tendent. Salary, £200 per annum. Application! to tbe
Chairman, Newport and Mon. Hospital, Newport, Mon.

Clifden Union.—Medical Officer. Salary £160, with £10 a year s»
D.P.H., and Registration and Vaccination Foes. Applications
to P. H. Bodkin, acting Clerk of Union. (See Advert.)

girths.

McNabb.—O n July 31st, at Withern, Alford, Lines., the wife
of A. A. J. McNabb, M.B., of a eon.

Hey.—O n August 1st, at 1 Princess Terrace, Rlpon, the wife of
Samuel Hey, M.R.C. 8 ., of a daughter.

Underhill.— On August 1 st, at Caetle View, Newport (I.of W.).
the wife of S. O. H. Underhill, M.R.C.S., L.B.C.P., of a son.

JffarriagcB.

Hebb — Wolfgang. —On August 1st, at St. Mary’s Church, Byfleet.
John Harry Hebb, B.A., M.B., B.Ch.Oxon.. only son of the
Rev. H. A. Hebb, M.A., headmaster of the Royal Masonic
School. Bushey, Herts, to Ethel Kathleen, youngest daughter
of the late Elias Wolfgang, of Liverpool.

Hughes—Riddell. —On July 31at, at St. John’s, Meads. East¬
bourne, Stanley, younger ton of tbe late John Hughes.
Esq., of Tero-Law, to May, elder daughter of the late James
Hiddell, Esq., of Beckenham, and Badulipar, Assam.
Powell—Sinnett. —On July 31at, at St. Patrick’s Church, Hove.
Sussex, Edgar Elkins Powell Major. R.A.M.C., to (Hadrs
Violet, elder daughter of Lieut.-Colonel and Mrs. C. i-
Bennett.

Death.

Aubin.—O n July 27th,
Thomas John Aubin,

at La Motte Street, St. Heliere, Jersey.
M.D., M.B.C.S., in his 70th year.

Digitized by G00gk

The Medical Press and Circular.

-SALUS POPUU SUPREMA LEX.*

Vol. CXXXV. WEDNESDAY, AUG. 14, 1907. No. 7

Notes and Comments.

In August, it has been said,
Aagutt the middle-aged man’s fancy
CMfreues. lightly turns to thoughts of con¬
gresses, and this year the first
half of the month has produced,
if not a surfeit, at least a plenitude for the most
hardy medical digestion. The British Associa¬
tion and the British Medical Association meet¬
ings are annual events, but the holding this
year of the International School Hygiene, the
Housing, and the Esperanto Congresses in
England forms a pleasing method of bring¬
ing those important subjects to public notice.
Although there is nothing peculiarly medical
about Esperanto, there is no doubt that
the want of a lingua franca for medical men has
been badly felt since an intimate knowledge of
Latin ceased to be part of the education of mem¬
bers of the learned professions. In the fifteenth,
sixteenth, and seventeenth century, before the
English had developed a good flexible prose, it
was almost possible to write with scientific
accuracy in the language, but when the common
tongue became capable of expressing definite
and exact shades of meaning, writers naturally
preferred to use it rather than an alien one. The
result, however, was that the British scientists
became more and more isolated from their
continental brethren, till now, in spite of sum¬
maries and extracts of foreign papers in the
medical press, the average opinion of continental
medical men on subjects of current interest is com¬
paratively little known in this country. Moreover,
before conducting any scientific research, it is
necessary that a man should be a good linguist,
if he is to be furnished with knowledge of all
that has been done abroad in the particular line
he proposes to pursue, and wishes not to
work over ground that has been well trodden
already.

Recognising the enhanced value
Esperanto sad of a record which appeals to all
the Natural nations, the Pathological Society
Sciences. recently started appending a brief
Latin description of their speci¬
mens to the ordinary one in the vernacular, and
no doubt research-workers and record-hunters
abroad will be much indebted to them for the
trouble. Still it stands to reason that however
adaptable classical Latin may be for scientific
records, and even in this it is greatly inferior to
Greek, it is not possible to revivify the language
for ordinary purposes of communication, written
and spoken, as the educational curriculum and
brain of man would not bear it. On the other

hand we shall be curious to see whether Esperanto
which seems to answer well enough for the jargon
of the mart, is sufficiently accurate and flexible
for scientific records. We should think it highly
probable that it is not, in spite of the illimitable
facilities it possesses for coining words, because
of the paucity—or rather complete absence—of
inflexions it apportions to its nouns and veibs.
Certainly Esperanto has caught on as neither
Volapuk nor any of the dozen other artificial
languages has yet, and if it is capable of bearing
all the strain that medicine and the allied sciences
can put upon it, the boon to research-workers,
and indeed to ordinary practitioners, will be
immense. -

An immense amount of interest
The British was taken by the public in the
Associattoa debate on the value of alcohol
and Alcohol. in the Physiological Section of the

British Association Meeting. Con¬
sidering the importance of the subject from the
sociological point of view, and also the amount
of attention that has been drawn to the subject
in one way and another during the last few
months, there is not only no need for surprise
that so much interest was exhibited, but con¬
siderable cause for thankfulness. It cannot,
however, be said that the debate advanced the
question very far, nor is it likely to make converts
to either side, but at any rate it sets forth, to a
certain extent, the general opinion of the pro¬
fession that alcohol is not nearly so useful a drug
as was thought thirty or forty years ago. That
perhaps is not much, but it must be remembered
that even in the Olympian atmosphere of the
British Association it is difficult, if not impossible,
for speakers to rid themselves entirely of pre¬
possessions, so that, whereas the temperance
advocate is likely to minimise a piece of evidence
that tells against him, the moderate drinker
will insensibly be biassed the other way. The
weight of the speakers on the whole was certainly
in favour of alcohol in small quantities not being
deleterious ; but then it might be asserted that
those speakers were themselves wine-drinkers.

Professor Cushing, who opened
Prefeisor the debate in a long and able
Catblaf’s speech, probably put the case as
Views. fairly and temperately as can be.

Taking the question of alcohol
as a digestive he showed that although there
was slightly more active movement of the digestive
organs when pure alcohol was administered in

Digitized by LaOOQLe

160 The Medical Pees*.

LEADING ARTICLES.

Aug. 14, 1907.

small quantities, and a larger secretion of gastric
juice, yet thisfsecretion was poor in ferments,
and therefore of less avail for purposes of digestion.
On the other hand appetite is a great factor in
the regulation of digestion, and therefore in
those people who are accustomed to a wine and
like drinking it, there may be some increase in diges¬
tive power by taking a little. Professor Cushing
argued, moreover, that it is an undeniable fact
that 95 per cent, of alcohol taken undergoes
combustion in the tissues, and is consequently a
source of energy. Its action he compared to sugar,
showing that the energy produced by its combus¬
tion may be used for heat formation and mechani¬
cal work, and that it may lead to the deposition
of fat and consequent economy of the nitrogen
store. Further he said that while it is universally
admitted that alcohol in large quantities dimin¬
ishes the tissue-resistance to disease, it is not
shown that small quantities had this effect, for
although animals treated with alcohol are
more susceptible to pathogenic inoculations after
they have been subjected to alcohol than before,
it is important to remember that alcohol has a
very different effect on animals to that which
it has on man, animals being merely narcotised,
whilst men are excited. He further described
some experiments with type-setters and with
students which showed that their respective
capacities for quick and accurate work were
diminished by alcohol.

A more admirable summing up
Man needs bat of the present position of the
little. alcohol question than that given

at the end of Professor Cushing’s

paper it would be difficult to
find. He said that alcohol may be of some value
in therapeutics as a means of making food more
attractive, and thus of improving digestion;
that it possesses some good value in itself ;
that it acts as a cerebral depressant, and may be
valuable in disease on account of this quality ;
that it may aid a failing heart; that small doses
exercise no definite poisonous effects on the
tissues, but that small repeated doses, though
suspect, have not been shown to be deleterious.
These conclusions were criticised in one way and
another by the various speakers, but we venture
to think that they stood it very well. As a
working hypothesis they would be difficult to
beat, and as such they may remain till fuller
knowledge is gained on this vexed question.
We stand in about as little danger now of heroic
doses of alcohol as of heroic blood-lettings, and
probably for the same reason, that they were
both overdone.

Of the School Hygiene Congress
The King cad the first thought that occurs is
the School Hy- that the Committee were lucky in
gleae Coagrees, getting together a Congress at all.

From the revelations of Sir
Lauder Brunton in his inaugural address, it
seems that a fortnight ago the whole thing
seemed likely to fizzle out, and it was only through
the personal influence of the King that the matter
was eventually put through. The King, indeed, is
the humanising influence in our Government ma¬
chinery, which last creaks and rumbles ominously
when subjected to any unusual strain. The
difficulty which the Board of Education and the
Foreign Office manufactured for themselves was

not apparent to anybody but the disputants,
and if it were not humorous it would be utterly
degrading to think that the squabbles of two
public offices had to be reconciled by the personal
intervention of His Majesty before a useful
scientific Congress could be held and the guests
invited. Scientific men at least will feel grateful
to the King for not allowing a slur to rest on
their hospitality, and we trust that the lesson
that the incident involves will be taken to heart
by the young gentlemen in Whitehall who like
to direct the affairs of the nation according to
their own ideas of what should and should not
be done.

LEADING ARTICLES.

The Cult of the Child.

One of the more important signs of the times
is the increasing care- we are paying to our off¬
spring. Fortunately our awakened interest is
not fated to assume the attitude of simple curi¬
osity that is sterile of results, for the whole range
of achievement of modem medical hygiene is at
hand, to say nothing of its complicated and
extensive machinery. Nor can it be said that we
are dealing with matters that have not come
within the purview of modern science, for the
study of the environment and conditions of child¬
hood has become an exact and comprehensive
speciality. No better proof of the latter
statement could be wished for than the Inter¬
national Congress of School Hygiene which has
recently concluded the labours of a great meeting
in London. The number and variety of the
communications and discussions advanced by the
members of that body emphasises in no small
degree the far-reaching relations of the particular
condition of environment dealt with under the
title of school hygiene. One of the most interesting
considerations, however, is the fact that the
subject is engaging the earnest attention of all
civilised nations; in short, wherever the need of
State education of the child has been recognised,
there the necessity of the scientific care of his
school environment is becoming accepted
as an inevitable corollary. The position thus
entailed is so strictly logical that it is somewhat
of a wonder that it was not established
long ago. But after all the science of public
health is itself a comparatively recent creation
and its application, notably in the case of tuber¬
culosis, , still halting and unsatisfactory. Yet
who can doubt that the millenium of early sanitary
pioneers like Parr and Simon will one day come
upon the’nation ? In a certain sense the delib¬
erations of the International School Congress
may be regarded as the natural outcome of their
labours. At any rate, it is certain that civilised
society will in future take steps to safeguard
the health of its school children. It is obviously
of little use to bewail the physical degeneracy
of our race if we neglect its nurture during the
crucial years of infancy and childhood. There are,
of course, many difficulties in the way of securing
an effectual control of the health of scholars.

zed by Google

Diqiti:

Aug i 4, 1907.

CURRENT TOPICS.

The Medical Piim. l6l

both as regards parents and as regards local
administrative bodies. There is no d oubt that the
legislature must sooner or later enforce proper
standards of sanitary construction in all cases.
More delicate ground is touched in the attempt
to apply individually a system of detailed
medical inspection, which is an absolutely essential
condition of the hygienic control of school life.
Without the consent of parents, and possibly
also of scholars themselves, it would probably
be illegal to conduct an ordinary physical examina¬
tion, including such necessary steps as an enquiry
into the state of the scalp and the throat. Diffi¬
culties of this kind, however, are of a somewhat
theoretical nature, and are hardly likely to
present any serious obstacle in actual practice.
So far as the medical profession is concerned
there are several aspects of the question that
deserve careful attention, especially now that
universal medical inspection of schools is certain
to become an established fact in the near future.
First of all there is the relation of the school
medical inspector to the general practitioner,
obviously a matter of importance. At first
sight it would seem advisable, wherever possible,
to insist that the inspector shall be a special
officer not engaged in private practice, and
therefore not likely to come into collision with
outside general practitioners. Then there is the
question of fees payable for outside medical men
by education authorities. At present there is
a reprehensible tendency for the State to demand
the services of medical men without remuneration
as in the case of birth and death certificates. The
school authorities wisely determine a child suffering
from ringworm shall not attend school. They
demand a certificate which is, as a rule, obtained
free from a hospital or from a general practitioner.
In any case the school committee pays nothing
for the information, and in other cases the general
practitioner is expected to supply his professional
information gratis. A matter of this kind
should be most carefully safeguarded by medical
members of Parliament, for as a rule the legisla¬
ture year by year demands fresh services of medical
men, but neglects to make provision for their
adequate remuneration. In this problem of
school hygiene the medical profession is the
primary’ source of inspiration, and as a matter of
common fairness its material interests should
be placed on a basis of adequate pecuniary re¬
cognition.

CURRENT-TOPICS.

The British Medical Association and The
General Medical Council.

In commenting recently on the relations
existing between the British Medical Association
and the General Medical Council, we expressed
the hope that the Association would soon come
to a definite decision on the question of its position
as prosecutor before the General Medical Council.
In this we have not been disappointed, for by
an almost unanimous vote, the Representative
Meeting at Exeter last week expressed its ~p-

proval of the action of the Ethical Committee in
appearing as prosecutor in a recent case. That
the members feel very strongly in the matter is
evident, not merely from the vote, but still
more from the fact that the vote was given in the
face of the opinion of counsel that the application
of the funds of the Association in this direction is
illegal! If any member objects to the funds
being spent in this way, it will be necessary for
him to proceed in the High Courts for an in¬
junction to restrain the Association—a risk
which apparently the Representative Meeting
was willing to run. Apart altogether from the
question of the wisdom of the Association taking
on these extra functions, there can be no doubt
but that it is unwise to proceed by illegal means
to arrive even at an admirable end.

Fingrer-Lioking by Clerks.

In these latterday scientific times many of our
cherished habits and customs have gone by the
board. Beyond a doubt a host of others will
follow before the man in the street may hope to
approach the standard fixed by men of science.
Of all the filthy and disgusting habits there can
be none less capable of defence than that of
licking the finger which is used for turning over
leaves, for counting money and so on. The
tram conductor offends in this way that he may
get a quicker and a lighter grip of the ticket that
he hands, laden with countless bacteria, to his
luckless passenger. So too, among other public
servants, the hurried railway clerk, to whom
fractions of seconds are of value, does the
same thing with tickets and with money, in which
latter case the customer pockets myriads of
microbes along with his change. Clearly if the
finger-licker is suffering from tuberculosis, diph¬
theria or any of the hundred-and-one microbial
maladies that may affect the mouth, he dis¬
tributes to the public the germ of disease on the
surface of tickets and of coins. Therefore he
should not lick his finger. How is he to be
prevented ? Shall the man in the street read him
lectures, or educate him at an early age in schools,
or make it a punishable offence ? Somehow
he must be convinced of the horror of his ways,
and persuaded that in future he must not lick
his fingers.

Mr. Carnegie's Gift.

Mr. Carnegie, among his many princely
benefactions, has never given anything, at any
rate on a large scale, to the London hospitals,
although it is well known that they all need
extra support badly. The reason has always been
supposed to be that Mr. Carnegie objected to the
way they are managed; that he thought, in
fact, they are not managed on sound business
principles. His splendid gift of ;£ 100,000 to
the King Edward VII. Fund last week came to
Londoners as a pleasant surprise, but though
Mr. Carnegie did not accompany the money with
a stipulation, he sent with it a heart-felt wish
that the committee would get to work on reform
as soon as possible. While everybody admires.

D

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j62 The Medical Pies*.

CURRENT TOPICS.

Aug. 14, 1907.

the public spirit and self-sacrifice displayed by
the many high-minded gentlemen who give up
their time and energies to hospital work, it
must be admitted that they have allowed con¬
ditions to master them, and that in the stress
of competition for funds and patients they have
been driven to use methods which in the course
of private business they would condemn. Not¬
withstanding the fact that there are at the
moment some one thousand beds unoccupied
at London hospitals, and debts to the amount
of £150,000 to bankers and tradesmen on current
account, appeals for building funds still appear
over and over again. As a matter of fact com¬
mittees have found that the safest “ draw ” for
subscriptions is to announce a building scheme
or special appeal, and the temptation to resort to
this measure of despair increases with its success.
When the buildings are finished all the money is
used up, and as likely as not either the beds are
not occupied or the hospital has to sell stock
to keep them open. We hope with Mr. Carnegie
that more reasonable methods will take the place
of these gambling expedients.

Perform infir Lions and their Performances.

Judged from the point of view of the circus
contents bill, the British public must retain
a fair share of primaeval savagery. Otherwise,
the enterprising showman, who reads his audi¬
ence like an open book, would not take so much
pains to provide them with a hundred and one
entertainments in which human life hangs, as it
were, on the hazard of a thread. Every now and
then some acrobat breaks his neck, or some lion-
tamer is torn to pieces before a shrieking mob of
sightseers. Yet humane society which passes bills
to prevent cruelty to animals, and holds the
scientific vivisectionist up to public pillory, per¬
mits these wanton side shows, with their gruesome
work, to go on in the interests of the showman’s
till. Only the other day at Gloucester an attendant
was killed by a lioness belonging to a travelling
lion-tamer, who declared that the beast had
always been regarded as harmless and docile.
That fact merely proves that it is impossible
to say when the lion has been effectually “ tamed.”
A terrible death of the kind mentioned furnishes
a grim satire on the civilisation and humanity of
to-day, which appeals to great Heaven anent
atrocities in Macedonia or the Congo State, and
allows fellow countrymen and countrywomen to
be mauled to death before their eyes, not only
without a protest but even paying for the privilege
of witnessing the unholy and degrading per¬
formance, which attracts many by its proffered
butchery.

Mr. John Burns and Gratuitous Medical
Service.

When Parliament passes a measure that necessi¬
tates legal work, the lawyers in the House take
care that provision is made for proper payment for
such service. When new medical services are de¬
manded, however, it is only rarely that the question
of remuneration is mentioned. As a rule, the 1

politicians concerned adopt the attitude of the out¬
side public, namely, that they shall get as much
gratuitous work as possible out of the medical pro¬
fession. A good instance of this kind is the Bill
for the Notification of Births recently brought
before the House as a private Bill, and since
adopted by Mr. Burns on behalf of the Government.
It provides that a medical man must notify a birth
within 36 hours, but gives him no fee for furnish¬
ing the information and signing the necessary docu¬
ment. Were a corresponding duty to be thrust
upon a solicitor he would secure six and eightpence
for every step in connection with the formality. Of
all men we should imagine Mr. John Burns would be
the first to recognise that the labourer is worthy of
his hire. Now that the injustice of the proposal to
saddle an honourable but by no means rich profes¬
sion with fresh unpaid responsibilities has been
pointed out to the right honourable gentleman, he
surely will take steps to remove an obvious flaw
from an otherwise most desirable measure. If the
income of the medical practitioner is not reinforced
from State sources, directly or indirectly, there
seem? to be some danger of his being forced ulti¬
mately out of the field, so keen is the competition
with hospitals and with numerous forms of un¬
qualified practice.

Japan leads the way in School Inspection.

The appearance of Japan upon the stage of the
world’s politics offers much food for reflection.
Perhaps the most salient feature of that remark¬
able people is their firm grasp of the practical
aspects of modern scientific principles. By seizing
upon advanced methods of tactics, weapons, trans¬
port, and medical service, the Japanese have
crushed the power of probably the most potentially
powerful country on the globe. But it is not only
in warfare that Japan leads the way. In the mat¬
ter of education she is an easy first, so far as medi¬
cal inspection is concerned, and, in point of fact, has
left the United Kingdom lagging hopelessly in the
rear of the international struggle. Japan has recog¬
nised the fundamental truth that the aim of all true
education should be to produce that type of citizen
who shall be the fittest in all respects, whether men¬
tally, bodily, or morally. She has not entrusted so
vital a matter to the selfish arbitration of party
politics, but has gone straight down to the root of
the thing, and straightway appointed something
like 9,000 medical school inspectors. Here, in
Great Britain we have less than a hundred such
officers appointed by local authorities who have
availed themselves of their power in that direction,
and even then their chief care is for the buildings
rather than for the scholars. The first serious
attempt to apply the system of medical school inspec¬
tion universally was made in Mr. Birrell’s Educa¬
tion Bill thrown out last year. It is to be hoped,
however, that before long the Statute Book will be
extended by a provision of the kind, which will to
some extent enable England to remove the defect
which now so seriously handicaps her in the develop¬
ment and progress of her race.

Lead as an Abortifacient.

An inquest last week in the neighbourhood of
Sheffield has called attention to the lamentable prac¬
tice of taking lead pills to procure abortion. The
deceased was a married woman, who died in hos-

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Aug, la , 1907.

PERSONAL.

The Medical Peess. 163

pital as the result of blood poisoning following
abortion. While under treatment she confessed to
the surgeon that she had taken diachylon from a
plaster mixed with bread crumbs. Careful inquiry
failed to reveal where the lead was obtained, and
the jury returned a verdict that death was probably
caused by the taking of diachylon pills to procure
abortion. The Coroner spoke in the strongest pos¬
sible terms of this terrible evil which of late years
had sprung up among women. In certain dis¬
tricts, of which Sheffield appears to be one, the
practice has become notoriously common. In these
days of social legislation it would be well for the
Government to revise the Sale of Poisons Acts,
especially with regard to the sale of diachylon.
Another point that at the same time might be
alluded to with advantage is the resolution to make
it compulsory to keep ali liquid poisons in distinc¬
tively shaped bottles. Only a few days ago a lady
was poisoned by mistake with carbolic acid which
a servant took from a bottle precisely resembling
the regular physic bottle by her side.

Medical Referees and Women.

In the report of a recent meeting of the Brad¬
ford Trades Council, objection was taken by the
Executive to the appointment of a particular medi¬
cal referee for their district on the ground that he
was medical officer to a railway company on whose
behalf he would also have to act in cases of
accident as employers’ medical adviser. Mr. F. W.
Jowett, M.P., said he had spoken to the Home
Secretary personally about the matter, and in
the course of his interview Mr. Gladstone told him
that he was anxious to know if women workers
were desirous of having medical referees of their
own sex to examine them, and Mr. Jowett proposed
taking steps to find out. We venture to express
our opinion that this suggestion raises the sex
question in medicine in a most unfortunate form,
and one which we fancy the women members of
the profession will resent as much as men. The
only possible reason why women workers should
be examined by special women referees is that
there would be some unpleasantness or im¬
propriety in their examination by men, a sugges¬
tion which we fancy the Home Secretary will see,
on reflection, to be offensive to medical men.
Women workers in factories are accustomed to
statutory examination by the factory surgeon on
many occasions, and they come to look on him in
the light of a tutelary deity who guards them from
any injustice on the part of inconsiderate em¬
ployers, and that view is exactly what the profession
likes them to take. Moreover, it is common know¬
ledge that such women-workers in their confine¬
ments and in times of sickness seek the aid of mas¬
culine medicals, who become, in most cases, their
honoured friends. Women doctors, for their part,
are generally anxious, as we have always gathered,
that they should be treated on their professional
merits, and be looked upon, from the point of view
of society, as medical practitioners, simply and
solely, without reference to sex. It is, therefore,
quite gratuitous that the latter question should be
raised in regard to the appointment of medical re¬
ferees, and we think Mr. Gladstone will be well
advised if he makes his appointments in the present |

bv professional suitability, as recommended by the
Departmental Committee. It is much to be hoped
that the Government and other official bodies will
steadily discountenance the importation of the ele¬
ment into medical appointments in which it does
not naturally exist.

PERSONAL.

A Banquet was recently held at Porth in honour
of Dr. Ivor H. Davies, who has left the district to
take up his residence at Llantrisant. The occasion
was marked by the presentation of a handsome silver
service and an address.

Lieut.-Col. A. W. Browne, late R.A.M.C., has
been appointed to Militia medical charge at Armagh.
Major S. Macdonald, M.B., C.M., from Woolwich, has
been appointed to Army Medical Service at Hong
Kong.

Mr. Andrew Carnegie has given unconditionally
the sum of £100,000 to King Edward’s Hospital Fund
for London. Mr. Carnegie expresses the desire
that it should be used as seems best, “ the more
strenuously for reform the better.”

Sir John Dickson-Povnder opened the Inter¬
national Housing Congress at Caxton Hall, West¬
minster, on August 5th.

Dr. Hugh MacLean, of Aberdeen, has been
awarded a Carnegie Fellowship for his research on
“ The Carbohydrate Material and Ferments of the
Blood.”

The executors of the late General Baynes has
forwarded a second sum of £10,000 to the King’s
Hospital Fund for London.

Professor Howard Marsh has been offered, and
it is understood, has accepted the Mastership of
Downing College, Cambridge, which has been vacated
by Dr. Alexander Hill.

The Foundation-stone of the new Out-Patient
Department of the Cardiff Infirmary was laid by
Sir William T. Lewis on July 30th. Mr. Edmund
Owen subsequently addressed the visitors.

Dr. W. Wynn Westcott presided at the annual
general meeting of the Medico-Legal Society at the
end of last month. Mr. Justice Walker was elected
president for the coming session.

We regret to record the death of Dr. W. D. Miller,
of Michigan, till last year Professor of Odontology in
the University of Berlin. Professor Miller was known
throughout the world as an authority on the teeth, and
he had been for a long time at the head of the Berlin
University Dental Institute. He introduced the game
of golf, in which he excelled, into Germany.

About one hundred of the American, Colonial and
foreign delegates attending the second International
Congress on School Hygiene paid a visit to Oxford on
Saturday. Luncheon was partaken of in the hall of
Christ Church, at the invitation of Dr. W. Osier, the
Regius Professor of Medicine, who presided.

We regret to learn that, whilst cycling down a hill
near Colwyn Bay, Dr. Greenhalgh, of Bury, lost
control of his machine. He was thrown off, and sus¬
tained a broken arm, and an injury to his forehead.

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164 Th> Medical P»m

CLINICAL LECTURE.

Aug. 14, 1907.

A Clinical Lecture

ON

THE MORE RECENT TREATMENT OF THE INSANE (a)

By G. H. SAVAGE, MJX, FJLGP.,

Consulting Physician for, and Lecturer on, Mental Diseases, Guy's Hospital 1 Examiner In Mental

Pathology, University of London.

Gentlemen, —I have named my address for
this afternoon "The More Recent Treatment of
the Insane," because I am always protesting
against treating insanity as an entity, as a de¬
finite disease. We have to consider the insane
person, and the treatment of the insane differs
very materially now from that of even a very few
years ago. A history of the treatment of the past
is almost an essential to an understanding of the
stage which we have reached now. By the way,
the recovery-rate is not much greater now than it
was 100 or 150 years ago. That, of course, one
regrets, and hopes for better things. The Biblical
treatment of the long past was not unreasonable ;
the treatment of Saul by David was certainly
correct; and as to the treatment of Nebuchad¬
nezzar—turning him out into the country till he
recovered—that was a case of non-restraint treat¬
ment effecting a cure. We have only come back
to that even now. The next idea was that all
insanity was associated with theological error,
that, in fact, every insane person was afflicted
by some spirit, generally a spirit of evil; but,
sometimes, a prophetic spirit. Therefore the
only way was to eject the spirit. Consequently
chains, chastenings, and whips were used. Some¬
times he had to be cast out by stinks, therefore
remedies like asafsetida, which is still used in the
treatment of neuroses, were used for the ejection
of the devil. There is still, in the centre of
Europe, a cathedral and a town, and around it
some fifteen villages, called Gheel, " The City
of the Simple,” where for 700 years the people
have been treated at the shrine of Dymphna. Here
I spent a week of great interest years ago.

I suppose I am asked once a week whether there
is any objection to a patient being treated by
“ Christian Science,” thus coming back to the
old thing. Hypnotism I am constantly being
asked about, and I shall refer to that later. As
society came more closely together, people said
they must be protected against the accidents re¬
sulting from the insanity of certain people and,
to effect that protection, the insane were shut up.
Asylums grew, and are growing still. In the
earlier days they were not specialised ; all cases
of all kinds, whether curable or incurable, were
lumped together. Now one of the great develop¬
ments is the separation of them ; so that there
are^not only idiot asylums, but idiots are being
separated. Thus you find schools for feeble¬
minded and institutions and colonies for the weak-
minded, who are not distinctly idiotic. And one of
the developments which will have a very great in¬
fluence in the future is hospitals for the insane.
I have said to you before that there are two
words which I should like to get rid of from the
English language—" asylum ” and " lunatic.”
It will take a hundred years, even after they have

Delivered et the Polyclinic, Chenlee Street, London, February 27 th,

been abolished, to do away with the stigma; the
old feeling that a person affected in his mind is
therefore alien and must be shut off, so that a
person suffering in his highest faculties is an
outcast. And when one remembers that a very
large proportion of these people get well, and a
larger proportion than the public believes remain
well for the rest of their lives, it is a shame that
they should be treated as if they were altogether
useless as soon as they have had one attack of
mental disorder. In Glasgow—and we must
admit that North of the Tweed they are in advance
of us in many ways—they have now a Receiving
Hospital, so that every person suffering from
mental disorder who falls into the hands of the
equivalent of the relieving officer or the police
is sent to this hospital, not to an infirmary or an
asylum straight away, unless he happens to be a
typical general paralytic, or to have some in¬
curable disease of that kind. There are two
wards in this receiving hospital, and I spent a
day there not long ago to see the types of cases,
and to see the results. The result is that not
more than half these cases go to an asylum at all,
but are discharged. Drink is, of course, the cause
in many of these cases, but not by any means the
majority. I said to the superintendent that I
supposed the acute alcoholics came back fairly
frequently, but he said " No ”—that their ex¬
perience was that, short of a year, or even more,
the treatment of an alcoholic for a month or six
weeks in the hospital was as useful, in the long
run, as asylum detention for two or three months.
In fact, he said that unless an inebriate was going
to be secluded for a year or two, the result of
hospital treatment in bed, with strict supervision
and dieting, and medicine to a certain extent
was as useful as prolonged treatment, and much
more useful than simple detention for three or
four months.

Another development is hospital asylums, of
which type Bethlem is the oldest example. St
Luke’s is another old institution. Scattered over
the country there are establishments like the
Holloway Sanatorium. What salvation is in that
word “ sanatorium ” ! People do not mind going
to Holloway Sanatorium, but if it were called
the Holloway Asylum they would shy at it In
York there is a Retreat and similar institutions
at Exeter, Gloucester, and Manchester; and they
are to a great extent self-supporting ; some pay
for their care, some pay but very little ; but those
who pay more help to support those who pay very'
little. At Bethlem Hospital, the majority of
patients pay nothing at all; a certain number
pay two guineas a week ; in some places patients
are received for even a guinea a week. There is
I another development, which I feel particularly
interested in, because when I was at Bethlem
I revived it, that of voluntary boarders. At
i that time there was still permission for the Royal

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Diqiti:

Aug. 14. 1907.

CLINICAL LECTURE.

hospitals, such as Bethlem, to receive a certain
number of patients suffering from mental dis¬
order, as voluntary boarders. I had difficulties,
and I had a struggle. The authorities said:
" Well, but this man is of unsound mind ; he has
got delusions.” " Yes.” “ Will you receive a
voluntary boarder who has got delusions ? ”
" Yes.” “ But he could be certified.” “ Yes,
but that is exactly what I don’t want. The man
says, 4 1 am supposed to be of unsound mind. I
do not think I am. I am quite willing to come
into a hospital where I can be under observation,
and where you will see that you are wrong and I
am right.' ” A person who has had an attack of
mental disorder once, or twice, and has recovered,
says, 44 Next time I get like this I shall prefer to
return.” I remember in the old days a patient
driving to Bethlem Hospital and saying, 44 1 want
to be taken in ; I feel I am going off my head ;
only if you take me in you will send word to my
family where I am.” At Bethlem Hospital there
are probably 25 voluntary boarders ; at Virginia
Water there are a large number of voluntary
patients, and one hopes it will be still further
developed. You can understand that in county
asylums it would be rather a dangerous thing to
have voluntary boarders. The Commissioners
quite properly require that those who wish to
become voluntary boarders shall say in writing
that they wish voluntarily to so place them¬
selves ; and there must be some statement by an
outside medical man, preferably a general prac¬
titioner, that in his judgment the case is a fit and
proper one. Over and over again this sort of
thing occurs to me: A man comes and says,
44 1 will kill myself.” 44 Nonsense ! You feel you
will kill yourself ? ” 44 Yes, and I will.” 44 Don’t.

It will be inconvenient for you, for your friends,
and for me, now you have consulted me. I will
telephone to see if they will receive you at either
of these institutions.” Yes, they can receive him,
and he goes. I send with him a note that I con¬
sider him a fit and proper person to go as a volun¬
tary patient, and he goes. The wave of despair
passes; he is treated medically, and is dis¬
charged recovered. The more people recognise
that hospitals for mental disorder can be used like
homes or like hospitals of another type, the more
will be removed the current dread of those in¬
stitutions. It is a great thing to feel that they
are going there for treatment, not for detention ;
the great trouble felt by the insane is that they
are no longer free agents.

The next improvement, again along Scotch lines,
is boarding-out. They have a patient here and a
patient there at small houses, people who have
been acutely insane but have recovered up to a
certain point And we must remember that
many surgical and medical cases have only par¬
tially recovered when they leave the hospital, but
they may have at once to perform their social
duties. One who has had acute insanity may be left
lamed in mind ; he may no longer be able to fill
the position he did ; he is weak-minded, but he
may be perfectly harmless; he is the class of
man who is a hewer of wood and a drawer of water
in asylums. A large amount of work is done in
asylums by chronic patients. Some of them are
specialists ; there was one in Bethlem who would
do nothing but polish brasi knobs, though he still
believed himself to be the Holy Ghost. Boarding
such people out enables them to live happier,
freer, and less costly lives; and no doubt the

Tb« Med ical Pxxsa. 165

practice is extending in England. In 1890, it
was decided that there should be no more private
asylums’ licenses granted; consequently, the
hospitals have grown, and are receiving large
numbers of patients of a class who used to be sent
to private asylums or to the cheaper asylums.
Hundreds of people all over the Kingdom are
asking to have patients. Nurses leave asylums,
marry, and say they have a nice little house and
can take a patient. Three thousand doctors have
applied to me for patients, therefore there are a
large number of patients living scattered about, I
presume, and I fear there is great danger of abuse.
The abuse which called lunacy legislation into
being was largely the fact that, literally, people
were living upon lunatics under their care ; people
farmed them. I am always maintaining that we
do not so much want certification of the insane as
notification of them. Let there be a notification
of insanity when it reaches a certain line, just as
there is a notification of fever. If a person is
insane, but not dangerous to society, let it be
known and the patient kept under some kind of
supervision. Otherwise, I feel sure there will be
abuse. Certain so-called 44 colonies ” I find very
helpful; there are epileptic, feeble-minded, and
inebriate colonies. I do not like to give names,
but I will describe one. A doctor has a farm of
1,200 acres. On that he has ten or a dozen small
villas, bungalows, cottages, and in each of these is
a farm bailiff, a cured patient, a City missionary,
a cured inebriate, a cured morphinomaniac, or
someone else who has experienced mental trouble.
In each of these houses are two or three border¬
land cases, who have fallen in some way, and are
out of step with society, yet who are not dangerous
or suicidal. These individuals are absorbed into
this colony, and they are gradually educated back
to self-respect; they are trusted. The doctor
himself knows nothing about payment; that is
arranged with the head of each house. The
results are extraordinarily good. I had a letter
from him this week, wishing I could go down and
see the batch of discharges which he is sending to
Canada, they having been there a couple of years
and learnt many occupations, including, of course,
agricultural ones. Of course, one has to recognise
that there are failures, but who does not fail ?
Our successes are built up upon our failures.
Therefore the future treatment of insane people,
especially young growing cases, is to put them in
healthy conditions. Insanity is not a disease
depending on a micro-organism, though it may in
some cases spring from diseased states ; but it is
a want of relationship of the individual to his
surroundings, and if you modify his surroundings
you may often get him back to usefulness.

Now as to treatment. It seems to me we are
always inclined to sway backwards and forwards.
First, every lunatic must be shut up, and now the
feeling among certain physicians seems to be that
every lunatic ought to be sent travelling ; and I
have sometimes said that part of the Atlantic
must be paved by these people. It is a very
dangerous thing to send a person of unsound
mind travelling unless you know all about him.
Some time ago, I was told a patient was to be sent
for a voyage, and I said I was very glad I was not
going with him. Next I heard that after being a
short time at sea he attempted to drown himself.
The consequence was that the rest of the voyage,
which was to do him so much good had to be passed
in the cabin under the strictest supervision

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i66 th* mldical puss-

clinical LECTURE.

Aug. 14. 1907-

Doctors have the common failing of recommending .
that which suits themselves. If a person has an 1
inflamed eye he does not at once go to a picture
gallery. He is put into a dark room, and is kept
quiet. Melancholia, in many cases, is mental
pain ; and do you suppose that when the mind is
suffering painful impressions it is best to exercise
it ? It requires rest. One man finds rest at the
seashore ; another in pottering about a garden
or on a farm. One man who had an attack of
melancholia which lasted a year, showed me a
road he had made entirely, including quarrying
the stone. He said, “ That was my cure for
melancholia.” Doctors sometimes say, “Don’t
you think it will be a good thing to make him
buck up ? ” I think it would be disastrous;
but there are some to whom it would be immensely
useful. A man makes a fortune before he is
middle-aged, and he is induced to retire from
business. He has devoted twenty-five years to
making money, and thinking of nothing but
money, and the making of it. He retires ; and
he has not got a healthy vice at all. If you cannot
get him back to some business, then if you send
him for a year or two’s travel he may gradually
settle down into a different man. Travelling is
useful in certain hypochondriacal cases. When
insanity depends upon physical disease, treat that
disease ; do not treat the insanity, but treat the
individual. Travelling has its advantages, but
it also has grave dangers. I have seen many
people made very much worse by travelling, and
many cases have ended fatally as a result. Then
comes the swing of the pendulum the other way.
“You say hospital treatment for the insane is
good ; very well, give them all 4 rest cures.’ ”
If the patient is badly nourished, if his digestion
is failing, if he be physically weak, Weir-Mitchell
treatment may be of enormous advantage. But
if the person be a self-indulgent adolescent, he or
she must not be allowed to soak in self-indulgence ;
it would be the worst thing possible. Brooding
leads to hatching, and brooding in bed leads to all
sorts of delusions. I have seen a person put to
bed slightly depressed, and get up confirmedly
deluded. But in some cases it is beneficial, as in
the following case which recently came before me.

I was asked whether a certain lady would not be
benefited by a “ rest-cure ” in a nursing home.
First, one had to decide : Is that person really
insane, dangerously, so that it is not justifiable
to send her to a nursing home ? No. She was
hypochondriacal, quarrelsome, and inclined to
upset the household generally, wherever she was.
She was about 2J st. below her normal weight.
She was put into a nursing home, isolated from
her friends. Nurse No. 1 does not get on with
her ; Nurse No. 2 did very well. There are the
surroundings of peace ; she is not seen much by
a doctor, nurses look after her chiefly, and massage
is increased. She puts on 2$ st., and even more,
and begins to think she is going to become too fat.
But she is inclined to say “ I am so happy here
that I will stop here.” Now comes the time to
break down adhesions, and therefore one tells her
to go somewhere else. She is sent to the home of
a cultured lady who has had experience of such
cases, and slowly she gets perfectly well. If she
had had her way she would have gone on having
“ rest cures ” for the remainder of her life. I
have known a patient drift into that condition
and not leave her room for twenty years ; she
/iked the habit of living in retreat. One use of the

Nursing Home is : You are called suddenly to
see a woman who has become insane. Pending a
decision as to the future, it is extremely con-*
venient to be able to say : “Yes, the doctor think9
that a rest would be good for you, therefore you
must go to bed, and you must have a nurse.”
That,of course, is watching to see which way the
current is going to run.

Next, as to treatment by drugs. Nowadays
people are apt to disparage drugs and drug treat¬
ment, but there is no doubt they are useful in
some cases of mental disorder. They may pre¬
vent, or may shorten, a breakdown, or they may
alleviate it in some way. I remember the day
when patients were kept quiet by antimony and
purges. That is no better than mechanical
restraint; we have got past chains, sudden baths,
shower-baths, and electricity. But it is impor¬
tant to remember that purges may be essential.
I have known a person freed of his delusions by a
very copious action of the bowels. You may
need to purge so that you may be sure you are
starting fairly. And in regard to sedatives, there
seems to prevail a sort of healthy dread. In re¬
gard to half the patients I see in consultation the
doctor says he is not giving anything to induce
sleep. That may be right in principle, but no
principle is right if you dogmatise on it too abso¬
lutely. If you have a patient suffering from
sleeplessness, it is your duty to procure him sleep
somehow. Nowadays the latest drug is always
the best—veronal, or trional. Paraldehyde
is the nastiest, and, therefore, in many cases, the
best. Both bromide and chloral are given less
than they were. Alter the diet, see that the
patient does not take so much tea and coffee. If
the patient has his last meal at 6 or 7 and goes
to bed at 10.30, it is well to give a little hot soup,
or something of the sort, with a little stimulant
in it. Sleeplessness, especially in old age, is
frequently relieved by stimulants.

Baths at one time were much used, and in two
or three ways. The old brutal method was the
“ surprise bath,” intended more as a punitive
than as a therapeutic measure. In some cases,
especially adolescents, a warm or hot bath, with
a cold effusion to the head and neck, is useful:
and very violent patients have derived much
benefit from the prolonged bath, which can be
readily arranged in any house. At Bethlem I
have kept patients in such a bath eight or nine
hours, and they frequently calm down quickly,
when everything else has failed. In cases of
chronic sleeplessness, it is good to add to the hot
bath £ lb. of mustard to which has been poured a
quart of boiling water, first letting it stand for
ten minutes. Turkish baths are sometimes useful.

I have no experience of the subcutaneous in-*
jection of saline fluids.

Finally, I may say, I never, or very rarely,
neglect to reason with my patients. (Dr. Savage
gave instances of good results from this.) As to
hypnotism, that is a subject large enough for a
separate lecture. But hypnotism would do harm
' in patients who are emotional and already too
sensitive. However, it is often successful in in¬
ducing sleep in those who badly need it. Some¬
times delusions are shifted by hypnotic sugges-
. tion. Society is very much alert on the subject
of prophylaxis, but we have not got so far as our
i American friends, and I do not think we ever
j shall: “ Although it is desirable for the good of
1 the community that only individuals who are

Digitized by GoOgle

Aug. 14. 1907.

mentally sound should propagate their kind, it is
scarcely to be expected that the passage of laws
similar to the one in Minnesota will in any degree
do away with the possibility of marriages, even
amongst those who are mentally defective. Hence
we are left with only two methods by which these
doctrines can be met, namely, ample provision for
the poor unfortunates in institutions, or, if they
be left at large, castration.”

Note.— A Clinical Lecture, by a well-known teacher,
appears in each number of this journal. The lecture
for next week will be by R. J. Kinkead, M.D., Dub.,
L.R.C.S.I., Professor of Obstetrics in Queen’s College,
Galway : Physician and Gynecologist to the Galway
Hospital. Subject; “ The Consequences and Treat¬
ment of Laceration of the Female Perineum."

ORIGINAL PAPERS.

RHEUMATOID ARTHRITIS

AND THE MORBID CONDITIONS WHICH SIMULATE
IT ; WITH SPECIAL REFERENCE TO PATHO¬
LOGY AND TREATMENT, (a)

By ARTHUR P. LUFF, M.D., B.Sc., F.R.CP.

(Lond.).,

Physlolan to St. Mary’s Hospital.

The term “ rheumatoid arthritis ” is objection¬
able, as suggesting a causal connection with
rheumatism. If, however, it is employed and
understood as merely meaning an arthritis some¬
what resembling some forms of rheumatism, the
term may be retained, although the name
“ arthritis deformans ” is less open to objection.
I suggest, however, in this discussion that we
retain the term “ rheumatoid arthritis ” owing
to its long usage, as I am afraid that the description
of the disease under another and less recognised
name may lead to confusion.

Rheumatoid arthritis is held by some to be a
very complex disorder which has many factors
concerned in its etiology. I do not hold with
this view. My own opinion is that although
there are several infective diseases of the joints
which somewhat resemble it, yet that rheumatoid
arthritis is a distinct clinical entity, which, with
care, may be distinguished from other forms of
arthritis.

Rheumatoid arthritis is a constitutional disease,
not a local one—the affection of the joints is only
a part, although an important part, of the morbid
process. It is, I believe, a disease due to the
presence of micro-organisms which gain access
to the blood in the majority of cases probably
through some chronic catarrh of the alimentary
tract, although the invasion may occur from
the nose, pharynx, or air tubes. After gaining
access to the circulation they find a suitable nidus
for their growth in the joints, where they grow
and propagate in the synovial membranes, liga-.
raents, cartilages, and bones. As a result of
their presence inflammatory changes occur which
result in ulceration, erosion, destruction, and,
coincidently as a rule, in hypertrophy also.
During the active growth of these micro-organisms
toxins are produced and discharged into the
circulation, and by their action on the nervous
system give rise to the nervous symptoms of
the disease, while the toxins acting on the vaso-

(«) Opening of DIboumIoo In the Section of Medicine at the Exeter
■taetlnf of the British Medical Association, August, 1907.

The Medical Peess. 167

motor nerves and the trophic nerves of the skin
produce the local sweatings and pigmentation
which occur in connection with rheumatoid
arthritis.

That it is an infective disease is shown by the
febrile disturbance, which, although not severe,
always accompanies the early stages of the
disease, by the rapidity of the pulse, the local
sweating of the hands and feet, and by the pro¬
gressive involvement of many joints. In its
early stages it may very closely simulate sub¬
acute rheumatic fever, but it may be distinguished
from it by not reacting to treatment wth salicy¬
lates. The disease usually commences in one
joint, commonly one of the metacarpo-phalangeal
articulations, and then rapidly spreads to other
joints. Shortly after its commencement it is
always polyarticular. The so-called forms of
monarticular rheumatoid arthritis are, in my
opinion, always traumatic in origin, and are due
to degenerative changes set up within the joint
as the result of chronic inflammatory processes
which result in the disintegration and wearing
away of the joint cartilage. It would be better.
I think, to restrict to these forms the name
“ osteo-arthritis.”

Rheumatoid arthritis occurs in two forms—
acute and chronic. Both are due to the same
infective cause and simply differ, as regards their
clinical features, in the degree or virulence of
the infection, or in the different results of a
similar process attacking the joints at different
ages. It is commoner in females than males.
In the acute form it is generally met with in earlier
adult life. The chronic form may be a later
stage of the acute disease, or, as is more frequently
the case, it is chronic from the first, and occurs
especially in middle life and in females. In the
latter it is specially prone to start about the
climacteric period. Comparatively slight injuries
of a joint, especially of a small joint, may lead
to rheumatoid arthritis, and to an extension of
the process to other joints in a symmetrical
order. The injuries are frequently the outcome
of excessive work and strain, especially in elderly
and enfeebled persons with a diminished power
of resistance, increasing with years, and with
imperfect nutrition.

In the acute form the synovial membranes are
primarily and mainly affected, while the liga¬
ments are softened and infiltrated, presenting
the well-known spindle-shaped enlargements of
the joints. The cartilages are damaged second¬
arily, and it is not until the disease has assumed
the chronic form that the signs indicative of
destruction of cartilage become evident, accom¬
panied wdth cartilaginous and osteophytic out¬
growths.

Cases of Heberden’s nodes represent the
mildest degree of the disease. The nodes consist
of little hard swellings of the finger joints, affecting
almost entirely the terminal phalangeal, and are
due to a very chronic form of rheumatoid arthritis.
This type is more commonly met with in women
than in men, and usually at or after the middle
period of life. The nodules are due to enlarge¬
ment of the ends of the bones, which are fre¬
quently covered by a pouch of the projecting
synovial membrane, which acts somewhat as a
bursa. The joints become swollen and tender.
The cartilages are softened, and the ends of the
bones are ebumated. The enlargements are
I osseous in character, but there may be a certain

ORIGINAL PAPERS.

Google

Digit

168 Tqx Medical Puss.

ORIGINAL PAPERS.

Atjo. 14, I 9 ° 7 *

amount of increase of the periarticular fibrous
tissues. After a time the disease usually be¬
comes arrested, but the swellings remain, and
eventually may cause no discomfort.

In the great majority of cases rheumatoid
arthritis is a primary diseasfe, but at the same
time it is probable that in a small number of
cases an antecedent attack of rheumatic fever,
or of some form of septic arthritis, such as gonor¬
rhoeal arthritis, or even an acute attack of gout,
may have left the joints in such a vulnerable
condition that they may subsequently become
the seat of true rheumatoid arthritis. Any
debilitating condition may predispose to this
disease, and especially of late years I have seen
many cases of rheumatoid arthritis which have
followed repeated attacks of influenza.

Treatment .—Rheumatoid arthritis, if left un¬
treated, tends to spread from joint to joint, and
produces progressive destruction of the joint
tissues. Occasionally treatment fails to effect
any arrest of the disease, and this is especially
apt to occur in connection with the rheumatoid
arthritis of the old. For the successful treatment
of this disease it is essential that the treatment
should be commenced while the disease is in its
early stages ; hence the importance of an early
recognition of the malady, and of its distinction
from gout and rheumatism. The treatment
must be persevered in for a long period of time,
generally a year or two, and during the treatment
everything possible must be done to increase
the patient’s strength, and to maintain the
general condition of nutrition at the highest
possible level.

If rheumatoid arthritis is seen and recognised
early in the acute stage it is curable. In the
later chronic stages it is possible to arrest the
disease, to remove the pain, and to secure greater
movement of the joints; but it is not possible
to bring the disorganised and deformed joints
back to their normal state. It is remarkable,
however, even in many chronic cases, what a
considerable amount of improvement may be
effected in the joints if suitable treatment is
persevered with for a prolonged period of time.

The not infrequent mistake of diagnosing
rheumatoid arthritis as gout, and the consequent
placing of the patient on a restricted and spare
diet, has undoubtedly led to the development of
severe and incurable forms of the disease. It is
essentially a disease that requires good and
nutritious feeding, and I have seen many cases
of rheumatoid arthritis which have gone tho¬
roughly to the bad, through the initial error of
mistaking the disease for gout, and treating it
with a spare diet. The diet should be as liberal
and as good as the patient can digest, and animal
food should be partaken of freely, though not to
the exclusion of vegetables. A moderate quantity
of wine or stout should be taken with lunch and
dinner. Any kind of wine that agrees with the
patient may be taken, but perhaps a generous
red wine, such as Burgundy, is the most suitable.

The drugs that I have found most useful in
the treatment of rheumatoid arthritis are guaiacol
and potassium iodide. I have now employed
guaiacol in over three thousand cases, and as the
result of my experience I do not hesitate to say
that, if administered in sufficient quantities and
for a sufficiently long period, it is capable in the
great majority of cases of arresting the disease,
ofjiiminishing the size of the joints, and of per¬

mitting increased movements. It also relieves
pain markedly. It is useful in both the sub¬
acute and chronic forms of rheumatoid arthritis.
The guaiacol probably acts by inhibiting the
growth of the specific micro-organism in the
intestinal tract, and after absorption by com¬
bining with the bacterial toxins and assisting in
their elimination. It is not to be imagined for
one moment that the guaiacol renders the intes¬
tinal tract sterile, but just as the administration
of cinnamon oil in cases of enteric fever exerts a
restraining influence on the propagation of the
typhoid bacilli, and renders them less capable
of elaborating a virulent toxin, so, I believe, the
guaiacol exercises an inhibiting effect upon the
micro-organisms responsible for the production
of rheumatoid arthritis. The iodide of potassium
probably acts by promoting absorption of the
hypertrophied fibrous tissues.

The most convenient form of administering
the guaiacol is the carbonate in cachets. This
salt is a white powder which is free from the
disagreeable odour, taste and irritating effects on
the stomach of guaiacol itself. In the intestines
it is slowly split up into guaiacol and carbonic
acid gas. At first from five to ten grains of the
carbonate of guaiacol should be given three times
a day, and the dose should be increased by one
to two grains each week until from fifteen to
twenty grains are being taken in each dose.
It is essential that this treatment should be
continued for at least twelve months. The
beneficial effects of the guaiacol are very much
increased by administering at the same time a
mixture containing potassium iodide; the de¬
pressing effect of the iodide should be counteracted
by its combination with tonics.

The treatment that I have just detailed, is, in
my experience, incomparably superior to the
prolonged treatment for two, three, or more
years of such cases with small doses of arsenic
and iron, a method of treatment which still has
many supporters.

After the treatment with guaiacol carbonate
and potassium iodide of a very large number of
cases of rheumatoid arthritis I am convinced
that it is capable in the great majority of cases
of arresting the disease, and so of preventing
the frightful suffering connected with movements
of the affected joints, a condition which is so
common in cases of unrelieved rheumatoid
arthritis. If the treatment is commenced in
the comparatively early stages of the disease,
then recovery with very little deformity may
result; but even if after arrest of the disease
much deformity results, very considerable mo¬
bility of the joints may be promoted by baths,
superheated air, massage, and passive move¬
ments. It is frequently remarkable to find after
such treatment what an amount of mobility and
capacity for usefulness has been restored to joints
\trhich have been left in a severely deformed but
quiescent condition.

The thermal treatment of the affected joints,
either by means of baths, superheated air, or
electric light baths, is most beneficial. Douche
massage is the most effective form of treatment
with hot water, and perhaps next to that rank
peat baths and brine baths. Electric light baths,
in which the affected joints are bathed in the
heat and light rays reflected from a number of
incandescent electric lamps, are also beneficial
in many cases. Properly regulated movements

Digitized by GoOgle

Aug. 14, 1907.

ORIGINAL PAPERS.

and properly applied massage are of great use
in overcoming the stiffening and fixation of the
joints, and the muscular wasting in their vicinity.

Climate .—Dry heat benefits cases of rheumatoid
arthritis, whereas damp cold increases the disease.
Seaside resorts are not suitable for most cases.
As a winter resort there is no better climate
than that of Egypt.

ON

AUTO'DEFORMITIES OF THE FOOT.

By PAUL GALLOIS, M.D.,

Surgeon to the Paris Hospitals.

[specially reported for this journal.]

The perfection to which the hand has attained,
making it an incomparable weapon in the struggle
for existence has been in great measure rendered
possible by the fact that the whole weight of the
body falls upon the lower limbs. This weight is
a matter of moment, seeing that it averages nine
stone. If we suppose a foot 30 cm. long
and 10 cm. in breadth at its widest part, this gives
us 300 square centimetres, a surface of 300 q.c.
for each foot, i.e., 600 q.c. for the two. Every
square centimetre of the plantar surface conse¬
quently has to support 100 grammes pressure.
But if we take the imprint of the moistened foot
on a plane surface, we find that only a part of the
plantar surface comes into contact with the ground
(1) the heel ; (2) what has been called the anterior
heel, constituted by the metatarso-phalangeal
articulations and (3) by a band running along the
outer border of the foot joining the anterior and
posterior heels.

In standing, a man distributes the weight of
his body fairly equally over the various parts of
both soles, but this is by no means the case in
walking, when necessarily each foot has to bear
the whole weight in its turn, and in respect of each
foot the weight is successively shifted from the
posterior to the anterior heel. Let us assume for
instance that the heel measures 6 cm. in length and
5 cm. in width, i.e., 30 q.c. of surface area, it will
be seen that at certain moments each square centi¬
metre of the heel surface is called upon to support
a weight of two kg. and this weight is notably
increased in running and jumping.

Overstrain is a recognised cause of disease in
any organ, and it is therefore by no means sur¬
prising if persons, who are obliged by their calling
to walk a great deal or to stand the livelong day,
ultimately suffer from various local disturbances
in the feet thus subjected to excessive functional
strain. This is so self-evident that it seems almost
idle to insist upon the fact, but it has often hap¬
pened to me to see patients suffering from troubles
due to foot fatigue, the existence whereof had been
ascribed by their medical advisers to various other
causes. In some cases the pain &c., had been
ascribed to rheumatism, this refuge of the destitute
in diagnosis, and the patients were accordingly
stuffed with salicylate. In others, surgical inter¬
vention had been proposed yet in all immediate
and marked improvement usually followed a period
of functional rest. It may therefore be as well,
after all, to emphasise this pathogenesis and to
discuss the various troubles due to foot fatigue
as a whole, so that they may all be grouped under
one head.

The term I propose is "auto-deformity of the
foot." No doubt the term deformity is rather too

The Medical Press. I69

strong for certain forms of foot fatigue, and in
reality only applies to extreme cases, but on the
other hand a milder term would fall short of the
graver cases. “ Auto-deformity, ” therefore, seems
to me to express with sufficient precision the
troubles determined in the bones of the foot by
the excessive or unduly prolonged pressure of the
weight of the body.

The foot rests on the ground on the anterior and
posterior heels, but these two heels are but the
pillars of an arch which has to support the direct
weight of the body and transmit it to the cal-
caneum on the one hand and to the heads of the
metatarsal bones on the other. This arch com¬
prises the tarsal and metatarsal bones. The
troubles induced by the weight of the body may
therefore bear on (1) the calcaneum ; (2) the tarsal
bones; (3) the metatarsal bones; and (4) on
the heads of the metatarsal bones which together
form the anterior heel. It follows that we have
to consider four distinct types.

(1) Talalgia .—Talalgia is characterised by a
more or less troublesome pain on the plantar
aspect of the heel. The pain is felt especially when
standing, and may be elicited by pressure with
the finger. It may persist even in the absence of
pressure. Talalgia is especially frequent in persons
who are constrained to the erect position possibly
more than in those who have to walk a great deal.
It has been described as “Policeman’s Disease."
It is also met with in bank messengers, shop
employes, omnibus conductors and porters. It
may be caused by irregularities in the boots
throwing the weight of the body on a part only,
instead of the whole, of the calcaneum. This
bone, which is in this way subjected to a sort of per¬
petual bruising, becomes painful. Now, as a general
rule, once a bone has become painful it remains
so for a long time. Talalgia was attributed by
Jacquet to gonorrhcea which he claimed gave
rise to hyperosteosis of the calcaneum. I am not
disposed to deny this possibility but I cannot say
that I have ever observed an example theieof,
although my attention was long since drawn to
the question. On the contrary the perpetual
bruising of the calcaneum appears to me to be a
much more frequent cause. Some practitioners
attribute the pain to rheumatism and have re¬
course to the salicylates which rarely give any
result worth speaking of. Enterprising surgeons,
having discovered the existence of abnormal
prominences on the calcaneum, have gone so far
as to propose partial resection of the bone. The
conception of chronic bruising infers much milder
measures. All we have to do is to get the patient
to change his occupation if that be possible.
Otherwise we must advise him to wear rubber
soles inside his boots or to fix rubber heels out¬
side, these articles being now on sale everywhere.

(2) Tarsalgia .—Tarsalgia occurs in all degrees of
severity. In slight cases, which are the most fre-
quent, patients complain of pain in the instep.
If we run the finger over the arch in order to make
out the exact spot it will usually be found on the
inner side of the foot opposite the inter-articular
spaces separating the first cuneiform from the
scaphoid or the first metatarsal This mild form
of tarsalgia is generally ascribed to ordinary
rheumatism.

A more advanced form is that of " adolescent
tarsalgia,” or flat-foot. Years ago Gosselin attri¬
buted it to contraction of the lateral peronei, but
at present the theory of auto-deformity is generally

Digitized by GoOgle

I70 Th» Medical Pum.

ORIGINAL PAPERS.

Aug. 14, 1907.

admitted, and A. Broca in particular fully adopts
this explanation in his treatise on children’s
diseases. Crushed by the weight of the body,
the plantar arch gives way. Coincidentlv with
the flattening of the foot the scaphoid is displaced
inwards, and its normal prominence becomes
unduly pronounced. In flat-foot of old standing
the pain is often but slight, and patients suffering
therefrom, in spite of the deformity, are very good
walkers. This form is very frequently met with in
Arabs. Tarsalgia with flat-foot is particularly
frequent at adolescence at a time when the body
is rapidly increasing in size and weight, and the
bones of the foot become lengthened, although
retaining an infantile consistency. The treatment
consists in supporting the plantar arch either by
insisting on boots that hold the foot well together,
thickened on the inside, corresponding to the arch,
or by using pieces of cork or rubber modelled to
the normal arch, or metal supports of the same
kind. Simple or comparative rest, however, often
suffices to effect a cure.

The grave form of tarsalgia is that associated
with tabes. The mechanism is the same, but
as the bones in ataxic subjects are abnormally
fragile they do not merely slide one over the
other, but they give way and break, with a sudden
yielding of the arch, the fractured ends uniting
with deforming callus.

(3) Metatarsalgia. This type of crushed foot
is well-known to military surgeons under the name
of “ forced foot." It is an acute accident charac¬
terised by sudden painful swelling of the foot
over the metatarsal bones. Skiagraphy, confirm¬
ing what had already been suspected, has enabled
us to distinguish a fracture usually of the fourth
metatarsal bone.

It may be asked why this metatarsal bone should
be affected in preference to any of the others.
A fracture of the internal or external metatarsal
bone would be easier to understand but the first
metatarsal bone is very strong and the fifth is also
fairly resistent, moreover it rests its whole length
on the ground as shown by the footprint. It
follows that these two metatarsal bones are likely
to resist the crushing influence. As to the three
intermediate metatarsals they are approximately
of the same size, yet the fourth is, if anything,
rather smaller. Moreover, we must bear in mind
that the metatarsal bones taken together represent
an arch, not like the instep antero-posterior, but
transverse. It is the heads of the first and fifth
metatarsal bones that rest on the ground, as any¬
one can see for himself if he examines a normal
plantar surface. The skin over them is thicker and
the fatty padding is more marked. On dissection
we find bursas over them, indicating that these
are the two bones that do most of the work. Now
when the foot is fatigued by long marches, as in
soldiers who have, moreover, to carry a knapsack,
this transverse arch gives way, and of the three
middle metatarsal bones which are less protected
and less strong than the others, the first to come
into contact with the ground is the fourth, hence
the frequency with which it is fractured.

(4) Morton’s Neuralgia. In the affection known
under this name it is again the fourth metatarsal
bone that is the seat of pain, opposite to its articu¬
lation with the phalanx. When chronic the
mechanism is the same as in " forced foot. ” There
is also some relaxation of the ligaments binding
together the metatarso-phalangeal articulations,
with flattening of the transverse arch, bringing

the head of the fourth metatarsal bone into con¬
tact with the ground, and as it is less protected
the chronic bruising to which it is subjected pro¬
vokes an abnormal pain similar to that in the cal-
caneum in ordinary talalgia, in other words it is
an anterior talalgia.

The theory of neuralgia infers that the nerve
filaments are compressed between the heads of
the fourth and fifth metatarsal bones and the
advice usually given is to wear wide boots with thin
soles, or light slippers. But in reality it is better
to have thick soles, thus distributing the pressure
over the anterior heel and keeping the fore part of
the foot rather tightly bound so as to reform the
arch of the anterior heel. In some instances a
simple ribband tied round the metatarso-phalan¬
geal articulations will suffice to give relief.

Rest is obviously the best way to effect a cure,
but we must remember that, just as in talalgia of
the calcaneum, the pain induced by bruising of
bone is usually very persistent and subsides but
slowly. 1 Surgical operation, resection of the head
of the painful metatarsal bone, has been proposed
in Morton’s neuralgia, just as in talalgia.

It will be seen then that overstrain of the foot
determines various deformities of the bony frame¬
work of the foot. By considering them together
we are better enabled to appreciate the mechanism
of their pathology. It is important to recognise
them properly, if only to avoid useless medical
treatments and uncalled-for surgical interventions.
They may be improved by various modifications
of the foot gear, by massage, electricity, baths,
and the administration of phosphate of lime,
but we must at all times bear in mind that there
is really only one effectual means, viz., rest.

THE MEDICAL ASPECT OF DENTAL
CARIES IN CHILDHOOD, (a)

By G. F. STILL, M.A., M.D., F.R.C.P.,

Prof«aaor of DIhun of Children, King'* College, London : PhyilcUo
for Diseases of Children, King's College Hospital; Assistant Physician
to ihe Hospital for Sick Children, Great Ormond 8treet.

Caries of the teeth is an important cause of
ill-health in children, and one which is apt to be
overlooked ; the converse is also true that ill-
health in children is a cause of dental decay.
Decayed teeth interfere with the proper assimi¬
lation of food, and such interference is most serious
in childhood when growth and development,
physical and mental, should be at their greatest
activity. Any widespread prevalence of dental
decay in childhood is a menace to our national
physique. A series of observations taken amongst
children brought to hospital for other conditions
showed that 827 per cent, of children between
5 and 12 years of age had decayed teeth, and
39"8 per cent of children between two and five
years old. Some of these children had 10-15 carious
teeth.

Parents as well as medical men ought to know
how much a child’s health may suffer from de¬
cayed teeth. The commonest evil therefrom is
digestive disorder, and this in a child is often
shown by loss of flesh, loss of appetite, enlarge¬
ment of the abdomen, and sometimes by frequent
pains in the abdomen. Anaemia is also sometimes
due to dental caries, perhaps in consequence of
chronic poisoning from the foul condition of the

(«) Ab*tract of paper read before the Dental Section at the Eietrr
meeting of the British Medical Association, August, 1907.

Digitized by G00gle

Apg. 14, 1907.

THE OUT-PATIENTS’ ROOM.

Tim Medical Eras'. Xjt

teeth. Decayed teeth also form a nidus for micro¬
organisms which may set up inflammatory dis¬
orders in the mouth or pass into the blood or into
the neighbouring glands and produce more serious
disease. It has been thought that tuberculous
disease of the glands in the neck may arise from
infection from decayed teeth ; the tubercle bacillus
has been found in decayed teeth, and enlargement
of glands is very frequently associated with de¬
cayed teeth, but it is very uncertain how often
any tuberculous infection is due directly to the
teeth, for there are other and probably much
commoner sources of infection ; but there can be
little doubt that indirectly by causing swelling
of the glands dental caries is a powerful predis¬
posing cause of tuberculous infection of these
glands.

Decayed teeth are also a cause of frequent
headaches in some children, and occasionally give
rise to more troublesome nervous disorder such as
habit spasm, and in a few recorded cases even
epilepsy.

Lack of proper cleaning of the teeth is one factor,
but not the only one, in the production of dental
decay. Considerably more than 50 per cent, of
children of the hospital class at the school age
have never cleaned their teeth in their lives.
But it has been shown that children of the well-
to-do classes are just as liable to dental caries as
the poorer and less well-cared for children, and
whilst the most scrupulous cleanliness will not
always prevent decay, complete ignorance of a
tooth-brush is not inconsistent with a perfect
set of teeth.

There are differences in the teeth of different
children ; in one the enamel is thicker and more
perfectly formed than in another, and this differ¬
ence may be congenital and perhaps peculiar to
particular families so that the children of one
family may have teeth more resistant to decay
than those of another family ; but imperfect
development of the teeth, particularly of the
enamel, may be due to preventable disease, namely
rickets : and any profound disturbance of nutrition
in infancy, such as is produced by improper
feeding, may interfere with the perfect develop¬
ment of the teeth and so make them more liable
to decay.

Diet has some influence in producing decay of
the teeth after they have already been cut, but
probably this influence is chiefly indirect; any
food which causes digestive disorder, thereby alters
the secretions of the mouth so as to favour the
action of bacteria in producing fermentation
and eroding the enamel. Sweets, which are gener¬
ally supposed to harm the teeth, probably do so
only in this indirect manner, for, given at wrong
times and too frequently they are specially apt
to upset digestion.

The prevention of dental caries must date from
earliest infancy. If 39-8 per cent, of children
between two and five years of age have decayed
teeth, it is evident that the mischief is often present
before the school age, and no dental inspection
of schools can take the place of parental care in
preventing this evil. Proper feeding in infancy
and the prevention of rickets and of digestive dis¬
turbances in early life are of prime importance.
The teeth from their earliest appearance, should
be cleaned twice daily, especially in the evening.

There is a most erroneous and mischievous
idea current that decay of the first teeth is of little
importance, whereas, it is probably more liable to

injure the general health and the physical develop¬
ment then than at any other period of life. If
parents would take their children regularly to a
dentist for inspection two or three times a year,
and if dentists would see that decayed teeth were
stopped whenever possible, there would be less
ill-health and difficulty of digestion in early
childhood, and probably also less decay in the
permanent teeth.

THE OUT-PATIENTS' ROOM.

ROYAL FREE HOSPITAL.

Patient on whom Colotomy had been performed for
Intestinal Obstruction.

By J. P. Lego, M.S., F.R.C.S.

Mr. Lego showed a patient on whom he had per¬
formed colotomy for chronic intestinal obstruction
more than a year ago. She was a woman, act. 44,
who had suffered from gradually increasing constipa¬
tion, abdominal pain, and distension during several
months previous to the operation. She had lost flesh
also to some extent, but was not emaciated. On
examination of the abdomen, peristaltic movements of
the descending colon and sigmoid were very obvious,
and whenever a wave of peristalsis occurred she com¬
plained of a certain amount of discomfort and wind
which could be heard gurgling in the intestine. Deep
down in the left iliac fossa a definite hard mass was
discovered which was easily felt in Douglas's pouch on
making a vaginal examination. She had had no mucoid
or blood-stained discharge from the rectum, which was
found to be quite healthy. At the operation it was
evidently impossible to do an excision of the growth,
and therefore a colotomy into the highest part of the
sigmoid was done. As the symptoms were not very
urgent, the bowel was not opened till the seventh day.
Mr. Legg showed the case, and pointed out the several
indications for doing a colotomy, the advantages and
disadvantages of the operation. As regards the in¬
dications, he said, this woman furnished a typical
example of a patient suffering from intestinal obstruc¬
tion with an irremovable growth, and it was important
to remember that the obstruction was the chief factor
in influencing' the surgeon to do a colotomy. Many
patients had an irremovable growth in the rectum, but
this fact alone was not a sufficient indication for the
performance of this operation. Before advising such
patients to have a colotomy, the symptoms which the
malignant disease was causing had to be carefully
considered. Thus, if a growth was extensively ulce¬
rated and there was a constant discharge of bloody
mucus from the anus, or if the patient was suffering
from diarrhoea and very severe pain caused by the ulcer¬
ation colotomy was frequently of great value in relieving
the symptoms. One had also always to remember that
at most colotomy was only a palliative operation, and
although patients frequently obtained a certain degree
of control over the artificial anus, yet that control was
never perfect and the presence of the colotomy might
add to the discomforts of the patient without re¬
lieving the symptoms if it was done in unsuitable cases.
In doing the operation, an essential feature was to
obtain a good spur separating the upper from the lower
opening in the bowel. Then, it should be done through
as small an incision as possible, and the lowest part
of the descending colon or the highest part of the sig¬
moid should be fixed to the parietes, thereby lessening
the chance of the formation of a ventral hernia and of
prolapse of the intestine through the incision. In
order to obtain a good spur, a V-shaped loop of the
intestine must be brought out on to the abdominal
parietes and the meso-sigmoid transfixed by a suture,
which also fixes the two sides of the incision to each
side of the mesentery, and in order to increase the
chances of the patient having more perfect control
over the passages of the faeces, it was a good plan to
split the muscles of the abdominal parietes in the

oogle

D

OPERATING THEATRES.

Aug. 14, 1907.

iy 2 The Medical Puss.

direction of their fibres rather than to cut straight
through them. Mr. Legg, however, was inclined to
attach more importance in this respect to obtain a
good spur separating the two openings in the bowel ;
both openings were circular in shape and were com¬
pletely surrounded by the muscular coats of the in¬
testine, and if the surgeon’s finger was inserted into
the orifices it was easy to feel the grip or contraction
of the muscle fibres. As in this patient, the skin around
a satisfactory colotomy should be quite healthy, not
red or excoriated, and, as in this patient, the colotomy
should not require dressing more than twice a day.
To further add to the comfort of the patient, it was a
very good plan to irrigate the lower piece of bowel,
namely, that to which the growth was still connected,
either through the lower colotomy opening or through
the anus. By this means the discharges from the
growth were washed away every day. A belt of some
sort was necessary, and he thought the most con¬
venient and useful, most easily kept clean, was one in
which there was a thick glass reservoir covering the
openings into the bowel Plugs fitting into the aper¬
tures should not be used, and if the operation was done
as described in this case there was no tendency for a
stricture of the orifices to form. The woman as now
seen was in very good health ; she had been able to do
her work as a caretaker in a large warehouse for the
past seven months. The skin around the colotomy
was quite healthy, there was no prolapse, and only a
slight amount of bulging of the scar. The colotomy,
she said, acted two or three times a day, and she
knew when it was going to act if the bowels were not
relaxed from any cause, and this, she asserted, rarely
happened. On making a vaginal examination the
growth did not appear to have extended, and there was
no evidence of secondary growth in the liver, although
it was more than a year since the colotomy was done.
Mr. Legg pointed out that carcinomata of this type
found in the sigmoid were not so malignant as other
carcinomata of the rectum, and, as a rule, can be
excised with or without a colotomy ; in this particular
instance the growth was not excised because it had in¬
filtrated an adjacent portion of small intestine and was
closely bound down to the pelvic walls. He added
that such growths were the commonest cause of chronic
intestinal obstruction in people aet. over 40.

OPERATING THEATRES.

KENSINGTON GENERAL HOSPITAL.

Nephropexy: Spinai. Analgesia.—Mr. Canny
Ryall operated on a woman, aet. 40, who had been
admitted suffering from movable right kidney. For
some years the patient had had all the cardinal symp¬
toms of this affection, but the usual nervous symp¬
toms, which are so often met with in these cases, were
absent. The patient was seated on the operating
table with the shoulders well arched, the skin over
the lumbar spinous processes, which had been pre¬
viously prepared, was now thoroughly swabbed with
alcohol, then frozen with ethyl chloride. A puncture
was then made with Mr. Canny Ryall’s puncture knife
and the platinum iridium needle of his apparatus for
spinal analgesia was next inserted into the spinal
canal through the median plane; cerebro-spinal
fluid at once flowed in a good stream, and 10 cc.
were withdrawn. A 1 per cent, solution of novocain
with synthetical suprarenin was injected. The
patient was kept seated in the vertical position for
five minutes, and then placed on her left side with
a sand-bag under her loin, and the usual oblique
incision immediately below the last rib was made.
The kidney having been rapidly exposed and drawn
through the wound, a narrow strip of the capsule
was raised from the lower to the upper pole of the
kidney and twisted into a cord. A blunt needle
was then passed beneath the skin from without

inwards over the last rib. the twisted portion of cap¬
sule was next threaded through the eye, with¬
drawn from within outwards, and securely fixed to
the adjacent muscular tissue. It was then seen that
by this means the kidney was well slung. In addition
the remaining part of the capsule on its posterior
aspect was divided transversely : this enabled four
flaps of the capsule to be raised, which were fixed
with catgut to the adjacent muscles. It was now
apparent that the kidney was securely placed in a
high position. The wound was then closed. Mr.
Canny Ryall said that the first point to be noticed was
the sleepy condition of the patient when she was
brought into the theatre : this was due to her having
previously had two injections of scopalamin and
morphia, given, the first two hours before, the second
one hour before the operation. In some cases he
gave three injections. He pointed out that he now
always uses scopalamin and morphia in conjunction
with novocain for operations on the gall bladder,
the stomach and kidneys, also for hysterectomies, and
where it is anticipated peritoneal adhesions exist.
In the first place the lumbar puncture should be
made in the median line, and not to one side of it,
as it is sometimes done by surgeons in this country.
If the lateral method is employed semi-analgesia or
imperfect analgesia may be the result; the advan¬
tages in his opinion of median puncture are that
one always gets perfect analgesia, and there is no
risk of injuring the cauda equinia. He said he was
the first surgeon in this country to use novocain for
the production of spinal analgesia; also synthetical
suprarenin in conjunction with it, as well as scopala¬
min and morphia as an adjunct for higher operations
in the abdominal cavity. He stated that he could
not speak strongly enough in favour of spinal anal¬
gesia, for, of all methods for combatting shock, none
could compare with this one. It was particularly
indicated in patients suffering from heart disease,
diabetes, alcoholism, for aged people, for those suffering
from shock following injuries to the abdomen and
lower. extremities, or in operations such as excision
of the rectum, strangulated hernias, hysterectomies,
amputations of the thigh, prostatectomies, and to
ward off the shock which so commonly follows these
operations. He had performed all these operations
with analgesia produced by this method, and was
particularly struck by the absence of subsequent
shock. As regards drugs for spinal injection, surgeons
had novocain, stovain, tropococaine and alypin' to
choose from, all of which had been discovered within
the last few years. Novocain, in his opinion, was
far superior to any of the others. He had used a
10 per cent., 5 per cent., 2 per cent., and now only
employed a 1 per cent, solution of novocain. In
ge neral anaesthesia the rule was to use as little ether
or chloroform as possible, and going on these lines
for spinal analgesia, he now worked with a 1 per cent,
solution of novocain in conjunction with synthetical
suprarenin, which gave perfect results. He con¬
sidered that the duty of injecting the patient should
fall to the lot of the ordinary anaesthetist, provided
that he (the anaesthetist) was well versed in aseptic
measures, and the duty of the anaesthetist after the
injection would be to keep the patient’s attention
occupied by continuous conversation. Mr. Canny
Ryall would advise chloroformists to practise lumbar
puncture on the dead body before performing it on
the living ; he said spin ail analgesia should never
be carried out in acute septic or infective cases.

A Co. 14. 1907.

CORRESPONDENCE.

The Medical Press. 173

CORRESPONDENCE.

riOM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Pari*. Aug. 11th, 1907 .

Exophthalmic Goitre.

The first complete description of exophthalmic
goitre was due to the celebrated physician, J. P.
Graves, and to a German doctor, Basedow ; conse¬
quently this affection is frequently' called Graves',
or Basedow’s, disease. These two authors, whose
publications date as far back as 1840 and 1843, had,
however, some predecessors amongst whom may’ be
cited Parry (182;) and Flagani (iSc2). an Italian.
In Italy it is still called Flagani's disease.

In France, the clinical lectures of Trousseau and the
publications of Charcot, Rendu Marie and Bellet,
made known the symptomatology of exophthalmic
goitre.

Goitre, exophthalmia, tachycardia, trembling, such
are the four essential signs of Gra%-es’ disease. These
symptoms are not, however, of equal value, for in the
attenuated form certain of them may r be absent; but
the most constant is tachycardia or cardiac palpitation.

Exophthalmic goitre is most frequent in women ;
rare before puberty, it is exceptional after the age of
fifty.

Card.io-vascular troubles are generally the first
symptoms observed ; the others develop little by little.

In very rare cases, the initial symptoms set in very
suddenly, but even here, intelligent questioning, of
the patient will reveal that the malady had already
set in by* slight signs which had passed unperceived.

Vet there are on record certain cases where the
attack came on suddenly from violent emotions.
Trousseau relates the case of a woman who had lost
her father, to whom she was greatly attached. In
one night that the patient had passed in weeping,
she felt all of a sudden her eyes swelling so as to pre¬
vent her from closing the eyelids, the thyroid gland
developing considerably and violent palpitations.
Dieulafoy mentions a similar case provoked also by' a
violent emotion. However, in the immense majority
of the cases, the disease sets in gradually.

Hypertrophy of the thy roid gland generally' begins
insidiously, and it is not until after some months that
the patients remark that the front of the neck is some¬
what enlarged. It rarely attains a considerable
volume, and sometime® it is hardly’ visible, palpation
alone permitting to assure oneself of the extent of
the hypertrophy’. Both lobes of the thyroid gland
may be affected, but that on the right side is always
the larger. In any case, the degree of consistence
and the volume vary from one moment to another ;
an attack of palpitations, deep emotion, anger, are
sufficient to provoke a notable increase in the dimen¬
sions of the gland. The tumour is pulsatile, animated
with a movement of eiqjansion at each contraction of
the heart. These pulsations are a distinctive sign, as
they arc not found in ordinary goitre.

Exophthalmia Is the most inconstant of the four
cardinal signs of the disease, but where it exists it!
does not fail to draw immediate attention by the
strange look it gives to the physiognomy.

Many patients, says Trousseau, affected with
exophthalmic goitre come to consult for palpitations
of the heart; but the strange look on their faces, 1
seeming to express both astonishment and fright, will
soon attract attention and render the diagnosis easy.

When the exophthalmia is very accentuated, com¬
plete occlusion of the eyes becomes impossible even
during sleep ; the cornea remains exposed and is only
protected by the lacrymal hyper-secretion which is
generally produced ; but if this secretion ceases, the
cornea dries up and sometimes becomes infected and
ulcerates. Grave lesions may’ be the result.

In every patient suffering from Basedow’s disease,
three symptoms should be sought for which generally

accompany cxophthalmia, and although they are not
always present, they are of a certain importance.
The most frequent of these symptoms is the sign of
Graefo, which is characterised by a want of synergia of
the movements of the eyelids and the ocular globe ;
when the patient looks up or down, the movement of
the eyelid is slower than that of the eyeball. The
sign of Stellwag is less frequent; it consists in a con¬
siderable enlargement of the palpebral slit and in the
incomplete occlusion of the eyes when the patient
thinks he has closed them.

The third symptom, or sign of Mobius, is charac¬
terised by the difficulty or impossibility of converging
the eyes.

The cardiac troubles drew the attention of the first
authors, and in reality they constitute the most con¬
stant symptoms and in general the most precocious
of exophthalmic goitre ; the patients nearly all begin
by’ complaining of palpitations, which are sometimes
violent and prolonged, causing a bulging forward of
the thoracic wall and the heart-beat against the chest
is so considerable that it can be heard sometimes at
a distance.

These palpitations become more frequent and
stronger under the influence of moral emotions or
effort. The pulsations of the carotids arc stronger
than in the normal state, and are a cause as well as
the jugular veins, of the bruit perceived over efic thv-
roid tumour

They are not permanent, dux come on in the form
of attacks, provoked by moral emotions and efforts.
They’ are generally accompanied by a temporary
dilatation of the heart. True hy’pertrophy’ of the
heart is rare. Auscultation reveals an acceleration
of the heart-beats and frequentlv a souffle extra¬
cardiac .

Trembling in exophthalmic goitre was described by
Charcot and Pierre Marie. The patient, said P. Marie,
is in a state of continual vibration, standing or sitting,
the body is animated with a perpetual tremulation.
and all the surface of the body is the seat of a kind of
general palpitation of a very singular character. It
affects the body, head, and, above all, the hands.

Sometimes, it is localised to the extremities, the
hands ; but the whole hand, and not as in hard drin¬
kers, individual trembling of the fingers.

Other very important symptoms, although secondary
and inconstant, may be found grouped around Graves’
disease. Those belonging to the nervous system take
the first rank • paresia, asthenia, paraplegia, pseudo¬
chorea, cephalalgia, rachialgia, neuralgia. Psychictrou-
bles are nearly always constant. From the very be¬
ginning. says M. Boix, frequently before the cardinal
symptoms have commenced to reveal themselves, the
patients show’ sign-.- of a particular mental condition.
They are tormented by an indefinable agitation ; their
sensitiveness know’s no moderation, marks of joy and
sadness are excessive, and wdthout proportion with
the motives and even without motive. They pass
without transition from enthusiastic gaiety to bitter¬
ness and discouragement. Ideas rush upon them in
quick succession, and are ever changing ; they’ speak
with volubility,..and are haunted with an uncontrollable
desire to be doing something ; they cannot keep quiet.
At the same time, their character sours ; they become
difficult to live with. Impatient and irascible, thev
break out at the slightest contradiction ; they are
never satisfied, nor ever grateful for any services
rendered them.

GERMANY.

Berlin, Aug. Ilth, 19o7

At the Verein ftir Innere Medizin, Hr. Hans. Hirsc-
feld showed preparations from a case of

Poisoning by Chlorate of Potash.

He said the preparations showed not only the known
changes in the red blood corpuscles, but also changes
in the white corpuscles that had not been hitherto
described. The case was that of a girl, aet. 19, who
had taken 20grm. of chlorate of potash on June 4th,

zed by Google

174 The Medical Prem.

CORRESPONDENCE.

Aug. 14, 1907.

and was admitted into hospital two days later. She
was dull, had the typical blue-grey colouration of the
skin, the corneae were icteric, the urine scanty, dark
brown, and containing a large quantity of me'tha?mo-
globin. After venesection, performed at once, followed
by transfusion of human defibrinated blood, there
was slight improvement. During the following days
the excretion of urine was scanty, oedema and vomiting
were present, and there were also signs of cardiac
failure. The treatment consisted in saline infusions,
hot baths, injections of pilocarpine and inhalation of
oxygen. Death took place on the ninth day after
the poisoning. On the first day, the red blood cor¬
puscles showed discolouration of the stroma, within,
small nuclei containing a large quantity of methaemo-
globine ; many had escaped, and were floating free
in the blood plasma. On the fourth day of obser¬
vation red cells were no longer seen undergoing the
process of destruction ; the number of erythrocytes,
1,500,000; of leucocytes, 15,000; neutrophile hyper-
leucocytcsis, also myelocytes. Repeatedly leucocytes
with polymorphous nuclei were observed, the remains
of red blood corpuscles. Besides this, cells with dis¬
tinct alteration of the neutrophile granula were seen
(swelling or destruction); further, neutrophile ele¬
ments, with clubbed nuclei, i.e., a number of globular
structureless nuclei intensely coloured ; such cells
had never been described as seen in the blood, but in
pus, and especially in that of gonorrhcea. Further,
quite small cells with round nuclei containing neutro¬
phile granula, which were identical with Ehrlich’s
pseudolymphocytes. Ehrlich had only once seen
them in the blood—in a case of haemorrhagic small¬
pox. Lastly, neutrophile cells containing polymor¬
phous nuclei, were very singular, as also some large
mononuclear elements which contained from one to
several large colourless vacuoles. The speaker be¬
lieved these were cells that had eaten up red blood
corpuscles or their remains ; the vacuoles remaining
at the spot where this nutrient material lay. It was
in favour of this that here and there small fragments
containing hamoglobine still remained in them. That
these structural anomalies which had been already
described as being present in pus were present also
in the bleed had not before been recorded.

Hr. Hans Kohn demonstrated preparations from a
case of

General Melanosarcomatosis
(liver, lungs, pleura, spinal column, skull, brain, supra¬
renal capsules, intestine, and uterus) in which the
starting point from a pigmented organ was not de¬
monstrable (the suprarenal capsules contained only
metastases), and two nsevi could not be looked on as
point of origin as they had a perfectly harmless appear¬
ance and other pigmented organs, such as the choroids
were healthy. For this reason the question pressed
as to whether if such a starting-point in a pigmented
organ was necessary, the pigment may not be deve¬
loped in the organ itself, as a result of some chemical
process. That pigment may develope from chemical
causes, Addison’s disease and other cachectic pig¬
mentations showed. One might think that a chemical
cause perhaps a special ferment, might lead to the
formation of a pigment out of the albumen of the
tumour. It was in favour of this that in similar cases
many tumour nodules were strongly pigmented, many
only in part, and others not at all. The liquefying also
of many nodules spoke in favour of a fermentive pro¬
cess. V. Fuerth also had made a certain ferment re¬
sponsible and had assumed that tyrosinase, acting on
tyrosine and other hydrochloric substances of the
aromatic series formed pigment, and Gessard claimed
that he had found tyrosinase and tyrosine in a mela¬
notic carcoma of a horse.

Hr. Westenhoeffer remarked that he had seen a
similar case along with V. Leyden. It led a rapid
course, and terminated fatally under febrile symptoms
in three weeks. What was the course in the case
shown ?

Hr. Kohn replied that the case ended fatally after
a six to eight weeks’ febrile course.

AUSTRIA.

VImm, Ah*. * 1th, 1907.

Secondary Vaccination.

At the Gesellschaft fiir Innere Medicin Friejung
presented a four-year-old child with a perfect vesicle
on the face, the result of contact with her younger
brother. The transmission seems to have taken place
thirteen days after fhe vaccination of her brother,
which was looked on as very late, and rather remark¬
able.

Meningo-Cocci Serum.

Jehle showed a case of cerebro-spinalis which he
had successfully treated with meningo-cocci serum,
according to Pal'tauf’s theory. About seventy-two hours
after the disease had declared itself lumbar puncture
was made and 20 cubic centimetres of cloudy purulent
matter withdrawn which, the microscope demonstrated,
held large quantities of meningo - cocci. Twenty
cubic centimetres, i.e., the whole of the fluid, was
intra-durally injected, after which the temperature
fell within twelve hours from 40° centigr. to 36.4°
centigr., but the stiffness in neck remained unchanged.
The fluid from the lumbar punctures which were made
on the next two days was free from all trace of the
cocci as far as the microscope could discern, but by
cultivation a few tiny colonies presented themselves.
About forty-eight hours after the first injection the
temperature again rose to 39.2 0 centigr., but on the
following day fell to 36.8° centigr. In the evening of
this same day the temperature rose again to 39.3 0
centigr. with increased stiffness of the neck. Another
serum injection (freed from the cloudy purulent matter),
containing 30 cubic centimetres this time, was injected
which brought the temperature to a normal state,
relieving all the stiffness from the neck and, twenty-
four hours afterwards, the patient was apparently
quite well.

Forty-eight hours after the second injection the fluid
extracted by lumbar puncture was perfectly clear and
free from any morphological element or bacteria. On
the sixth day of the disease, or three days after the
first serum injection, an interesting eruption appeared
on the upper part of the left arm covering an area as
large as the palm of the hand, and resembling Herpes,
which rapidly spread on the following day. The ves¬
icles contained a purulent fluid which contained
the meningo-cocci, when examined by the microscope.

Escherich thought these meningo-cocci found in
the vesicles had found their way from the circulation
as a form of metastasis irritating the trophic nerve
and producing the vesicle. He said this experiment
was no novelty as he had been practising this for some
time with perfect success. He had used different
meningo-cocci sera, but more particularly Jochmann
and Ruppel’s better known to the Austrian Sera-
therapists. He usually injected 10 to 20 centimetres
intra-durally at the earliest moment after diagnosis
was complete and before any cerebral destruction took
place. In slight or moderate cases the favourable
effects are early observed by a rapid fall of the temper¬
ature, disappearance of the delirium, and relaxation of
the stiffness in the neck—sometimes a perfect recovery
within 24 hours. In all cases local disinfecting of the
nasal and buccal cavities should be thoroughly carried
out.

^ Disease in the Quadrigemina Region.

Infeld next showed specimens taken frem subjects
who had suffered from morbid change in the brain in
the neighbourhood of the quadrigemina. The first was
taken from an old man, act. 70, who had suffered from an
injury to the head when five years old. In life there
was paralysis of the trochlear and oculo-motor muscles
on the left side, while the right side of the bedy was
atrophied with spastic paresis, disturbed sensibility,
and chorea from movements of the paralysed side.
There was also hyperflexibility of the fingers, clonic
reflex of right leg, but the reflex was absent on the right
side of the abdomen, while Babinski phenomenon could
not be excited.

The bost-mortem confirmed the diagnosis of tubercle
in the left red neucleus of the quadrigemina.

nOOQle

o

Aug. 14. 1907.

CORRESPONDENCE.

The Medical Pmu, 175

The second preparation was from a young woman,
*t. 25, who had suffered from left otitis, subsequently
undergoing operation for radical cure. In life she com¬
plained of a numb condition of the left side, diffuse
bronchitis, tubercle in the apex of left lung, congestion
of the papilla in the fundus of eye, stiffness and feeling
of pressure in the neck, vaso-motor disturbance in the
skin, hyperesthesia of the lower half of trunk, marked
ptosis of right eye with slight facial paralysis on same
side, right papilla wider than left, but reflex lost in
both eyes. At an earlier period in the disease, there
were right-sided hemianopsia, paralysis of lids, ataxia
in the upper extremities, loss of patellar reflex in left
leg, but only reduced in right, and no Babinski pheno¬
menon. For two years she had suffered from headache
and giddiness, and the last year with vomiting.
The post-mortem revealed tubercle in thequadrigemina.

HUNGARY.

Budapest, August 11 th, 1907.

At the recent meeting of the Budapest Inter-
hospital Association Dr. Bauer exhibited a case of
Sclerosis Multiplex Congenita.

All the chief symptoms consisted in the greater
spasticity of the lower and less spasticity of the
upper limbs. The deep reflexes were exaggerated.
Besides, there was in some measure tremor
present, which seemed to be more expressed at in¬
tended movements. We are encountering the patho¬
logical picture of sclerosis multiplex often enough in
old individuals, but it is very seldom seen in children
especially when we can easily diagnose that it is con¬
genital.

Dr. Keller exhibited a case of

Paralysis Progressiva Juvenilis.

In a patient, xt. 19 years, acquired syphilis could
be excluded ; according to probability nervous disorder
of other nature could also be regarded as excluded
Thns we had to assume that the paralysis affected a
man who had inherited the tendency, and in whom
the disease occurred, on the ground of unknown
influences.

Dr. Iv&nyi read a paper on the
First Manifestation of Syphilis on the Cheek.
Also in this case, the patient, on account of the ex¬
tragenital manifestations having been overlooked, came
under proper treatment when already infected with
grave symptoms. The patient, a female servant, at.
.24 years, was admitted to hospital with general
papular syphilides, which had existed for three weeks
while the primary sclerosis on the right cheek and
the glands, the size of nuts, on the right side of the
neck, had been seen for three months. The

patient was not attended to up to this time. The
cause of infection could not be detected.

A Case of Spastic Spinal Paralysis.

Dr. Salgo exhibited a patient, aet. 31, who fell ill
three years ago with similar symptoms as those com¬
plained of at present. Three years ago, after finishing
a systematical antisyphilitic cure, the patient has
improved so far, that he could follow his vocation
without any trouble. At present he can walk only
with the aid of a stick, and even so his gait was un¬
ready, he could not bend his knees, his paces were
short and the feet almost stick to the earth,
lhe knee was stiff, and during the act of walking
not only the muscles of the lower limbs became
strained, but the exertion was apparent even on
ue upper limbs, too ; besides, walking was uncertain
and on the whole the complexity of symptoms showed
iiat type, which is called by Charcot and Erie, the

1^ ,- paret l c S ait Beside this paresis of the
°wer limbs the atrophy of the muscles were absent,
J n a *y in g posture the muscles were able to show

considerable strength.

Further, any lesion of sensation and urinary
difficulties were absent. However, the general

S5T t,0 ? S ° f the knee i erks was striking; a
■ght knocking of the knee tendon resulted in
*reat elevation of the foot. The touching of the

Achilles tendon resulted in a clonic spasm. The
passive dorsal flexion of the foot was followed by a
long-standing clonus. If the sole was touched the
toe had a dorsal flexion. (Babinski’s symptom).

From these positive and negative symptoms
the diagnosis of spastic spinal paralysis was drawn.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

BELFAST.

Paintings by a Medical Man. —An interesting
exhibition of pictures by the late Dr. James Moore
has just been opened in the Municipal Art Gallery
at Belfast. Dr. Moore was one of the foremost sur¬
geons in Ulster some thirty years ago, and at the same
time an artist of no mean ability. It is said that he
never went to a country consultation without carrying
a colour-box and sketching-block, with which he
filled in many a spare hour when waiting for trains,
etc., so that when he died in 1883 he left behind him
a great number of sketches and paintings, chiefly of
landscape and seascape in Ulster. It is, indeed,
by his sketches and by the many tales of his ready
wit that he is now remembered. He was a frequent
exhibitor at the Royal Hibernian Academy, and was
elected an honorary member of that body. He was
probably more appreciated in Dublin than in his own
city, if one may judge from the story told of a hospital
bazaar, for which a lady persuaded him to do several
small water-colours, which he expected would sell
for about a guinea each. Some time afterwards
he met the lady who, with a pleased smile said, “ Oh,
Dr. Moore, I have sold all your pretty pictures and I
I got half-a-crown apiece for them.” Few of his
pictures have come into the market; but one, “Slieve
Bernagh, Moume Mountains,” has lately been acquired
by some of his old friends, and has been presented to
the Belfast Art Gallery as a permanent memorial of
Dr. Moore.

The Corporation and Physical Degeneration._

Some months ago there was some stir in Belfast over
a placard issued by the Corporation, and posted all
over the city, calling the attention of the people
to the conclusions of the Royal Commission on
Physical Degeneration on the subject of the abuse
of alcohol. The Vintners’ Association protested at
the time, but after much wordy warfare the placards
were eventually issued. But the Vintners still pro¬
tested, and appealed to the Local Government Auditor,
who had disallowed a payment of /io 10s. for the
placards, on the ground that he can find no statutory
authority for the payment. He has, therefore,
surcharged the three members of the Corporation
who signed the cheque for the amount, and it now
turns out that one of the three was a leading member
of the Vintners’ Association—a truly Gilbertian con¬
clusion to the affair !

LETTERS TO THE EDITOR.

THE COLLECTION OF DEBTS BY DEBT-
COLLECTORS.

To the Editor of The Medical Press and Circular.

Sir,—I ask space for a few remarks on the letter of
" Medicus ” and your comments on it. The collection
of debts by debt-collectors is very common, and in
most parts of the United Kingdom solicitors will

generally undertake to collect debts at a percentage_

usually 25 per cent.—relieving the client from all
risk. But, of course, this is only done when the
medical man places a number of debts in the hands of
the same solicitor for collection. Against debt-collec¬
tors generally I have nothing to say ; but I fancy
what Judge Mulligan said was that when a debt-
collector was Dot a solicitor he would not allow him
to plead a cause in his Court. In this I think he was

/Google

Digit

17 6 Thi Medical Press. _ SPECIAL A RTICLE.

right, whatever the practice of his predecessor may
have been. When a proceeding has to be taken in
Court and the plaintiff cannot attend in person (or
at all events, by his clerk, foreman, &c.), I think he
should be required to employ a solicitor. The debt
collector cannot be in a position to prove the debt
unless he produces his employer's books, &c., for the
purpose. That the doctor told him it was due and
asked him to recover it is not evidence, and it would
be unsafe to accept the evidence of a debt-collector,
whose remuneration depends on his success, as to
verbal admissions by the debtor unless there was some
one to examine him.

But I apprehend that the debt-collector more fre¬
quently appears on the subsequent application for an
instalment order or a committal order, though even
here I am doubtful whether it ought to be permitted,
He makes inquiries as to the debtor's means and
knows much more about them than the creditor
probably does ; and he is the proper witness to show
what instalment the man is able to pay and whether
he should be committed to prison for non-payment.
But we must here also distinguish between the man
who conducts the case and the witnesses whom he
calls. If nobody appears on behalf of the plaintiff
except the debt-collector, whose function is merely
to give evidence, would not the judge be justified in
striking out the case on the ground that there was
no appearance for the plaintiff ?

What you say about a solicitor is correct enough,
but the solicitor need not personally interview the
debtor or write to him. He may employ a clerk for
the purpose or even employ a debt-collector to do all
the business except the conduct of the case in Court,
and though his commission would be somewhat
higher it would be worth paying, and I think solicitors
would find it worth while to take up this class of
business at a percentage.

But I do not think a doctor would gain much by
trying to collect his debts by imprisonment—the
favourite remedy, it would seem, of debt-collectors.
If there were two doctors in the same locality one of
whom imprisoned his debtors while the other did not,
the latter would soon obtain all the business of the
poorer people. And imprisonment for debt has now
attained such dimensions and has created such an
outcry that its days seem numbered. Certainly the
public will not support any measure for making im¬
prisonment cheaper and more expeditious than at
present.

I am. Sir, yours truly, '

B. L.

LAW FOR DRUGGISTS AND LAW FOR QUACKS.
To the Editor of The Medical Press and Circular.

Sir, —At the Mansion House on Friday last a firm
of chemists was fined 40s. and 20s. costs for dis¬
pensing a prescription deficient in cinchona alkaloids
to the extent of 55 per cent, of the amount that should
have been present. The Magistrate wisely observed
that it was a serious case because it was important
to protect the public when they had prescriptions to
be made up. In this case, the firm being one of re¬
pute, it is probable that the deficiency occurred owing
to a mistake, and of this they, pleading guilty,
accepted the responsibility. If the law has been
made sufficient to reach comparatively trivial offences
of this kind is it too much to ask that it should be
extended to include the systematic and cruel frauds
which are now allowed to be carried on with impunity’
by proprietors of quack medicines ? Deducting the
value of the small percentage of legitimate prepara¬
tions paying stamp duty from the gross sum expended
annually on “patent” medicines there remains a
total of not less than £2,500,000 out of which the
people are annually fleeced by vendors of quack
nostrums. If this plunder represented merely pocket¬
picking it ought not to be allowed, much less ought
such a trade be tolerated when associated with the
infliction of suffering, injury and death. In previous
communications I have explained and illustrated

Aug. 14, 190/-

the cruelty of this form of quackery’. My r enquiries
into the question continue, and they strengthen my
opinion that the educated public and the legislature
would not long tolerate the present abuses if once
fully exposed. During the past few weeks, as visiting
member of a hospital committee, I have given atten¬
tion to cases of gastric ulcer. These have been patients
of the domestic servant and dressmaker class. In a
large proportion of instances I have found that these
I poor girls, often for prolonged periods before applying
for medical advice have been relying upon one or
other of the advertised cures for dyspepsia and stomach
troubles ; and have thus passed into a serious or
dangerous condition (I have seen one fatal case of per¬
foration within the past few weeks) which proper
treatment might easily have averted. The bogus
medical remedy trade is not only fraudulent, it is
murderous ; and this could be easily proved before the
Royal Commission, which, let us hope, may be de
manded and granted within the next few years.

I am, sir, yours truly,

Henry Sewill.

Cavendish Square, August 10th, 1907.

MILK AND TUBERCULOSIS.

To the Editor of the Medical Press and Circular-
Sir, —In view of the fact that Dr. Granville Bantock's
opinions put forth during a discussion under the above
heading in April last, must have influenced many of
your readers and perhaps made some of them sceptical
as to the necessity of the precautions against tuberculous
infection insisted upon by the great majority of
scientific sanitarians, it would be most 'interesting if
Dr. Bantock would tell us whether he has read Dr.
H. E. Armstrong’s paper, published in the Medical
Press of to-day (August 7th), and, if having read it,
he adheres to the opinions he held four months ago.
The tremendous practical importance of the issues in¬
volved seems to me to make it almost obligatory upon
Dr. Bantock to justify his position, or to confess that
it can no longer be maintained.

I am, Sir, yours truly,

A Family Doctor.

August 7th, 1907.

SPECIAL ARTICLE.

ANNUAL MEETING OF THE BRITISH
MEDICAL ASSOCIATION.

Exeter, July 27th to August 3rd, 1907.

(From our Special Correspondent].

( Conclusion .)

The seventy-fifth Annual Meeting has come and
gone and by one and all has been voted a great success.
Scientific discourses, social functions, and renewals of
friendships have each played a part ; and if we
mistake not the tastes and wishes of every type of
visitor must have been thoroughly met. And now
all that remains are pleasant memories and a plethora
of papers which we imagine will more than meet the
requirements of our contemporary, the British Medical
Journal, during what even in the medical profession
must be considered “ the slack season.”

Recollections and Reflections.

Our retrospect fills us with a general sense of satis¬
faction. The more successful a meeting is, however
the more anxious should we be that its benefit and
influence may be widespread and permanent. As
compared with the conferences held by many other
scientific and technical bodies, it must be admitted
that the chief annual meeting of British medicos
would not strike the onlooker as being what is most
comprehensively described as “ serious.” There are
many who deplore, and rightly so. the apparent lack
of real interest in the consideration and discussion of
those scientific principles and facts which should afford

Digitized by boogie

Aug. 14. 1907.

SPECIAL ARTICLE.

Thk Medicajl Puss. 177

a sure and rational basis for the practice of the healing
art. There certainly seems to be a danger that while
the British Medical Association is undoubtedly attract¬
ing to its annual gatherings those who are keenly in¬
terested in what may, without discredit, be termed its
“ trade union ” matters, those caring little for medico-
ethical and medico-political discussions, but deeply
concerned with scientific research and pathological
progress, are quietly dropping their adherence and
silently ceasing to take their part. Certainly in the
recent meeting some of the best-known scientists and
experts in medical science in this country were con¬
spicuous by their absence. If this lapse of the
scientific side of the annual meeting is to be allowed
to continue, medical science will suffer incalculable loss.
It is clear that there is need for special encourage¬
ment and thorough organisation. The work of the
Sections requires to be arranged with greater care.
Discussions should be planned with discrimination,
and thcee specially qualified to take a useful part
should be individually invited. Papers should be
printed in advance. A Manual of Abstracts of all
papers to be presented should be available a week
before the meeting commences. It should be per¬
missible for an author to arrange for the publication of
his paper whenever he thinks fit. And perhaps most
important of all, the scientific work should be collected
and published in a special single number of the Asso¬
ciation's Journal immediately after the meeting.
These are not impossible suggestions, and if carried out
they would go far to increase the real scientific value
and general instructiveness of the meeting, without
impairing its social enjoyments or robbing it of its
justifiable picnicking.

The Pathological Collection.

Undoubtedly the most valuable feature of the
Exeter Meeting was the very admirable Pathological
Museum. Last week we were only able to refer to
some few of the exhibits. Where every specimen pre¬
sented points of interest it is extremely difficult to
particularise. The catalogue provided was excellent,
but it needed an index and lacked a conveniently
arranged list of exhibitors. ►

A particularly helpful section was that por¬
traying morbid affections of the skin. Mr. Jonathan
Hutchinson sent a series of photographs and
water-colour drawings illustrating various forms
of cutaneous disease. Dr. David Walsh ex¬
hibited some particularly interesting photographs
showing a frontal band area devoid of long hair or
sparsely-haired or pencilled with a thin rim of hair,
on one or both sides of the forehead, in cases of enlarged
thyroid, and patients with potential Graves’ disease
and other somewhat allied affections. He also showed
interesting water-colour drawings and photographs of
generalised condylomata following primary infection
of the left side of the upper lip.

Other valuable skin exhibits were made by Dr. P. S.
Abrahams, Dr. B. H. Spilsbury, and the London
School of Clinical Medicine. Dr. A. Moritz and Mr.
P. B. Tubbs furnished a beautiful series of colour
photographs of syphilitic and other lesions, taken by
the Sanger-Shepherd process.

A feature of particular interest to teachers of morbid
anatomy was Mr. G. Lenthal Cheatle's collection of
giant sections, invaluable for the instruction of the
student. Dr. William Hunter showed a number of
specimens illustrating the h»molytic, glossitic, gastric,
and intestinal infective lesions of pernicious anaemia,
which proved a valuable supplement to the discussion
on this subject held in the section devoted to pathology.

It is quite impossible to mention anything like all
the exhibitors, but we may note that preparations
of particular interest were shown by Professor W r alker
Hall, Dr. F. W. Mott, Professor Syminers, Dr. J.
Mitchell Clarke, Dr. T. Grainger Stewart, Dr. C. H.
Miller, Professor G. A. Wright, Mr. B. G. A. Moynihan,
and Mr. J. Bland-Sutton.

Many X-ray photographs of considerable clinical
interest were exhibited by Dr. Reginald Morton,
Mr. Rutherford Morison, Dr. J. Delpratt Harris,

Dr. W. Cheyne Wilson, and Mr. E. W. H. Shenton.
It should also be added that many specimens had
been lent by the Royal Devon and Exeter Hospital ;
the Faculty of Medicine, University College, Bristol;
the Royal Dental Hospital ; the London School of
Clinical Medicine, and other public bodies.

We have at least shown that the collection was
a thoroughly representative one. Its usefulness
would have been immeasurably increased if arrange¬
ments had been made whereby the various exhibitors
could have demonstrated their particular specimens
at set times. It is to be hoped that those responsible
for the Museum at next year’s meeting at Sheffield
will make special arrangements for lantern and
other desirable forms of practical demonstration of
the more important specimens, instruments and
photographs exhibited in the Pathological Museum.

We would suggest that those arranging for the
collection at Sheffield would do well to endeavour to
provide specimens and photographs of those particular
deformities and diseases which directly or indirectly
are connected with or in any way dependent on the
very special forms of employment followed by such
large numbers of the population in that great centre
of industry'.

Gatherings : Official and Non-Official.

The Association’s Annual Meeting furnishes oppor¬
tunity for numerous and varied gatherings, some
scientific, many social, both official and non-official.
A broad-minded spirit of tolerance, sympathy and
co-operation prevails, and such is to the general good.

On August 1st the Science and Education Com¬
mittee of the National Temperance League held its
annual breakfast, when some 160 members attended.
The Mayor of Exeter (Mr. W. H. Reed) presided,
and the president (Dr. Henry Davy), the Sherin of
Exeter (Dr. Ransom Pickard), the ex-president
(Dr. R. A. Reeve, of Toronto), Sir John Moore, Mr.
McAdam Eccles, Dr. A. T. Schofield. Dr. William
Odell, Dr. T. N. Kelynack, Dr. Basil Price, and Mr.
J. T. Rae (secretary of the National League) took
part in the proceedings.

The same evening the Annual Dinner of the Associa¬
tion was held under the presidency of Dr. Henry
Davy, when many toasts were enthusiastically
honoured, and numerous eloquent speeches delivered.

Also on August 1st the Continental Anglo-American
Medical Society held its annual luncheon, Professor
W. Osier being in the chair, with a representative
gathering of members and guests, including Dr.
T. McCrae, of Baltimore, Dr. F. M. Sandwith, Dr.
Newton Pitt, Dr. Ward Cousins, Dr. Galabin, Dr.
Watson Williams, Dr. T. N. Kelynack, Dr. Herbert
Tilley, Dr. Cholmeley, and many others.

The Irish Medical Schools’ and Graduates’ Associa¬
tion also gave a luncheon, and held their annual
summer meeting.

Numerous garden parties, receptions, private
luncheons, short tours, excursions, golfing and other
pleasurable pursuits were crowded into Exeter’s
record week.

Among the many who have earned the sincere
thanks of the Association and all its members, reference
must be made to the genial and indefatigable President,
Dr. Henry Davy, the alert and painstaking Hon.
local secretaries, Mr. Russell Coombe, Dr. Clapp and
Mr. Leonard Tosswill, and their numerous colleagues
and helpers, the organisers of the Pathological Museum,
Drs. Solly and Hawker. Indeed, to all our pro¬
fessional brethren in and about Exeter, and to the
civic authorities and citizens generally, we offer on
behalf of those who have enjoyed West Country
hospitality, a very warm expression of appreciation
and thanks.

The Annual Exhibition.

Owing to the necessarily condensed review of the
recent Exhibition at Exeter, we were unable to deal
as we could wish with certain preparations of particular
interest to medical practitioners. Prominent amongst
these the Nestis’s Anglo-Swiss Condensed Milk Co., Ltd.,

litized by G00gle

1 78 Tax MlDlCAL Pum.

MEDICAL NEWS IN BRIEF.

Auc. 14, tgo~.

showed specimens of their Infants’ Food, now well-
known under the name of “ Milo.” This food has
been produced in accordance with the strict physio¬
logical requirements of infant life.

A new Non-Irritant local anaesthetic “ Novocain ”
was shown by the Saccharin Corporation, Ltd., of
165 Queen Victoria Street, E.C. This agent is
being extensively employed for infiltration anaesthesia
as it is much less toxic than Cocaine and can be used
in conjunction with Adrenal products and is most
effectual for lumbar anaesthetics, and in Ophthalmic,
Dental and Naso-Laryngological work.

but by no means necessarily a danger. He concludes
by expressing his belief that it is by the study of
cellular pathology in its strictest sense that the surest
advance has been and is to be made in our knowledge
of this the dominating process in disease. Professor
Adams has been well advised in issuing in separate
form this contribution to the modern pathology
of inflammation. His observations shed a vast
amount of light upon a somewhat obscure subject.

Medical News in Brief.

REVIEWS OF BOOKS.

THE MIND AND THE NERVOUS SYSTEM, (a)
This volume adds still another to the valuable series
of works on general topics that have been given us
by the well-known Zurich psychiatrist. As might
have been expected, it is written in an interesting
style and from a broad standpoint. It aims at pre¬
senting the rules of mental hygiene that should guide
both the individual and society, and, as the author
holds that for a full comprehension of the rationale
of these rules, a fair knowledge of the mind and nervous
system is essential, he has devoted two-thirds of the
book to expounding the elements of normal and patho¬
logical psychology and physiology. The first section
on psychology is written in a popular way that should
increase its value to those medical men—unfortunately
only too numerous in this country—who have had
no training in this subject. The hygienic admonitions
are sound throughout and largely follow the lines laid
down in the author's larger work, “ Die Sexuelle
Frage.”

ADAMS ON INFLAMMATION. (6)

We presume that many of our readers are already
perfectly familiar with this monograph, which is
in reality an extension of the article on Inflammation
in Allbntt’s well-known System of Medicine. It is,
however, more complete and up-to-date. A fuller
descriptive account of Wright’s Opsonic theory is
given. Likewise Bier’s treatment of inflammation
by induced hvperjemia has received attention. As
regards the definition of the term inflammation, Adams
leans to that put forward by Grawitz, who maintains
that inflammation is the reaction of irritated and dam¬
aged tissues which still retain vitality. The mani¬
festations of this process, under favourable conditions,
are redness, swelling, heat and pain, to which Adams
adds a fifth, viz., disturbance of function. Under
unfavourable conditions all or nearly all of these
symptoms may seem wanting, yet a minute examina¬
tion of the tissues will show the same succession of
changes.

The comparative pathology of inflammation is
treated in an interesting manner, and a summary
of the results so far reached at present is given. In
the second part of this monograph the part played
by the leucocytes in this process is very fully and clearly
set forth. The chapters in this part of the book,
describing the varieties and classification of the leu¬
cocytes, their functions and properties, and the
theory of phagocytosis, are certainly, to our mind,
the most valuable of all, and will be read with great
advantage by every medical man who wishes to have
a clearer conception of these matters. The author’s
remarks on the nature of the inflammatory exudation
and the part played by the blood vessels and the
nervous system in the process are clear and precise.

A very suggestive and helpful chapter is that dealing
with the principles of treatment. The author shrewdly
remarks that inflammation is a danger signal^

(«) " L’Ame et le Syiteme Nerveux : Hygiene et Pathologic." By
Auguste Forel. 1906. Pp. 334. Paris: SteinhelL 5 tapes-
6 ) *• Inflammation: an Introduction to the Study of Pathology.
Being the Reprint (revised and enlarged) of an article in Professor
Allbutt's “ System of Medicine.” By George Adams, M.A., M.D.,
F.R.S., sometime Fellow of Jesus College, Cambridge; Professor of
Physiology, McGill University, Montreal. London: Macmillan and
Co., Limited. 1907- 3 *- net.

Second Intorwattonml Congrooa of Sch oo l Hyglaos

At the University of London Buildings on Monday,
August 5th, at 3 p.m., the Earl of Crewe, Lord President
of the Council, formally opened the Second International
Congress of School Hygiene. On the previous Saturday
an informal reception of the delegates had taken
place at the University, and also two invitation
receptions in the afternoon and evening respectively
by Lady Londonderry, at Londonderry House, and
by the Mayor of Westminster, at Caxton Hall. The
Congress was very well attended, remarkably so when
it is considered that a fortnight previously all the
foreign invitations were in a state of chaos owing
to the formalities that the Government offices insisted
on with a determination worthy of a better cause.
Most of the large and many of the smaller continental
countries were represented, together with many of
the Colonies and the United States, and a host of
municipalities, large and small, in Great Britain.
It may be taken as an indication of the world-wide
interest exhibited in the Congress that even Siam
thought well to appoint a representative. Lord
Crewe, after conveying a special message from the
King and a formal welcome from the Government,
proceeded to deliver one of those happy speeches
of which he is a past master and in which he threatens
to rival his brilliant father-in-law. Lord Crewe
had made himself well aware of the objects of the
Congress and the methods by which those objects
were to be pursued, and, speaking with ease and
freedom, he created an excellent impression. No
one who heard him was surprised that he had teen
chosen as the Government spokesman, though the
absence of Mr. MacKenna, as Minister of
Education, was much regretted. After Lord Crewe’s
speech. Lord Londonderry said a few agreeable words
to show that the interest in the question in political
circles is not confined to our side. Sir Lauder
Brunton then delivered his presidential address. He.
too, welcomed the delegates on behalf of the
Executive of the Congress, and told them how much
of the success of the undertaking was due

to the personal influence and interest of that
excellent diplomatist, the King. In an address, that
was directed as much to the public as to the audience
before him—for the great object of the Congress
is to awaken general interest in the subject of School
Hygiene—it was difficult for Sir Lauder to give those
evidences of the originality of his genius which he has
displayed in so many other fields, but his was a sound
common-sense speech, and one eminently calculated
to impress people with the idea that the question at
issue is a practical one, and not an exotic off-shoot
of the imagination or the silly creed of whimsical
fanatics. After his speech, votes of thanks to himself
and Lord Crewe having been passed with acclamation,
a telegram was sent to the King expressing the thanks
of the Congress for his interest. A conversazione
was held in the University buildings in the evening, and
on Tuesday the sections got to work. They met even-
day for papers, and such discussion as time permitted
on the papers from 10 a.m. till 2 p.m., but their work
was somewhat interfered with by the holding of a
general discussion each day at noon on some set
subject. On Tuesday this discussion centred on the
methods of the first and subsequent medical examina¬
tions of school children ; on Wednesday it concerned
the lighting and ventilation of classrooms; on Thurs-

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Aug. 14, 1907.

MEDICAL NEWS IN BRIEF.

Thi Medical Pm8i. 1 79

day, the school and its relation to tuberculosis, and
on Friday, the last working day, on school-work in
its relation to the duration of lessons, the sequence
of subjects, at this season of the year. In the evenings,
before and after dinner, there were lectures by eminent
men on school subjects, and a number of excursions
and visits to places of interest were organised by
various committees and individuals. We hope to
publish abstracts of some of the more interesting
and important papers in the course of the next few
weeks.

Exhibition of Buildings and Appliances.

Although the International Congress on School
Hygiene nas concluded its sittings, the exhibition of
school building and furnishing appliances organised
by the Royal Sanitary Institute will remain open at
London University, South Kensington, until to-day.
Taken collectively the exhibits brought together at
South Kensington appear to present many essentials,
from a hygienic point of view, for the equipment
of elementary schools. International in its character,
the exhibition shows in tangible form the movement
for improving the hygienic conditions of schools now
going on in so many countries. The features of the
various systems favoured by countries other than
our own in many cases are presented to the visitor
by means of illustrations merely. In part, however,
the exhibition consists of practical examples of school
building and furnishing appliances. All departments
of school hygiene are represented, ranging from building
materials, floor and wall surfaces, water supply,
drainage, sanitary appliances, warming, lighting,
and ventilating, to the details of equipment, furnish¬
ing, teaching and technical appliances, gymnastic
apparatus, and the accessories of the playground.
To the appliances attempting to solve the problem
of securing efficient ventilation without draughts
one will naturally turn between much of the restless¬
ness and inattention of which teachers complain
arises from the enervating effects of stuffy class-
1 ooms. There is much in the exhibition to encourage
hope of the problem, as applied to the schoolroom,
being successfully solved. Improved types of desks,
facilities for drying children’s coats, shoes, and other
apparel, and many more well-considered devices are
shown for minimising the discomforts of school life
and keeping children in health. In the grounds
forms have been erected, among other structures, a
handsome portable school pavilion of German make
and design which, with the model and photographs
of the Charlottenburg Forest School, presents many
features that may profitably be studied.

Cholera Nostras In St. Petersburg.

On August 9th there was a suspicious case of
death at St. Petersburg. A post mortem examination
has revealed the fact that death was due to cholera
nostras. Telegrams from Samara, however, state
that further fatal cases of cholera Asiatica have
occurred there.

Status Lymphatlcus Again.

At Islington Coroner’s Court on August 3rd,
Mr. Schroder held an inquest on the body of
William Percy Bishop, at. 17, an indoor servant at
Kensington, who died at the Great Northern Hospital.
Bishop had a swelling in the upper part of the nose
and went to the hospital to be operated upon. Dr.
A. C. Brown, senior house surgeon, said that the opera¬
tion took place, Dr. Rubra being the anassthetist and
Dr. Gay French, of St. Mary's the surgeon. The
first incision had just been made in the nose when
Bishop became white, and both operation and anaesthe¬
tic were stopped, but he died about two minutes
later in spite of the efforts to revive him. The witness
made a post mortem in the presence of Dr. Willcox,
°f St. Mary’s, the Home Office expert. The post
mortem revealed an enlarged thymus gland, a most
unusual thing for a lad of 17. There was also an
adenoid growth in the nose. Death was due to syn-
Sppe caused by his condition from status lymphaticus.
ihis condition could not possibly be_diagnosed and

could only be found in the present condition of medical
knowledge after death. Dr. Rubra said he gave
less than two drachms of chloroform and ether. The
disease was receiving very careful medical attention
at the present time. He had administered anaesthetic
in over 10,000 cases. Dr. Brown, recalled, said
status lymphaticus meant that certain glands secreted
some fluids which acted as a poison, and evidence
of this was found in several organs. There had been
a very similar case some time ago in the West-end,
that of a young baronet. A verdict of “ death by
misadventure ” was returned.

An UnltrtHMto Accident.

An inquest was held in Sheffield on August 12th
on Mrs. Elizabeth Carlisle, the widow of a Sheffield
ivory cutter, whose death was due to carbolic acid
poisoning. The deceased's doctor, it was said, had
several times taken to the house a small quantity
of carbolic acid for use as a disinfectant. One morn¬
ing, being in a hurry, he did not prepare the solution,
but left the acid behind for Mrs. Carlisle’s sister to
mix later. Before she did so, however, the servant
gave Mrs. Carlisle her medicine and inadvertently
added a teaspoonful of the poison. A verdict of
“ Accidental death ” was returned.

Qaoeral Mid wives’ Beard.

During the August sittings of the Examiners one
hundred and thirty-one candidates were successful.
Of these, the largest number were trained at the
Maternity Charity, Plaistow; the General Lying-in
Hospital, Queen Charlotte’s Hospital, and the Salvation
Army Maternity Hospital were also large contributors.
Other candidates had undergone training at the
Rotunda, Dublin, the Edinburgh Royal Maternity
Hospital, Brighton Hospital for Women, etc., whilst
a considerable number had attended the classes of
Dr. St. Aubyn-Farrer and Dr. A. B. Calder.

Tbt AHtymynydd Sanatorium.

A meeting of the executive of the West Wales
branch of the National Society for the Prevention of
Consumption was held at the Carmarthen Guildhall
on August 2nd, Mr. E. Trubshaw, of Llanelly, pre¬
siding. Dr. Douglas Reid, of Tenby, referring to
the main object of the meeting—the consideration of
the steps which should be taken to provide funds for
the sanatorium at Alltymynydd, near Llanybyther—
suggested that, in order to maintain the 20 beds
there, the counties of Carmarthen, Cardigan, and
Pembroke, should be divided into 20 districts, each
of which should be responsible for a bed. He pre¬
sented two alternatives, that there should be eight
or ten districts in Carmarthenshire, six or five in
Cardiganshire, and six or five in Pembrokeshire.
The yields of the counties in the above order, if each
person gave a penny a year, would be £67 10s., or
£54 ios. per annum, with a population of 130,000.
£.43 or ^52 with a population of 62,000, and £62 10s.
or £ 7 5 with a population of 90.000. If possible,
patients should pay a small weekly sum. In the
event of fewer districts for each county, a few beds
could be kept for the paying patients. A district
which did not collect the sum required should not
have the nomination to a bed. After a discussion,
the executive decided to issue circulars to all likely
subscribers in the West Wales counties.

University of London—The Rogers Prize.

Under the will of the late Dr. Nathaniel Rogers,
the Senate offer a prize of ^100, open for competition
to all members of the medical profession in the United
Kingdom, for the best essay or dissertation setting
forth the results of original investigations made by
the candidate on any medical pathological subject
during the preceding two years. Candidates will be
permitted to present papers published during the
preceding year as the dissertation. The essay or dis¬
sertation. by preference typewritten or printed, must
be sent in not later than May 1st. 1908. addressed to
the Clerk of Committees, University of London, South
Kensington.

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WEEKLY SUMMARY.

Aug. 14, 1907.

l 80 The Medical Pxzss. - •

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled lor The Medical Press and Circular.

RECENT MEDICAL LITERATURE.

Treatment of Syphilis by Intramuscular Injections
of Mercury. —Lambkin {R.A.M.C. Journ., July,
1907) suggests a new preparation for use in this
method of treatment. Hitherto the difficulty has
been to find a vehicle which would remain aseptic,
and at the same time be soluble in the organism.
Glycerine, gumwater, olive oil, vaseline, oil of vaseline,
and lanoline have all been used to hold the mercury
in suspension, but each and all of them are open to
considerable objections. For the past eighteen
months Lambkin has been using palmatin as a vehicle.
This is a neutral fat derived from palm oil, and having
the same chemical composition as the palmatin of
the human body. The advantages claimed for it are
that it is non-toxic and non-irritant; it is as easily
oxidised as the other compounds of human fat; being
a normal constituent of the human organism it is
easily saponified and soluble therein, and does not
enter the circulation as a foreign body ; as a vehicle
it makes a more homogeneous preparation for in¬
jection than any other, and its melting point can
be raised and lowered with the greatest facility. In
order to obviate the pain which is a serious objection
to the injections, especially when calomel is used,
Lambkin suggests the use of a combination of pure
creosote and camphor. The formulae of the two
mercurial creams which Lambkin is now using are
as follows:—Hydrargyrum pur., 10 grammes;
creo-camph., 20 cc. ; palmatin basis to 100 cc. ;
10 m. equals metallic mercury one grain. Calomel,
5 grammes ; creo-camph, 20 cc. ; palmatin basis to
100 cc. 10 m. equals one half grain of calomel.
Each cream has a melting point of 37X. The creo-
camph. consists of equal parts of absolute creosote
and camphoric acid. Each of the creams can now
be obtained from Messrs. Oppenheimer in aseptules
graduated to hold a maximum dose of 15 m.

K.

Acute Dilatation of the Stomach. —Telford (The
Med. Chronicle, July, 1907) records a case of this
rare condition which ended fatally in three days.
The patient, a boy, set. 16 years, was suddenly seized
with severe colicky pains in the upper part of the
abdomen. These pains persisted for about thirty-six
hours, when he began to vomit large quantities of
reddish yellow fluid. The vomiting persisted, and
there was no motion of the bowels, although some
medicine had been taken. The boy left his bed
with the intention of going to stool, and on his return
was found to be in a very collapsed state, and died
in a very few minutes. The patient had not been seen by
a medical man before his death. At the post-mortem
examination the stomach was found to be very con¬
siderably distended, and contained six pints of fluid
of a similar nature to that which was vomited before
death. The stomach walls were deeply congested,
and on them there were many submucous haemor-
hages. The first and second parts of the duodenum
were involved in the distension, and the pyloric
ring was scarcely perceptible. The remaining part
of the intestines were collapsed and empty. The
distension of the duodenum ceased abruptly at the
point where the gut is crossed by the mesenteric
vessels, but Telford was unable to assure himself
that the gut had been constricted by these vessels.
It was ascertained that the boy had had six similar
attacks at various intervals during the three days which
preceded his death. K.

The Influence of Heredity In the Prognosis of
Phthisis. —Von Ruck (Amer. Journ. Med. Sciences,

August, 1907) investigates the commonly received
opinion of the unfavourable influence of tuberculous
ancestors on the prognosis in cases of phthisis. It
has recently been suggested that the old idea is not
correct, and that the children of tuberculous ancestors
enjoy a partial immunity from tuberculous infection ;
and even when infection does take place the prognosis
is better than in those not so protected. \ on Ruck
gives the figures of Turban and Weicker in support
of this hypothesis, as well as the records of the
last 1,415 cases treated at the Winyah Sanatorium.
Of these patients 31.11 per cent, showed a history
of tuberculous ancestry. Of those discharged cured,
and of those discharged improved, 32.16 and 31.5 per
cent, respectively had an hereditary taint, while of
those who failed to improve or got worse only 25.13
per cent, gave such a history. The numbers are not
sufficiently large to warrant any dogmatic conclusions,
but the indications point in favour of the view that
the mere fact of a tuberculous family history need
not, in any individual case, diminish the patient’s
chance of recovery. K.

The Cause of Sea-Sickness. —Lund ( Practitioner,
August, 1907) investigates the cause of this condition,
and comes to the conclusion that the stimulus which
causes the vomiting reaches the brain through the
auditory nerves. He does not believe that the organ
of vision transmits the impulse as blind people are
found to suffer from sea-sickness to a greater extent
than those who can see. Thus sixty per cent, of the
pupils of the Liverpool School for tne Blind suffer
from the complaint, and another twenty per cent, are
uncomfortable when taking a sea trip from Liverpool
if the sea is at all rough. He has found, however,
that deaf mutes never suffer from sea-sickness, nor
do they experience that sensation in the stomach once
described as a momentary displacement of the viscera
to which most of us are liable when descending in a
lift. Lund concludes that there is some mechanism
in the auditory organ, possibly the system of semi¬
circular canals, which is directly affected by the
oscillations of a vessel at sea, and which acts as a
stimulus to the vomiting centre. It is conceivable
that these sudden movements may create in the
endolymph in the semicircular canals a condensation
or rarefaction, or both alternately, thereby altering
the pressure on the nerve endings and causing a
direct stimulus to vomit. K.

The Mongolian Pigment Spots. — Brennemann
(Archives of Pediatrics, June, 1907) deals with the
occurrence of these spots in the infants of the American
negroes. In the sacral or sacro-gluteal region of
nearly all Mongolian children are found one or more
well-defined distinctly blue or greyish-blue spots
varying in size from that of a small coin to that of an
expanded hand. These spots may be found in 97 to
98 per cent, of such children up to two and a half
years of age, and in 10 to 12 per cent, after four
years, and only rarely after the fifth year. For some
time the condition was looked on as a racial character¬
istic of the Mongolian, but Adachi has shown that it
it also occurs, though more rarely in the children of
other races. Brennemann has examined forty coloured
children under one year of age, and has found the
spots well marked in thirty-five of them. In older
children it is impossible in the majority of cases to
decide whether a spot is still present or not; but in
the younger children there is no such difficult}'
Brennemann is inclined to look on this pigmentation,
as a persistence in a rudimentary form of what was

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Aug. 14. 1907 -

WEEKLY SUMMARY.

Thf Mkhtcal Pkxss. 18 1

once a more wide-spread and functional layer of
pigment such as exists in certain monkeys; but
why the remnant should favour the sacral and adjoin¬
ing regions when there is no such tendency in monkeys,
he is unable to explain. It is, however, obvious
that we can no longer consider these spots as exclusive
race characteristics. K.

Kuhn's Lnng Suction Mask lor Hyperemia Treat¬
ment of the Lungs. —Kuhn’s (Mun. Med. Woch., 1907)
mask consists of a celluloid cap to cover mouth and
nose, which renders inspiration difficult, while ex¬
piration proceeds unhindered. This induces hyper-
aemia in the air passages and lungs. Kuhn’s expe¬
rience at Von Leyden's clinic has been decidedly
favourable, and Stolzenburg also reports great benefit
from the use of the mask in 24 cases of pulmonary
tuberculosis. It not only relieves the patients sub¬
jectively, but exerts a favourable influence on the
morbid process. He adds that it is perfectly harmless.
Kuhn found in 16 patients that the number of reds
increased by a million after one hour’s use of the mask,
while the whites increased by one thousand. He has
used the mask further in five cases of fibrinous pneu¬
monia and the disease assumed a very mild course.
In a case of severe asthma, the patient, a woman, has
been free from attacks for the first time for years since
she has been systematically using the mask. D.

Acid Intoxication, a Factor in Disease. —Talbot
{Med. Record, June, 1907), in investigating the cause
of erosion of the teeth, has collected tests of the total
acidity of the urine of a large number of patients.
He believes that excessive acidity of the urine is asso¬
ciated with interstitial gingivitis and is an indication
of faulty metabolism. D.

-4

The Diagnosis 0f Pyelonephritis Based on the
Abnormal Retention and the Delayed Excretion of
Methylene Blue. —Beer (Journal of the American
Med. Assoc., June 8th, 1907), in a preliminary com¬
munication, publishes the histories of two cases which
seem to point to a new diagnostic sign of the involve¬
ment in suppuration of the kidney parenchyma. In
the first case, the patient discharged methylene blue
stained pus in the urine at intervals up to two and
three-fourth years after the last administration of the
drug. The second patient had pyelonephritis (verified
bv nephrotomy) and recurrent discharges of methylene
blue stained pus over a month after the last admini¬
stration of the drug. He produced pyelonephritis in a
dog and then for several days administered methylene
blue. The kidney was removed two days later, and
after treatment with oxidizing agents, showed mul¬
tiple bluish-grey foci throughout its substance. He
summarises his conclusions derived from the facts so
far as follows : (1) There is no differential diagnostic
sign between simple pyelitis and pyelonephritis.
(2) Pyuria from the upper urinary tract may be due to
either of these conditions. (3) By use of the above
described methylene blue test it would seem that a
differential diagnosis may be made. (4) Methylene
blue is deposited in the parenchymatous abscesses and
may be stored in these for years. (5) A late discharge
of methylene blue, bound to the pus. is indicative of
the rupture of such parenchymatous abscesses into
the pelvis of the kidney, and is consequently diagnostic
of pyelonephritis. D.

The Examination of tbe Heart in the Trendelenburg

Position.—'The examination of the heart with the
pelvis elevated possesses, according to Stem (Mun.
■ied. Woch., 1907) the following advantages : (1) The
percussion of the right border becomes easier ; (2)
doubtful systolic murmur at the apex becomes more
^dent or disappears ; (3) the presystolic murmur in
roitral regurgitation complicated with stenosis is more
readily detected. D.

The Action of Atoxyl upon Syphilis.— Uhlenhuth, 1

o“man, and Rorcher (Deut. Med. Woch., 1907) report |

a series of eleven cases of syphilis treated by atoxyl
and conclude that it has an unmistakable good effect
when used in sufficiently large doses ; it is especiallv
beneficial in the malignant forms. They injected intra¬
muscularly ten cases with a 10 per cent, solution, and
one with a 15 per cent, solution. The injections were
of .2 to .6 gm. every two days at first, later every three
days. It caused no local disturbance. It makes a
very important addition to our means of combating
syphilis in those cases which have an idiosyncrasy
against the mercury and iodide treatment. D.

New Investigation on the Dorsal Foot Reflex.—

Lissman (Mun. Med. Woch., 1907). The dorsal foot
reflex consists in the movement of the toes on tapping
the outer part of the dorsum of the foot with a per¬
cussion hammer. Normally the toes (excepting the
great toe) are extended, but in disease plantar flexion
may occur. Lissman confirms the observations of the
two describers of the reflex, finding it positive (i.e .,
plantar flexion) only in cases with positive Babinski’s
sign, and absent altogether in anterior poliomyelitis.
He also found in infancy the reflex positive in all cases
with positive Babinski. The significance of this sign
is therefore identical with that of Eatinski’s, indi¬
cating (except in infants) disturbance of conduction
in the pyramidal tract. D.

Tuberculosis and Heredity.— With a view of testing
the doctrine of the hereditary' transmission of tuber¬
culosis, Hagen (Johns Hopkins Hospital Bulletin,
August, 1907) has examined the condition of certain
families, of each of which two or more members
were attending the Phipps Dispensary. In all 83
families were examined, containing a total of 534
individuals. Of these 254, or 47 per cent, were tuber¬
culous, and 13 were suspicious. In 62 per cent- of
the tuberculous cases there was no tuberculosis in
the immediate ancestors, 43 per cent, of those
exposed to marital infection became infected, while
only' 38 per cent, of those exposed to parental in¬
fection developed the disease. Only three persons
of tuberculous stock developed the disease when not
in association with their families. There were eleven
well marked instances of house infection. In fifteen
instances one or both parents had the disease, while
the children were entirely well. Hagen’s conclusions,
therefore, are entirely opposed to the doctrine of
hereditary' transmission. Moreover, as his families
were selected definitely on account of the large number
of infections occurring in each, one would expect in
them, if anywhere, to find evidence in favour of
hereditary' influence. On the other hand, he believes
that “ infection acquired by long continued and inti¬
mate association plays the only role in the transmission
of pulmonary tuberculosis.” R.

Manchester University.

At the Graduation ceremony last week the following
were recipients of degrees :—

Degree of Master of Science .—Harry Andrew, George
Henry Kenyon, Frederick William Dyson Marshall,
and Charles Watson Moore.

Degree of Master of Surgery .—Arthur Ralph Thomp¬
son.

Degrees of Bachelor of Medicine and Bachelor of
Surgery .—Thomas Wingate Todd, first-class honours ;
John Arnold Fairer, second-class honours; Frank
Hartley, second-class honours ; Robert Lakin, second-
class honours ; John Webster Pride, George William
Bury, Harold Coppock, Daniel Irving Dakeyne, James
Fleming Dow, Frederick Hall, Vasantrio Dinanath
Madgavkar, Peter Moran, Wilfrid Nightingale, Alice
Oberdorfer, George Rainford, Robert Robertson,
Douglas Rodger, Elsie Marsh Royle, Vincent South-
well, Gilbert Bertram Warburton, Henry Whitehead,
and Norman Reginald Williamson.

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Original Articles or Letters intended for publication
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Esperanto. —The address of the Esperanto headquarters is
Arundel Street, 8trand, W.C. You had better applv to the
Secretary, as he will probably be able to say whether anv
medical books are published in Esperanto. We do not know of
any.

Qtm.—T he founder of the system known as " Swedish Gym¬
nastics’ was one Henrik Ling, a university fencing Master
at Lund, Sweden. He founded the Central Gymnastic Institute
and published a large book on " General Principles of Gymnas¬
tics.” Ling was born in 1776, and died 1834. He was sue-
ceeded and his methods developed by Gabriel Branting (1799-1881)
and his own eon, Hjalmar Ling (1820-1886).

THE GREAT PEPPERMINT CURE.

Renders who are unacquainted with the recondite properties
of peppermint will be surprised to learn, from the following
•eitraot from the Financial Ne its, the amount of commercial
value they represent: —

” W. E. Woods Great Peppermint Cure Company.—Julv 30.
£20,000 (£1). To adopt agreements (1) with the W. E. Woods
Great Peppermint Cure Company, Limited (registered in New
Zealand), and W. E. Wooda; (2) with H. T. Tompsitt and S.
Fripp; and (3) with 8pottiswoode, Dixon and Hunting, Limited,
to pay to the said New Zealand Company royalties on sales bv
this company of ’’ Peppermint Cure,” and to carry on the business
of pr>prietors and manufacturers of and dealers in patent medi¬
cines, etc. No initial public issue. First directors (not less
than three nor more than five): J. P. Humphris, W. E. Wood
nnd R. St. J. Hughes. The said New Zealand Company may,
while holding £5,000 shares, appoint a permanent director, the
said W. E. Wood being its first nominee. Qualification (except
permanent director). 250 shares, £100 each per annum. 57
Moorgate Street, E.C.”

H. N. T.—The routine administration of potassium iodide in
cases where excess of mercury has been taken is not unattended
with danger, at by releasing the metal from the tissues it passes
into the circulation, and may considerably aggravate the
symptoms.

Ethical.—W e cannot undertake to recommend particular dis¬
infectants, as such advice is out of our province, but vou may
take it that the advertisements of such ns are admitted to the
columns of reputable medical papers are nil pretty efficient and
the makers will gladly supply you with literature concerning
them. 8

Uaomnes.

Bailbrook House, Bath.—Medical Superintendent. 8alary £450
per annum, with board for self and wife if married fur¬
nished quarters, laundry, attendance. Applications to
Herbert Coates, Secretary, 49 Broad Street, Bristol

North Lonsdale Hospital, Barrow-in-Furness.—House Surgeon
Salary. £100 per annum, with board and lodging. Applica¬
tions to the Secretary, North Lonsdale Hoepital, Barrow-in-
Furness.

Egyptian Government.—Kasr El Ainy Hospital.—Resident Medi-
cal Officer. 8alary, £250 a year, with quarters, servants
washing, coal, and light. Applications to The Director-
General, Publio Health Department, Cairo.

Egyptian Government.—Ministry of Education.—School of Medi¬
cine, Cairo.—Assistant to the Professor of Pnthologv
Salary, £E.320 per annum. Applications to The Director’
Government School of Medicine, Cairo, Egypt. ’

_Aug.~ 14, 1907 .

Roy p. , S ? uth _® ants and Southampton Hospital .-Howe

Physician. Salary, £100 per annum, with rooms, board

LoiivhWn'ih 11 *' , A PP licati °n8 to T. A. Fisher Hall, Secretarv!
Loughborough and District General Hospital and Dispensarv.-

rSf H ° USe ? urg f° n - Snlnr y- £m a year, with fur-

rinn.Th!?®' t bo “ rd ’ and "ashing. Applies-

tions to Thos. J. Webb, Secretary.

Glasgow District Asylum, Woodilee, Lenzie.—Assistant Medienl
Officer. salary, £135 per annum, with board, lodging,
"7' : "8” e,c ; Applications to the Medical Superintendent.
Worcester County and City Asylum.—Assistant Medical Officer.

Powick Worcester " nnuln- Applications to Superintendent

Devon County Asylum.—Assistant Medical Officer. Salary £U0
per annum, with board, apartments, and laundry. Applies-
« *° the Medioal Superintendent, Exminster.

Rochdale Infirmary —Kousc Surgeou. Salary, £100 per annum,
with board, residence, and laundry. Applications to Henry
Booth, Secretary. 58a Yorkshire 8treet, Roohdale.
The oS2- vft ' ic,orla Hospital, Dover.—House Surgeon. Salarv,
£100 a year, with board, lodging, and washing. Applica-
tions to the Hon. Secretary, Arthur B. Elwin, Esq., 2
Castle Street, Dover. ^

York County Hospital.—House Surgeon. 8alary, £100 per annum,
with board, residence, and washing. Applications to Fredk.
Neden, Secretary and Manager.

County Asylum, Prcstwich, Manchester.—Junior Assistant Medi¬
cal Officer. Salary, £150 per annum, with board, furnished
apartments, and washing. Applications to the Medical
Superintendent.

Royal Albert Hospital, Devonport.—Resident Medical Offloer.
Salary, £100 per annum, with apartments, board, fuel and
lights, and laundry. Applications to the Chairmnn of the
Selection Committee at the Hoepital.

County Borough of Northampton.—Medical Officer of Health.
Salary, £400 per annum. Applications to Herbert Hankin-
son, Town Clerk, Guildhall, Northampton.

5ppoiittmcnt£.

Senthall, Albert, F.R.C P.Edln., M.R.C.8.Eng., under the
Workmen’s Compensation Aot, 1906. a Medical Referee for
Circuits Nos. 40 and 42.

Burton, C. F„ M.R.C.8.Eng„ L.8.A., by the Shipping Federa¬
tion, Examining Officer of Seamen at Whitby under the
Compensation Act.

Davidson, Thomas, M.B.Edin., House Surgeon at the Stockton
and Thornabv Hospital.

De Souza, D. H., M.B., B.S., B.8 c.Lond., Demonstrator in
Physiology at the University of Sheffield.

Gouoh, A., M.B., Ch.B.Leeds, House Surgeon at the General
Infirmary, Leeds.

Greenwood, F. G., M.B.Cantab., House Physician at the
General Infirmary, Leeds.

Rodriquks, N. Joseph, L.R.C.P. and S.Edin., Assistant House
and Visiting Surgeon to the Stockport Infirmary.

Tinlet, W. E. F., ja.D.Durh., Certifying Surgeon under the
Factory and Workshop Act in the Whitby District.

Walxer, M. G. L., M.B., Ch.B.Leeds, Junior Resident Ophthal¬
mic Officer at the General Infirmary, Leeds.

jCitths.

Coltart.— On August 4th, at 714 Fulham Road, London, the wife
of Guy H. Coltart, M.B.Lond , M.R.C.S., L.R.C.P., of twins
(son and daughter).

Coo per. —On August 6th. at 87 Great Portland Street, the wife 0
A. Tanner Cooper, M.R.C.8., L.R.C.P., of a son.

JfiarriaguB.

Munro— MacLeod. —On August 7th, at St. James's Church,
Wcstend, Southampton, Ranald Martin Cunliffe Munro, BA.,
Barrister-at-Law, of Queen Anne’s Mansions, son of the late
Major-General A. A. Munro, Bengal Staff Corps, of Wood-
side, Frant, to Norma, daughter of Colonel Kenneth
MacLeod, M.D., LL.D., Indian Medical Service (retired),
Honorary Physician to H.M. the King, and of Mrs. MacLeod,
Duncaple, Westend.

Philip — Ktd. —On August 8th, at Rosebank, Aberdeen, James
Farquhar Philip, M.D., Ealing, son of the late Rev. William
Marshall Philip, M.A., minister of Skene, to Isabella Caith¬
ness, daughter of Thomas Kvd, resident manager at Aber¬
deen of the Northern Assurance Company.

Ramsdbn-Wood—Wilkinson.— On August 6th. at Cookshire
Quebec, Norris, eldest son of W. E. Ramsden-Wood, M.D., of
Waterside, Uplyme, Devon, to Eva Mllllcent only child of J
Wilkinson. Eaq,,of Cookshire, Quebec.

Bcaths.

Bennett.— On August 8th, at Blmpert House, Shaftesbury,
Elizabeth Louisa, widow of W. H. R. Bennett, M.R.C.S.,
L.R.C.P.

Buntino. —On August 7th, at Earlham, Torquav, Agnes Selina
(Chaplin), the wife of James Bunting, M.R.C.8.l£ng.

Kallky.— On August 8ih, atCampo Verde. Edit-burgh, Sarah Foul ton
Kuliev, beloved wife of the late Robert Reid Kalley.il .D., Madeira
and Brazil.

Kennard.— On Angust 2nd, at Bloomfield House, South Lyn-
combe, Bath, Thomas Atherton Kennard, M.R.C.S., (late of
Kempsey, Worcester), in his 74th year.

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The Medical Press and Circular.

•SALUS POPUU SUPREMA LEX."

Vol. CXXXV. WEDNESDAY, AUG. 21, 1907. No. 8

Notes and Comments,

The value of the medical referee
The Medical under the Workmen’s Compensa-
Refcree tion Act, 1906, was demonstrated
Begins. signally before the end of the first
month that the measure came
into force, by an incident in the Birming¬
ham County Court. A workman had been injured
in the head at some bedstead works, and been paid
compensation ; but after some time the firm thought
him fit to resume his duties. The medical man con¬
sulted by the workman’s solicitor did not take the
view of the firm’s medical man, and the question
was put by the court to the medical referee. This
gentleman, after examination, certified that the
workman’s pain and giddiness were not attributable
to the accident, but to his being out of work and
indulging in excess of alcohol. Under these cir¬
cumstances the judge naturally stopped the pay¬
ments. Before the employment of referees such a
case as this would have been fought out in Court,
and besides the waste of time and money, it is just
as likely as not that the judge would have given a
wrong decision. The whole question in these cases
turns on the medical aspect of the case, and no one
but a medical man is able properly to judge of that.
We venture to expect that if the medical referees
are freely employed at first by the County Courts,
the bogus claimant and the adventurous soli-'
citor will find the Act is not such a soft thing for
them as they anticipate. Under the old Acts, as is
commonly known, malingering and fictitious in¬
juries were commonplace scandals, which had only
too much chance of encouragement if they went to
court.

With a little observation and in-
^ genuity it was quite possible for a

Valuable sharp workman who preferred
Knee. half wages and nothing to do to
full work and full wages, to make
a comfortable living out of some old injury. All
that was necessary was to obtain employment, work
for a week or two, and then have an “ accident ” to
the old place. The employer was then bound to
pay till he got tired. A notable story' of an alleged
professional claimant was told at West Ham Police
Court the other day, when a man was charged with
obtaining money by false pretences from a confec¬
tioner. It was said that this man had a very profit¬
able knee, which every six months or so was served
up in a claim for damages against some local
tradesman for having a defective cellar-flap or
pavement-light which tripped up the owner of the
knee. A tobacconist gave evidence of parting with
£33, a caterer £6 in cash, the doctor’s fees, and
£1 in goods, and a tailor £$o in about 18 months,
all for the same knee and for similar accidents.
All medical men know the difficulty of resisting

a claim where there is a definite lesion involved,
even though convinced that it has little or no rela¬
tion to the accident. It may now reasonably be
hoped that in workmen’s compensation cases, at
any rate, the medical referee will be able to put a
stop to much misplaced ingenuity.

The dislike and distrust of the out-
Houislow patient department is growing, if

aid not on every hand, at least in

Out-patleati. many quarters, and the battles

that are being fought against hos¬
pital abuse certainly centre round that institution
as the worst offender. At Hounslow the medical
men attached to the hospital appear to have taken
the decided ground that the out-patient department
is more abused than legitimately used, and conse¬
quently they have intimated that they propose to
withdraw giving their services to it at the end of
the year. The subscribers who are privileged to
give’away four out-patient letters in return for a
guinea subscription wish to continue the depart¬
ment, and it will be interesting to see if any work¬
able arrangement can be arrived at. There seems
to be no doubt that the subscribers have been ex¬
ceedingly indiscreet in the way they have given
their letters away, and have thereby not only de¬
prived medical mien of their fees, but have by
their action directly discouraged thrift. I)r.
Gordon, of Hounslow, asserted in a recent interview
that there is absolutely no need for an out-patient
department, and that the medical men are deter¬
mined that it shall cease, at any rate, as far as
abuse is concerned. The subscriber who uses his
hospital letter as a cheap form of patronage, and
not as a public trust, is, alas ! only too well known,
and it is high time that he should be brought to
realise his responsibilities.

At the end of last month a letter
Lord Curzoo written by Lord Curzon to one of
aid those correspondents who ask such

tbe Plague. convenient questions of public men
was published in a Chester paper
and republished in the Times. In this letter the
ex-Vicerov pilloried certain statements made by a
Socialist orator that the British administration in
India is responsible for the plague, and the Indian
Government only exerted “ puny efforts ” to combat
the scourge, as “grossly mendacious and ignorant.
His Lordship asserts 'that the Government have
conducted an “unrelenting campaign” for nine
years, but that their efforts had been confronted
throughout with appalling ignorance and super¬
stition, and that the question often resolves itself
into one, not of scientific method, but of adminis¬
trative expediency. A very pertinent reply to this

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184 The Medical Press.

LEADING ARTICLES.

Aug. 21, 1907.

claim was made a few days subsequently in the
columns of the Times by Dr. F. Fremantle, a late
Plague Medical Officer in the Punjaub, who pointed
out that though the Indian Government certainly
undertook measures of some magnitude to combat
plague in the early stages of the epidemic, they
left undone the most important thing of all, namely,
the .scientific investigation of the cause of plague-
spread. The Government have now got together
some investigators—a small band—to try to work
out this vital point, but it is obvious that this should
have been the first step, and not the last. Public
health measures are so absolutely dependent on
exact scientific knowledge that it is often more than
useless to carry out heroic campaigns against the
most patent dangers, unless accurate information as
to their remedy is previously obtained.

In our last issue we published a
Jodje Milligan letter from a correspondent,
aid Defct “B. L.,” on the subject of Judge
Collectilf. Mulligan and debt collecting.

Much of what he therein said is
both true and to the point, and we would most
heartily associate ourselves with him in his
remarks about imprisonment. In theory, imprison¬
ment for debt in the case of those able but not
willing to pay is, of course, justifiable; in practice,
it is one of the worst blots on our civilisation. Those
who, like ourselves, have studied the question,
must we believe hold the very idea in horror, so
inequitably and so cruelly does the system operate
in practice. The point which we would criticise
in his letter, however, is where he speaks of the
appearance of the debt collector in court. As our
information goes, the debt collector is, to all intents
and purposes, the principal in the matter—he proves
the debt by means of producing a written acknow¬
ledgment of liability from the debtor. A County
Court judge has discretion to hear whom he likes,
but he can refuse to hear anyone except a party in
person or his legal representative. Now, it has
been found in petty debt collecting that by a sim¬
plification of machinery, sanctioned by custom, the
small debtor gets off much more easily than by em¬
ploying the full legal process, and the creditor is
much more likely to come by his own. If abuse
were shown we should be prepared to modify our
views, but as we read the case his Honour is insist¬
ing on the pedantic employment of the full legal
machinery, and thereby stultifying ,the ends of
justice.

LEADING ARTICLES.

SOME INDUSTRIAL DANGERS.

The Annual Report of the Chief Inspector of
Factories and Workshops, which was noticed
in these columns some months since, contains a
great deal of matter of medical and of medico-
social interest. Now that the responsibility of
the employer is fully recognised, the com¬
munity is to a great extent relieved of the cost
of supporting the sick and wounded of the in¬
dustrial army. It is only by an efficient system
of skilled inspection that the workmen will ensure
a proper protection and employers will be able
to reduce accident and trade diseases to a mini¬
mum. The Report of the Chief Inspector, Dr.
Whitelegge, for the year 1906, bears testimony
to the thoroughness with which an enormous
mass of detailed information has been collected
and dealt with. There were in all 255,189 works

inspected, employing in factories 4,150,000 persons,
in workshops 700,000 and in laundries ioo.cco.
The Certifying Surgeons, for medical reasons,
rejected no less than 3,257 children and young
persons desirous of obtaining employment in
factories, and 2,016 for non-medical reasons.
These figures afford some idea of the scope of the
operations of the Factory Department which has
during the year added to its Registers no less than
31,240 factories and workshops. There were 632
cases of lead poisoning notified in the year under
report, as against 592 in 1905, 1,058 in 1900, and
1,258 in 1899. In connection with claims under
the Workmen’s Compensation Act under the
heading “ encephalopathy,” in the cases of plum-
bism it is interesting to note eleven cases of
epilepsy and coma, three of mental derangement,
and seven of optic neuritis. The striking obser¬
vation occurs that in one factory the occurrence of
seventeen cases within the last four years led to
an examination of 87 of the workers, of whom six
showed a trace of a blue line, nine were pale or
anaemic, one had definite partial paralysis of the
right wrist and one weakness of the fingers. Of
sixteen cases in the printing trade eight occurred
in compositors, three in stereotypers, two in machine
operators, and one each in a type caster, a store room
hand, and a general worker. The blue line on the
gums, we are told, is rarely found among printers. In
thirty cases lead poisoning was returned as the
direct or indirect cause of death. There are
some ten or eleven thousand persons engaged in
the tobacco, cigar and cigarette industry, but out
of that number careful enquiry revealed only two
cases of nicotine poisoning, two of amblyopia, one
of gastralgia, and one of smoker’s heart. Clearly,
then, it would be impossible to consider that par¬
ticular industry as an unhealthy one. The
laundry industry presents some interesting statis¬
tics. In the year 1901 91,086 persons were em¬
ployed, of whom 50,547 were engaged in steam
laundries. During the year 1906 there were 301
accidents reported to the certifying surgeons, as
against 288 in 1902. Some interesting facts are
recorded in the Report of the Electrical Inspector.
There were eight fatal electrical accidents in
factories, engineering works, and so on. Four of
these occurred under the heading of faulty appara¬
tus, and it is significantly noted that many burns
of that class are due to the circuits being too
heavily fused, thus allowing heavy currents to
flow under short circuit conditions. In one in¬
stance a man took hold of a leaky lamp fitting
which he was repairing and received 230 volts
through his body to earth, whilst standing
upon some iron plates. A youth, in a cellar, the
floor of which was wet with pickling brine, took
hold of the pedestal of a leaky electrical fan with
one hand, while he turned on the switch with the
other. He received a current of 200 volts, alter¬
nating supply, through his body to the ground.
He was unable to drop the fan until the current
was cut off, when he immediately dropped to the
ground and shortly afterwards expired. In
another case an electrician was fitting up a tem-

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Diqitizi

Aug. 21, 1907.

CURRENT TOPICS.

The Medical Pkess

185

porary light, when he took hold of some wires in
a joint which he had neglected to “tape up", and
receiving a shock to earth with 200 volts was
killed. “ He probably,” remarks the Inspector,
“ held the popular but erroneous idea that with
such a low pressure there is no danger.” In
another instance a youth was killed whilst trim¬
ming an arc lamp which he had lowered to within
a few feet of the ground. The switch was faulty
and although the lamp was extinguished,the circuit
was broken at one pole only, one blade of the
switch remaining in contact with the other pole.
The lamp was, therefore, alive at 200 volts above
earth, the system being 3-phase, 350 volts per
phase. The unfortunate youth was unable to
release his hold of the lamp until switched off by
another person, when he fell to the ground. This
Report is in many ways full of interest to the
public in general and may be commended to the
notice of medical men in particular, for they will
find therein a vast amount of information likely to
be of great professional value.

PUBLIC HEALTH IN INDIA.

It is high time that the enormous waste of human
life in our great Indian Dependency should engage
the serious attention of the British Legislature.
The responsibilities of Empire do not end with the
simple establishment of law and order under the
influence of a mild military despotism. It is
impossible to disregard the moral obligation that
is attached to the dominant British race in main¬
taining a good standard of public health in India.
There is no lack of fearless and well informed
■criticism upon the point. Major Ronald Ross, a
clear-headed authority on all aspects of epidemic
disease, has spoken out his mind repeatedly in a
way that no governors of a civilised country can
permanently disregard. In a recent communica¬
tion he sums up the chief points of the indict¬
ment against the Indian Government for its
attitude with regard to the plague. The facts he
brings forward are as follows :—(1) Although the
■disease had been raging in Hong-kong for two
years before it appeared in Bombay, the Indian
Government did not make adequate preparations
to exclude it, or to detect and combat it on its
arrival in India ; (2) when it arrived in 1906 it
was allowed to remain undetected for months ; (3)
when it was detected at last it was met only with
the vacillating counsels of the unprepared ; (4)
although great efforts to check it have undoubtedly
been made since then, it is questionable whether
they have always been organized in the best
possible manner. From this it will be seen that
Major Ross accuses the Indian Government of
want of wisdom and of inertia rather than of
actual indifference to the plague. The root of the
matter, it is to be feared, is to be found in the lack
of a proper public health organisation throughout
India. Even in our military administration sun¬
dry matters are on a far from satisfactory footing,
an assertion that can be readily proved by a study
■of the Indian Army Medical Reports. In dealing
with the native populations of the East it is, of

course, necessary to realise that one is confronted
with the vices of ignorance, superstition, and
suspicion, but that is no excuse for defective
sanitary administration. Major Ross makes a
palpable hit when he points out that India has not
done so well as other countries in dealing with
malaria during the last ten years, that is to say,
during the administration of Lord Curzon, who, in
sanitary matters, is one of the.strongest support¬
ers of the policy and the administration 9f the
Indian Government, yet malaria causes more sick¬
ness than plague does, and it can be dealt with
medically without injuring the susceptibilities of
the natives. It is open to Lord Curzon to state
what serious practical measures were taken by
him during his administration of India to check
the ravages of malaria. Vague generalisations
are not a sufficient answer in reply to the cate¬
gorical thrusts of so doughty a knight as Major
Ronald Ross.

CURRENT TOPICS.

A Prescription for Childlessness.

The Herald of Health is a journal primarily
devoted to the cult of the vegetarian. Inciden¬
tally, however, it deals with a wide range of sub¬
jects, but appears to be mainly of the “ anti ”
type of faith. A page at the end is devoted to
“ Hygienic Answers to Correspondents,” for non¬
urgent cases and for those unable to pay fees.
The Editor declines to advise the use of Wallace’s
specifics, for information as to which readers
are referred to that gentleman’s work on “ Physian-
thropy.” We gather that the writer in question
is an unqualified practitioner and we further infer
that he has certain original views upon vaccination,
as on the same page a book is advertised under
the title of “ The necessity of small pox as an
eradicator of organic disease.” The Editor,
himself, deals with the case of a corres¬
pondent who has “ strained a gland in the
groin during a foot race which has since suppu¬
rated.” To meet this medically unknown patho¬
logical condition he advises a hot sitz bath 20
minutes nightly, or hot compresses for one hour,
and that the feet be kept in hot water half an hour
each night: salad oil and rest during the day.
The attitude of the man who regards suppurating
glands in the groin as non-urgent is somewhat
startling, whatever view may be taken of his
treatment of the following case, headed, “ Is my
wife well enough to bear a child ? ” The appli¬
cant having benefited by previous advice in
many troubles would like his domestic life to be
blessed by offspring. In his answer the editor
gives detailed directions for “ three good, slowly
eaten meals daily, two of them consisting of bread
made on Wallace lines or got from the P.R. (?)
bakery, and fresh ripe or stewed fruit. The third
meal is to consist of two new laid eggs, a heaped
teaspoonful of conservatively and thoroughly
cooked pulse, three ounces of ground nut, or three
or four ounces of home-made Wallace cheese.
The foregoing are to be eked out with various

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186 The Medical Press.

CURRENT TOPICS.

Aug.

1907.

vegetables. 15 or 16 hours are to be devoted daily
to exercise, domestic duties, visiting, reading, and
so on. As soon as that can be done happily
without being more fatigued than will enable you
to enjoy a good night’s rest and awake refreshed
in the morning, and maintain your health other¬
wise, then you may prepare your hearts for the
introduction of a little one into your home.” We
fancy that plain food and plenty of exercise is a
somewhat old fashioned prescription for sterility,
apart from bread and food ‘‘ on Wallace lines.”
By the way Wallace appears to be a baker who
advertises extensively.

State Medioal Attendance.

The recent plea of Dr. Newsholme in support
of the provision of medical attendance by the
State deserves careful consideration. It may be
that he is simply thinking ahead of the times, and
that the proposal which seems so revolutionary
to-day may become the established fact of a few
generations hence. For when the matter is looked
into a little more closely it is evident that the
principle has been already adopted in various
directions by a State that is not given to headlong
advances. For instance, the Poor Law of the
United Kingdom recognises the right of any
pauper citizen to receive medical attention at the
expense of the community. Further, for the pro¬
tection of the citizen, both individually and
collectively, the legislature has decreed that vac¬
cination shall be available free of cost to every¬
one. The most striking instance, however, to
be found is in the public infectious hospitals which
are open freely to all classes and are a charge upon
the community. An extension of such services
to the general public would, therefore, simply
involve the development of existing machinery.
Were the medical profession to discontinue the
vast amount of gratuitous services rendered to
hospital patients and to private persons from
whom no payment is to be expected, a huge
additional charge would at once be thrust upon
the Poor Law, whose work is to a great extent
anticipated by the contributions of the public
and the labour of medical men. Sooner or later
the State will probably have to protect or help to
support the general practitioners.

Medioal Papers and the Lay Press.

About six months ago a spirited protest was
made from several quarters against the practice
of certain medical journals sending round to the
lay press advance proofs of original communica¬
tions made to their columns. The objection
seems to have been so far successful that the
particular journal most concerned has not since
been quoted in the manner objected to; but of
late original papers in other of our contemporaries
have been freely and accurately reproduced in
some daily papers, with the author’s name so
prominently displayed as to suggest that the
editors have not been unaided in the process of
selection. Now though certain medical addresses,
such as the introductory lectures at the medical
schools, the Harveian oration, and so on, are

. 21

usually reported in the lay press, these addresses
are generally given with an eye to the diffusion
among the public of ascertained medical truths,
or medical views on socio-medical subjects. They
are not given to glorify the lecturer’s clinical skill
or professional acumen. Intthe case of the papers
spoken of above, it appears to be different. The
authors’ work as related in the particular communi¬
cations referred to represent simply their own views,
which may or may not be sound. Such papers
are published in medical journals so that the pro¬
fession may have an opportunity of forming a
judgment on them, and till such judgment has been
passed it is obviously most undesirable that sen¬
sational abstracts from the original paper should
be published with startling headlines in the lay
journals. The names of authors whose papers so
appear are not likely to smell the more sweetly
in the nostrils of the profession, and in their own
interests and that of the dignity of the profession
they would do well to put a stop to this unhappy
practice.

The Hospital Building Craze.

The proceedings of the Metropolitan Hospital
Sunday Fund do not always meet with our un¬
qualified approval. Indeed, we have on various
occasions criticised freely their policy, for in¬
stance in their neglect of small hospitals, and in
their arbitrary and inconsistent methods in en¬
forcing amalgamation schemes. With their recent
condemnation of the building craze on the part
of London medical charities, however, we find
ourselves in perfect accord. There are said to be
about a thousand unoccupied beds in London
hospitals at the present moment, but in spite of
that fact, quite a number of those institutions are
moving heaven and earth to forward fresh building
schemes. Sir Edmund Currie has taken the
matter vigorously in hand, and it is to be hoped
•jthat his efforts will give pause to not a few of
those unbusinesslike schemes. A standing monu¬
ment of “ how not to do it ” is afforded by St.
Mary’s Hospital, Paddington, which has erected
a gorgeous new building at vast expense, but is
unable to do more than keep the beds in the old
premises occupied. It would be much more to
the benefit of the community to insist upon
accommodation being provided in outlying dis¬
tricts, instead of permitting a few large central
hospitals to divert huge sums to their own
aggrandisement. It is to be hoped that the
hospital funds will exact their influence in
bringing the medical charities into some sort of
system as regards their present reckless expendi¬
ture upon extensions, regardless of debt and of
deficiences of income. At the same time, Sir
Edmund Currie may be trusted to look well into
the individual cases of the smaller hospitals before
coming to any decision as to their claims to public
support.

The New Public Health Act.

Although the Public Health Bill which has
lately passed the Commons is mainly consolidating,
yet there are various additions of some importance.

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A CO. 31. I907.

PERSONAL.

The Medical Press. 187

There is little doubt that the Bill, pretty much
as it now stands, will pass into law. The eighteen
clauses dealing with infectious diseases are spe¬
cially interesting. Among them are powers given
to the medical officer to examine school children,
to require a list of scholars when one is suffering
from infectious disease, provisions as to library
books, power to require dairymen to furnish a list
of sources of supply, dairymen to notify infectious
diseases existing among their servants, power to
local authority to pay expenses of persons in
hospital, and to provide nursing attendance. If
a dairyman is called upon to state the sources
from which his milk is obtained, he will be re¬
warded with the modest sum of sixpence ; and if
he fail to comply with the requisition he will be
subject to a fine of £$ and a daily penalty not
exceeding £ 2 . The provision as to furnishing the
names and addresses of all scholars applies to all
schools, and the sixpenny scale of payment to the
head of the school is the same as for dairymen,
but the fine for non-compliance is only £ 2 , and
there is no continuing penalty. The local autho¬
rity may provide nurses for persons suffering from
infectious disease who cannot be removed to
hospital, and may pay such reasonable sums
for the services of the nurses as they think fit.
But the operation of this, as of all the other
sections, depends upon the initiative of the local
authority.

A Permanent International School Hygiene
Council.

An important development of the late Congress
on School Hygiene is the formation of a permanent
International Council on the same subject. This
Council is to consist of the president of the past two
congresses and the president of the next congress,
together with nine other members yet to be elected,
but of whom three are to be natives of this country,
three of the country where the next congress will be
held, and three members from other lands. The'
Council is not to meet for discussion in the ordinary
way, but will deal with subjects that arise by cor¬
respondence, and will be empowered to make
decisions on urgent matters. The questions that
they will consider almost at once are how medical
inspection of schools can best be carried out with
the maximum of efficiency and the minimum of
cost; how far the laws of health can best be im¬
parted to the rising generation, so that they may
learn how to take care of themselves and those
dependent on them; what are the best systems of
physical training for both sexes at various ages;
and how the feeding of improperly-nourished chil¬
dren shall be carried out without developing pauper¬
ism and with due regard to those on whom the cost
falls. No one will deny the value of such functions
nor be disposed to withhold admiration from the
gentlemen who are sufficiently courageous to under¬
take them, but it may seriously be doubted whether
the questions the Council propose to themselves are
what may be termed international. They seem to
us to Tie more strictly national, and to raise issues
that each country must work out for itself according
to its own customs, habits, and means. Still there
are many points of general interest, such as the
setting up of normal standards of vision for children

of various ages, and the prevention of epidemics bv
school agency, in which the experience and know¬
ledge of experts in different countries will be of
high value, and we wish the new body everv success
in its honourable self-imposed mission.

The L.G.B. and Medical Salaries.

It is highly unfortunate when the profession is
striving to raise the quality and prestige of its
members that a department like the Local Govern¬
ment Board, which is so intimately connected with
medical work, should do anything to belittle medical
men or to lower their remuneration. An almost
incomprehensible instance of such action is reported
from Edmonton. The Board of Guardians for that
district lately advertised for an assistant medical
officer for the workhouse, requiring a “ whole-time”
man, and offering a salary of ^'180 a year, without
extra allowance. As a matter of fact, only two
replies were received, neither presumably suitable,
for the Guardians decided to advertise again, offer¬
ing a higher salary, to wit, ^'220. This salary was
disallowed by the Local Government Board, who no
doubt were fully informed of all the contingent
circumstances. With every desire that proper
economy should be observed in local administration,
it strikes us as preposterous that the Guardians are
forbidden to offer a salary which will attract a suit¬
able candidate for the purpose of looking after the
comfort and well-being of sick paupers, and still
more so that the whole time of a medical man is
a post not very attractive from the professional point
of view, should be rated at not worth four guineas
a week. The Local Government Board must surely
be aware that if it wishes for adequate medical care
to be bestowed on the poor, it must be prepared to
allow market rates of payment, and we hesitate to
believe that they wish anything less than skilled
service placed at the disposal of old and infirm
paupers.

PERSONAL.

Surgeon-General Bomford, Director-General of
the Indian Medical Service, has been granted the Dis¬
tinguished Service award.

We regret to learn that Major Fullerton, of the
Indian Medical Service, has died at Lucknow from
blood poisoning, contracted while performing an
operation with a pricked finger.

The Chief Inspector of Factories gives notice that
Dr. W. Carroll and Dr. J. H. Thomas have been
appointed certifying surgeons for the Rathdowney
district of Queen’s County, and the Market Har-
borough district of the County of Leicester respec¬
tively.

Sir Donald Currie, G.C.M.G., has given a further
sum of £ 2,000 to the Queen’s College, Belfast, in
order to complete the sum of ^5,000 which is required
for the recreation grounds of the College. This
gift makes a total of £ 22,000 which Sir Donald Cnrrie
has given to the College.

It is reported that plague has broken out at San
Francisco, and that an active campaign has been in¬
stituted in New York against rats in ships coming
from South America. The port authorities of the
United Kingdom will doubtless follow suit.

Digitized by boogie

188 The Medical Pres*. CLINICAL. LECTURE. Aug. 21, 1907.

A Clinical Lecture

ON

THE CONSEQUENCES AND TREATMENT OF LACERATION OF THE

FEMALE PERINEUM.

R. J. KINKEAD, M.D.Duk, LJLCSX,

Professor of Obstetrics In Queen's College, Galway; Physician and Gynaecologist to the Galway

Hospital*

Gentlemen. — I have selected for discussion
with you to-day the consequences of laceration ;
of the perineum in the female. I do not propose
to deal with the risks resulting therefrom during
the puerperal period, except to tell you that
in every case of laceration in labour, the rent,
be it big or little, should be sutured at once ;
and to quote for you from Dr. MacNaughton
Jones’ “ Diseases of Women," words of wisdom
you should imprint on your memories:

“ Assuredly if practitioners only recognised
the ills, immediate and remote, which follow
lacerated perineum, we should less frequently
hear of secondary operations. . . . Take it

all in all I believe there is not in the entire range
of gynaecological practice a point more necessary
to insist on than the early closure of the perineal
wound after parturition. This caution pertains
rather to midwifery than to gynaecology, but it
has such an important bearing on the future
happiness and comfort of the woman when
labour has been long forgotten, that it warrants
the stress laid upon it."

In the majority of cases union follows im¬
mediate suturing.

In relaxation, and in ununited laceration of
the perineum, an enlarged and gaping vaginal
orifice results, which by interfering with, or
incapacitating from, sexual intercourse affects
domestic happiness and tends to promote in¬
fidelity. Remedial operation is as imperatively
called for in the interests of marital felicity and
morality, as it is in those of the woman’s physical
well-being and her restoration to active useful
life.

To understand how disasters arise from its
injury, and how they are to be remedied,
you must have a clear comprehension of what
the perineum is, and of the functions it performs.

For about its upper two-thirds the posterior
vaginal wall is contiguous to the rectum, at
the lower third, however, the rectum bends
back to the anal orifice, while the vagina continues
its forward curve, in the space thus formed
between the lower end of the rectum and vagina,
a triangular mass, composed of strong elastic
connective tissue, the perineal body, is interposed,
with its base resting on the intersection of four
muscles, over which lies the skin.

This skin surface, which you can see, is about
one and a half inches long by two in breadth,
and extends from the level of the posterior com¬
missure of the vulva to that of the anterior
margin of the anus, is usually spoken of as the
perineum; and under the mistaken notion that
the perineum was only this and nothing more,
operations have been recommended and per¬
formed for its restoration utterly inefficient, and
which had better have been left undone.

“ The Transverse perineal muscles cross the
base of the perineal body horizontally, between .

the vaginal outlet and anal orifice, each one
; fusing with its fellow on the opposite side ; a
number of the muscular bundles diverge from
the horizontal fibres, anteriorly and posteriorly,
at angles of about 30°, to fuse in front with the
constrictor vaginae, and behind with the sphincter
ani.”

When I speak of the perineum, I mean this
composite structure of connective tissue, muscles
and skin.

The origin of these muscles, the transverse
perineal from the tuberosities of the ischium, the
constrictor vaginas from the pubes, and the
sphincter ani from the coccyx, being at a higher
level than that at which they pass under, and
fuse together beneath the perineal body act like
C springs, and with every contraction lift that
body upwards; while the levator ani arising
higher up within the pelvis, passing downwards
and backwards to its rectal attachments, not
only lifts the rectum, but draws it, the perineal
body and the vagina, forwards towards the
pubes.

Thus the anterior and posterior walls of the
vagina are kept in close contact, and the vagina
is maintained as a solid column—the chief factor
in supporting the uterus and preventing prolapse.

Lacerations almost invariably occur in the
middle line, and run vertically back ; they vary
in size from an unimportant tear of the fourchette,
or, a more serious one, down to or through the
sphincter, to a huge rent into the anus, laying
■ open the rectum for one or more inches,
and making the vagina and rectum a common
cloaca. In the graver cases the perineal body
is split vertically, the fusion of the transverse
perineals is rent asunder, and the sphincter ani
torn across; through the contraction of these
muscles, the lacerated tissues are pulled apart.
Hence—as I believe, the late Mr. Lawson Tait
was the first to point out—while the original
tear ran in the anterio-posterior plane of the body
the rent heals in the bilateral plane, as shown
by the transverse position of the cicatrix.

Thus the vagina is transformed from its
normal condition of a solid column, with its
posterior wall in apposition with, and supporting,
the anterior, into an open tube with an enlarged
and gaping vaginal outlet.

When the rectum is laid open, according to
the extent of the laceration, there is more or less
incontinence of faeces, unfitting the woman for
domestic or social life, and rendering her existence
miserable.

Whether involving the integrity of the rectal
wall or not, the usual consequence of grave
laceration is prolapse and procidentia of the
vagina and uterus.

Time does not permit me to tell you to-day
all the symptoms, and attending ills of rectocele,
| cystocele and “ falling down of the womb."

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CLINICAL LECTURE.

Thk Medical Press. 189

Aug. 3i, 1907.

Suffice it to say they injure the health, give rise
to rectal and bladder troubles, and incapacitate
the woman from work.

The uterus normally lies diagonally in the pelvis,
on the bladder, the cervix pointing backwards.
The anterior wall of the vagina is attached to
the base of the bladder by cellular tissue, and
lower down, more closely to the urethra. When
owing to relaxation, or deformity resulting from
laceration of the perineum, the support afforded
to the anterior vaginal wall is removed, more-
especially in women, unable to lead restful
luxurious lives, but obliged to be on foot most of
the day, or to earn their bread by laborious
occupations, procidentia may occur suddenly.
Usually, however, the process is gradual : under
the influence of abdominal pressure and the
weight of the urine in the bladder, the anterior
wall sags down, and its lower portion containing
the urethra protrudes at the vaginal orifice:
this is only the first step, and is followed by a
descent of more of the vaginal wall with the
base of the bladder.

When this occurs the bladder cannot be
completely emptied, a pouch being formed
below the internal orifice of the urethra.
The tendency to descent is now aggravated by
the weight of the urine contained in the pouch,
and by the force directed downwards into it
when the bladder contracts to empty itself.

Bearing in mind that the vagina is attached
to the cervix uteri, you will understand that as
the anterior wall descends its upper part must
pull on the cervical extremity of the uterus, and
tend to drag it down, at the same time tilting
the body of the uterus up.

Sometimes, however, this does not happen,
the uterus remains antiverted, and as an
antiverted uterus cannot prolapse, the cervix
after a time yields to the strain, and becomes
so elongated that we find it and the everted
vagina protruded from the vulva, while the
body of the uterus remains at its normal
elevation in the pelvis.

More frequently the pull brings the uterus first
into a vertical position, which facilitates its
prolapse, and as it sinks an increased protrusion
of both vaginal walls takes place; under the
influence of abdominal pressure and the increased
vaginal drag, the uterus falls further and further
down, changing its direction until it lies in the
axis of the outlet, and finally is extruded between
the woman’s thighs covered by the everted
vagina.

As in this lecture I am only dealing with
laceration of the perineum, I shall not discuss
the other causes of, nor attempt to enumerate
the mechanical expedients adopted, and the
operations devised to alleviate or cure, prolapse
and procidentia uteri.

The object of treatment of laceration should
be the cure of its immediate consequences and
the prevention of those resulting from neglect.
For both, operation is essential, and should be
performed as soon as the parts have healed.

Operations for the restoration of the perineum
are nearly as numerous as the leaves in Vallom-
brosa. For my own part I prefer and invariably
perform that of the late Mr. Lawson Tait: I
have done it in all sorts of cases, with some
modifications in dealing with the rent, when
the recto-vaginal septum was involved, and

am satisfied with the results, which I have found
stand the stress of subsequent labours.

I quote for you Mr. Lawson Tait’s description
of the operation in cases where the laceration
does not lay open the rectum.

“ Having the folds of the buttocks pulled
firmly apart so that the cicatrix is put on the
stretch, I enter the point of the scissors at its
extreme end on one side and, keeping strictly to
its line, I [run through to its other extremity.
The incision is about | of an inch deep, and it
forms two flaps—a rectal and vaginal. From each
end of the incision it is carried forward into the
tissues of each labium for about an inch, and
again backwards for about $ of an inch.

“The vaginal flap is held upwards (the patient
being on her back), and the rectal flap being
turned downwards, and the angles of the flaps
being pulled by forceps diagonally upward and
inward and downward and inward respectively.

“The sides thus become straight, and the wound
takes the form of a parallelogram.

“ By means of a stout-handled, well-curved
needle the silkworm gut sutures are entered on
one side about £ of an inch within the margin of
the wound (so as not to include the skin). They
are buried deep in the tissues, and then the needle
is made to emerge so as to miss the upper angle
of the wound. The needle again enters at same
distance from the angle and emerges £ of an inch
from the skin margin on the other side.

“ By thus missing the upper or deep angle of
the wound, the two great and divided masses of
the old perineum, which lie in the parallelogram,
respectively bounded by the points of entry and
emergence of the needles, are accurately adapted.

“ The rectal and vaginal flaps respectively point
into the rectum and vagina, and like an old-
fashioned flap valve, prevents noxious material
entering the wound.

“ The resulting mass of the perineum is amazingly
large, and union is almost inevitable.

“ The resulting cicatrix is absolutely linear, and
so resembles the natural raphe, that in three or
four months after the operation it is quite im¬
possible to determine from the appearance of
the parts that the perineum has ever been injured,
for there are no stitch hole marks left to tell
the story. I leave the stitches in for three or
four weeks, and take care that the rectum and
vagina are washed out daily.

“ My operation really restores the perineum to
its original form and dimension, and makes the
patient as good as new.

“ That this is so can be seen at once on con¬
sidering that the transverse incision, in splitting
the septum with its small exteniores, fore and
aft, really reproduces the original perineal tear,
which runs in the anterio-posterior plane of the
body.

“ The rent has healed in the bilateral plane of
the body, as shown by the transverse position
of the white line of the cicatrix. The new in¬
cision is made in transverse line, but the wound
is closed at right angles to it.

“ Then as the whole structure of the perineum
is opened up and the parts formerly continuous
are re-united absolutely in their original position,
the tom ends of the sphincters are thus again con¬
tinuous, and complete functional activity is
restored.

“ The peculiar method of inserting the sutures

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190 The Medical Press.

ORIGINAL PAPERS.

Aug. 21, 1 907.

is essential to this means, for in this way only
can the old relative of parts be restored.”

If the recto-vaginal septum is laid open the
operation is more complicated.

When the rent extends high up, the upper
portion is not affected by the transverse pull
of the muscles, and the tear assumes the
shape of an inverted V with the apex above.

I split the septum to about an eighth of an inch
above the angle of the tear, thus making four
flaps—two vaginal and two rectal. The comers of
the vaginal flaps are first caught and held up with
forceps, and beginning above the angle of the
tear, on the raw or rectal aspects the margins
of the flaps are sewn together by a continuous
suture of fine catgut, the needle being entered a
little more than an eighth of an inch from the
edge of the tear, and brought out close to, but not
through it; it is then entered close to the edge
on the other side, and emerges an eighth of an
inch from it, care being taken not to perforate
the vagina in passing the suture.

By this procedure surfaces an eighth of an
inch vide, for the entire length of the tear,
are brought into apposition, and the edges
project into the vagina.

The rectal flaps on their vaginal aspect are
then sutured in the same way, the comparatively
broad mass of tissue brought together, and the
closely-approximated edges projecting into the
rectum, prevent any leakage therefrom into the
wound.

The operation is then completed as before
described.

I performed this operation with complete
success last session in the County Galway Hospital
in a case of extreme laceration extending up to
Douglas’s pouch.

This affection affords an example of the adage
that the exception proves the rule; for we meet
with cases of ununited laceration in which, with
only a narrow portion of tissue between the
vulva and anus, the woman seems not a pin’s
worth the worse. You may ask, should such case
be operated on ? I unhesitatingly reply they
ought to be. The unfortunate possessor of a
relaxed vaginal outlet or lacerated perineum is
always in a state of danger, for while some may
end their days without evil ensuing, in others
from sudden strain, over-exertion, ill health,
or other causes, disasters may result, and it is
much simpler, more certain, and far easier, to
prevent prolapse or procidentia than to remedy
them once they have occurred.

Note. —A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture
for next week will be by G. F. Still. M.A., M.D., F.R.C.P.,
Professor of Diseases of Children, King’s College, London.
Subject ; " Infantile Diarrhcra.”

University College, London—School Hygiene.

A new course on School Hygiene, including lectures,
demonstrations, and practical work, has been arranged
to begin on October 16th, at University College. The
Course will be given by Professor Henry Kenwood
and Dr. H. Meredith Richards. It is designed to meet
the requirements of school teachers, school lecturers,
and those qualifying for school inspectorships and for
school medical officers. A certificate of proficiency
will be granted to those who qualify themselves.

ORIGINAL PAPERS.

PHAGOCYTOSIS^ &BACTERICIDAL
ACTION. (<t)

G. DEAN, M.B., C.M.Aber.,

Bacteriologist, Lister Institute of Preventive Medicine, London, &c.

Metchnikoff’s theory of Phagocytosis is one
of the greatest conceptions of modern biology.
Combated at the outset by many of the leading
pathologists of the time it has steadily gained
ground, till now it is almost universally accepted.

It would be impossible to consider as adequate
any description of infection, inflammation or
immunity which omitted to give a due con¬
sideration to phagocytosis. While upholding
the cell as the most important factor, Metchnikoff
and his pupils could not long overlook the part
played by the body fluids in the process of pro¬
tection.

The work of Nuttall, Pfeiffer and others showed
that the blood serum alone in the absence of
cells had powerful bactericidal properties. The
evidence in favour of this bactericidal action of
the serum was so conclusive, and the fundamental
experiments were so easily confirmed that the
phagocytic theory was for some time over¬
shadowed by the humoral. It soon appeared,
however, that bactericidal effects of serum due
to bacteriolytic action could not be demonstrated
in the case of all organisms, e.g., staphylococcus
and streptococcus. According to Metchnikoff
this bactericidal action did not play an important
part in the living body under normal conditions.
The blood plasma did not behave like the serum
in this respect. The bactericidal substance had
its origin in the phagocyte, and was set free by
its death, during the process of clotting, or in
the case of the living animal when phagolysis
was produced by an excessive dose of bacilli
injected experimentally. The bacteriolysis, there¬
fore, was a secondary phenomenon of phagolysis.

On the other hand, in the case of immune
animals, there were present in the blood sub¬
stances which played an important function in
aiding phagocytosis. These latter bodies are
thermostable and unlike the substance pre¬
viously referred to, the cytase or complement,
which is readily destroyed by a temperature of
56°c.

Two forms of activity have been attributed
by Metchnikoff and his pupils to those ther¬
mostable bodies. (1) A stimulin action; (2) a
fixative action.

When a highly virulent organism is injected
into a normal animal the leucocytes do not show
any great disposition to attack the invader. The
virulent organism tends to repel, or at least, not
to attract the phagocyte ; in other words, the
bacillus has a negative chemiotaxis for the
leucocyte. In an immunised animal, on the
other hand, no sooner does the virulent organism
find an entrance into the body than the leucocytes
crowd to the site of infection, surround the in¬
invaders, and if the immunity is sufficient, en-
globe and destroy the enemy. That this property
is due to something in the plasma or serum, and
not to properties of the leucocytes acquired by
education or otherwise, is shown by injecting
some of the blood plasma or serum of the immune
animal into a normal animal, in which case the

(«' Introduction of Discussion, British Medical Association meeting 1
Exeter, 1907.

Digitized by G00gle

Aug. 21, 1907.

ORIGINAL PAPERS.

leucocytes of the new animal thus passively im¬
munised behave in the same manner as did
those of the actively immunised animal. Sub¬
stances which thus heighten the activity of the
leucocytes Metchnikoff has designated “ stimu-
lins.”

In the second view, the serum is conceived
as acting primarily, not on the leucocyte, but
rather on the microbe, on which a change is
produced, so that it no longer repels, but rather
attracts the phagocyte; in other words, its
negative chemiotaxis is converted into a positive
chcmiotaxis.

It would be impossible here to detail even the
chief of the earlier contributions on the subject,
a brief rSsumi of some of these has been already
published by the writer in a former paper.

Interest in these questions had been re-awakened,
especially in this country, by the work of
Wright and Douglas, who, by a modification of
a method devised by Leishman, had made a
number of observations emphasising the im¬
portance of the serum in the mechanism of
phagocytosis, and showing for the first time in
an unequivocal manner the fact that normal
serum as compared with other fluids, such as
normal salt solution, had a powerful action in
preparing the microbes for phagocytosis in cases
where no bacteriolytic or bactercidal action
was apparent.

The substance in serum which had this action,
was found to be thermolabile, and was designated
by them “ opsonin.”

In the case of furunculosis, tuberculosis, &c.,
Wright and Douglas showed that the injection
of vaccines made from the appropriate micro¬
organisms was followed by an increase in the
opsonins. The phagocytic method introduced
by them attracted many workers, and the funda¬
mental experiment has been repeated and con¬
firmed by many. Much critical investigation
will be necessary, however, before the establish¬
ment of the claims made as to the value of the
method for clinical use. • 1

The nature of the opsonins, their relation to
substances previously described and named by
others, the value of the method from the clinical
standpoint, and the experimental error involved
have already been, and must still for some time
be, a subject of enquiry for many observers.
Such subjects as these would be appropriate for
the present discussion.

He then proceeded to review the recent work
on these lines, and detailed a number of his own
experiments bearing on the subject

The bulk of the evidence as sifted from the
literature and deduced from his own experiments
along with those of others, drove him to the con¬
clusion that the opsononising action was due
to the effect produced by two bodies acting
together: the one thermostable, known variously
as the fixateur substance, sensibilisatrice, am¬
boceptor, &c., is the essential substance. It
alone is capable of opsonising, but its activity
is greatly increased by the presence of free com¬
plement. known also as “ Cytase,” “ Alexin,” &c.
The amboceptor is present in only small quanti¬
ties in normal serum, hence the apparent thermo-
lability of the “ opsonin ” in normal serum,
whereas in an immune serum the amboceptor
plays a predominant part and though heating
results in a loss of activity, this is only partial.

The Medical Press. _191

In both cases the loss is due to the destruction
of the complement.

The reason why one type of organism such as
the typhoid bacillus is bacteriolysed by the
action of these substances, whereas another
such as the staphylococcus, though prepared
for phagocytosis, without any bacteriolytic effect
being apparent, probably arises not from the
fundamental difference in the method of action
of the serum, or in the substances in the serum
which produce the effects, but from a difference
in the physical nature of the microbe itself.
The experimental basis for these views was fully
discussed.

INDICATIONS FOR OPERATION IN
CASES OF INTRA-CR ANIAL
TUMOUR, (a)

J. S. RISIEN RUSSELL, M.D., Edin., F.R.C.P.

Lond.

Physician, Unlrerslty College Hospital, London. 4c.

Dr. Risien Russell introduced the Discussion
by referring to the importance of diagnosis in
which connection he called attention to the possi¬
bility of confusing cerebral tumour with dis¬
seminate sclerosis, general paralysis of the insane,
migraine ophthalmoplegique, and certain other
affections, including hysteria, which, in his ex¬
perience, had been operated upon in mistake
for intra-cranial tumour, and emphasised the
important points which serve to distinguish
these affections from cerebral tumour. In dealing
with the conditions under which operation is to be
recommended he drew a distinction between cases
in which it was advocated with a view to effecting a
cure, and those in which it was undertaken merely
as a palliative measure. Before advising opera¬
tion in the first class it was essential that the
exact localisation of the tumour should be deter¬
mined, and this not only in so far as to be able to
say that it occupied the brain, as opposed to the
cerebellum for instance, but also which cerebral
or cerebellar hemisphere, and which part of the
hemisphere, was involved. Tumours situated
near the surface of the cerebrum, and those
occupying one lateral lobe of the cerebellum or
the lateral recess, were the most favourable for
operation, while those in the mesencephalon, the
middle lobe of the cerebellum, notably the anterior
portion, and the deeper parts of the cerebral
hemispheres, might be regarded as inaccessible
from the point of view of the possibility of cure.
The probable nature of the growth had an im¬
portant bearing on the question under considera¬
tion, there being always a chance of recurrence in
the case of malignant growths, so that they offer
less chance of cure than do simple tumours. The
prognosis was also less favourable in cases in
which diffuse or multiple tumours were present
than when the neoplasm was circumscribed or
single. In this connection Dr. Russell referred to
syphilitic tumours. He laid stress upon the fact
that surgical intervention was necessary' in a
considerable proportion of these cases, and his
experience had proved that it was useless to
waste valuable time in pushing antisyphilitic
treatment when the symptoms were not yielding
to mercury and iodide of potassium. Another
important consideration was the degree of risk to

(•) Abstract of Paper to introduce Discussion in the Section o
Surgery, British Medical Association, Exeter, 1907.

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ORIGINAL PAPERS.

Aug. 2 i, 1907 -

life from the operation and its immediate effects,
and with regard to this he hoped to hear the
opinions of some of the surgeons who were taking
part in the Discussion. Where other considera¬
tions justified the belief that a tumour which had
been diagnosed and accurately localised could be
successfully reached and removed by the surgeon,
he considered that the risk of life ought not to
deter the physician from recommending operation.
In this connection the amount of permanent
defect likely to result from the operation should be
taken into consideration. In cases where paralysis
was to be expected, and death from the effects of
the tumour the only alternative, one could not
reasonably hesitate to advise operation, but it was
a much more difficult problem when permanent
aphasia was likely to result. The majority of
people must of necessity hesitate, if indeed they
could ever bring themselves to accept an alterna¬
tive to which death seemed almost preferable.
With regard to palliative operations there could be
no question as to the beneficial effects of trephining
for the relief of abnormal intra-cranial pressure.
He emphasised the importance of this procedure
as a means of arresting optic neuritis and of saving
sight, though it must not be supposed that every
patient suffering from optic neuritis had an intra¬
cranial tumour, or that optic neuritis of toxic
origin would be relieved by trephining. In con¬
clusion he referred to the circumstances under
which lumbar puncture could be substituted for
trephining. It should, however, be regarded only
as a palliative measure, which could not be ex¬
pected to permanently relieve the symptoms. It
was valuable as a means of relieving urgent sym¬
ptoms of pressure, when to wait for a surgeon to
trephine would be to allow the patient to die, or
when the patient’s condition was too bad to
permit of the major operation. He also called
attention to the importance of the part played by
lumbar puncture in the diagnosis of general
paralysis of the insane. He considered that it
was a procedure which should be employed for
diagnostic purposes and the relief of urgent
symptoms in cases of intra-cranial tumour,
but which should not be regarded as likely to
permanently relieve symptoms, prolong life,
or effect a cure. In quoting cases in illustra¬
tion of his remarks he referred to a typical
example, in which the diagnosis was easy and
the operation successful; another in which,
although the operation was successful, the diagno¬
sis was less accurate, in that an intra-medullary
cyst of the cerebellum was discovered instead of a
tumour external to the organ ; a third, in which
the diagnosis of tumour seemed certain, and yet
this was not discovered at operation, although the
patient subsequently recovered from the symptoms
which suggested the diagnosis which led to the
operation. A fourth case showed how cerebral
thrombosis might be readily mistaken for tumour ;
while in a fifth case, where disseminated sclerosis
accounted for the clinical picture, the earlier
symptoms strongly suggested a tumour of the
mid-brain.

Mr. Harcourt Coates. M.R.C.S., L.R.C.P., aged 54,
of the Hill, I.averstock, Salisbury, consulting surgeon
to the Salisbury Infirmary, surgeon to the police, and
Medical Officer of Health at Salisbury, has left estate
valued at £41,486. He left the residue of his property
(about £20,000) to the Salisbury Infirmary, upon trust,
to build a wing, or surgical ward, to be known as the
“ Harcourt and Maud Coates Ward.”

DISINFECTION CONSIDERED FROM
A MEDICAL, CHEMICAL, AND BAG
TERIOLOGICAL STANDPOINT (a)

Bv S. RIDEAL, D.Sc., F.I.C.

In opening the discussion on disinfection in
its medical, chemical, and bacteriological aspects,
I do not think I can do better than very briefly
summarise the more recent work on the subject
I have the more pleasure in doing this, and I
think you will have more interest, on account
of the decided advances that have been made
during the last few years in our knowledge of
disinfection, of the preparation of disinfectants,
and of the proper modes of testing them. How¬
ever, there are still many points requiring further
investigation, and these I shall have also to
indicate.

Firstly as to the disinfection itself, the growth
of knowledge in the public has to a certain extent
eliminated the old idea that it solely consisted
in removing smells or disguising them by other
odours. An examination of the various disin¬
fectants placed in the hands of our sanitary
authorities shows that the majority are several
times more potent than carbolic acid, on which
formerly such great reliance was placed. Simi¬
larly with disinfecting appliances great advances
have been made. Dependence is not now so
largely placed on aerial disinfection—the air¬
borne theory being to a large extent exploded—
but it is combined with other methods, such as
spraying and the removal of infected material as
far as possible; in fact, in certain cases the
necessity of destruction or steam disinfection of
clothes, &c., has been generally recognised ; and
in place of the disinfection being either inefficient
or equivalent to destruction, steam disinfectors
can now be obtained which ensure not only
safe and adequate heating, but also the complete
displacement of the air, which is such an essential
factor.

The fallacy of attempting to arrive at or con-
. trol the germicidal efficiency of disinfectants
from chemical analyses has often been pointed
out, but on the other hand the hopeless diver¬
gency of bacteriological tests was not helpful.
The desirability of standardising the test culture
in every experiment was emphasized in 1896 by
Pearmain and Moor (“Applied Bacteriology,”
p. 288): “In order, therefore, to obtain some
trustworthy datum as to the action of a disin¬
fectant upon a given species of organism, it is
desirable at the same time as observations are
made upon the disinfectant under examination,
to determine the strength and time of exposure
required for the disinfection of the particular
race on which the examination is conducted
when subjected to other common disinfectants.”
For this purpose they cited mercuric chloride
and carbolic acid. In conjunction with Mr.
Ainslie Walker, during 1903, I suggested a
method—the carbolic acid co-efficient test—as
an outline for the standardisation of disinfectants,
so that by adopting strict uniformity of procedure
and the insertion of carbolic acid as a control in
every test, comparable results could be obtained
by different observers; and, as the object of
considerable discussion, it has happily helped
to draw attention to the increasing necessity

(«) Paper read at the Conference of the Royal Sanitary Institute In
Dublin, June, 1907.

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ORIGINAL PAPERS.

The Medical Press. 193

for some standard bacteriological method for
the legal control of the commercial disi nfectants.

This test has been taken as the basis for disin¬
fectant tender forms by a considerable number of
authorities, and the Board of Agriculture in
their Disinfection Order (dated April 5th, 1906)
now permit the employment of preparations
equal in disinfective efficiency to a five per cent,
solution of carbolic acid. It has been alleged
that the Privy Council Order of July 27th, 1900,
permitting the sale without trial of fluids con¬
taining less than three per cent, of carbolic acid
or its homologues, on the ground that such fluids
are not poisons within the meaning of the Phar¬
macy Act, 1868, has resulted in flooding the
market with useless disinfectant preparations.
On June 4th this year the question was asked
in Parliament as to the necessity for action being
taken to ensure the standardisation of disin¬
fectants.

So as to approach as closely as possible the
conditions obtained in actual practice, the intro¬
duction of a quantity of organic matter into a
standard method has been suggested, and recently
a number of papers have been published dealing
with the results obtained under these conditions.
Kenwood, in collaboration with Hewlett, and
also Firth and Macfadyen, employed an emulsion
of fresh urine and fasces. The effects of the
solutions of definite organic substances such as
gelatin, casein, peptone, mucin, serum, and
also blood and urine have been investigated by
Sommerville and Walker. Wynter Blyth, during
1903, in reporting to a committee of this Institute,
alluded to the influence on disinfectants of .the
phenol class through the presence of even small
quantities of organic material, and later ( Analyst ,
May, 1906) he suggested milk as a suitable
organic material for testing purposes, as an easily
procured fluid containing a variety of organic
and mineral constituents in natural proportions.
In a paper read before the Chemical Society in
December last he compared the figures obtained
by fasces and milk, and claimed that by employing
a mixture of whole and separated milk so as to
adjust the amount of the fat present, similar
curves of results could be obtained.

The complex question of disinfection in the
presence of quantities of organic substances may
be viewed from many standpoints, and there is
again the danger of confusion caused by the
multiplicity of results, obtained by many in¬
vestigators working under entirely different
conditions. Faeces are perhaps one of the most
variable of organic products, and, as pointed out
elsewhere, it is doubtful if the results obtained
for example by Wynter Blyth could be duplicated
by himself, not to mention other observers.
More distinction should be made between organic
matter in suspension and that in solution;
sterilisation by means of chemicals can be brought
about with certainty in the presence of dissolved
organic matter, but this is not practical with
germs protected by being embedded in masses
of solids, until the latter are disintegrated. The
sterilisation of faeces, for example, is rarely
undertaken in actual practice, and after all,
beyond temporarily guarding against the spread
of infection during transit, such material is
better left to its natural disintegration by hydro¬
lysis in the sewage.

It will always be imperative to know for what
particular purpose or purposes a disinfectant is

required in order to arrive at its proper ultimate
valuation, and there can be no doubt that the
preparation should be scientifically tested under
conditions resembling as closely as possible those
that will be present during its application;
but it is hopeless attempting to evolve any one
single routine test that could apply to the very
divergent circumstances obtaining in every-day
disinfection—one that would apply equally to
the disinfection of a swimming-bath, to the
cleansing of cattle trucks, and to the sterilization
of surgical instruments. Reaction alone, whether
acid or alkaline, plays an important part in disin¬
fection, and some preparations, depending upon
a fine emulsion for their germicidal value, are
considerably modified by traces of acidity.
However, if a preparation that is stated in certain
dilutions to destroy disease germs does not kill
under the more simple conditions as those of the
carbolic acid co-efficient test, it is worse than
useless for any disinfectant purposes, and as a
fraud its sale should be prohibited. It would be
wrong to illegalise certain powerful germicides
because they are rendered uncertain in their
action by large quantities of organic matter, and
it is surprising to find in a paper published this
year such a miscellaneous list as preparations of
“ permanganate of potassium, eucalyptus, thymol,
boric acid, chloride of lime,” generally condemned
as being “ erroneously believed by the public
to be disinfectants.”

Certain oxidizing agents, such as chlorine,
which attack organic matter, are not necessarily
rendered ineffectual by an excess of organic
material, as I have shown when disinfecting
sewage effluents with electrolytic chlorine at
Guildford, the pathogenic organisms were killed,
even if there were sufficient organic matter
present to completely remove in a few hours all
the free or available chlorine added ; and pro¬
vided that the re-agent is added in excess of that
almost immediately taken up by powerful and
rapidly reducing substances, such as sulphuretted
hydrogen, that may be present, the majority of
the bacteria are destroyed.

It is singular that the question of time in a
standard bacteriological test has not met with
more attention, as although, given sufficient time,
many chemicals will destroy bacteria, a limit of
fifteen minutes throws out some well-recognised
germicides ; as an instance soap, which does not
give any carbolic co-efficient, and yet has marked
germicidal properties, and perhaps would with
advantage displace a few disinfectant preparations
which have been put on the market. Many of
our most reliable disinfectant substances are un¬
fortunately incompatible with soap, and in
ignorant hands this causes great waste. Disin¬
fection cannot replace care and cleanliness, but
is at times a necessary auxiliary to them. The
very act of cleaning with soap and water is in
itself a form of disinfection ; but occasionally
more active measures are required, and when
there is danger of personal infection the whole
procedure should be under proper scientific
control. Where there is much organic dirt it
should first be removed with precaution and
cremated ; by doing this the greatest economy
and efficiency in the subsequent disinfection is
secured. Indiscriminate scattering of costly
disinfectants on masses of filth is useless and
wasteful.

The necessity for the power of penetration is a

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ORIGINAL PAPERS.

ADG. 21 , I907.

factor which cannot be overlooked in a disin¬
fectant, but it is reasonable first of all to inquire
whether the preparation will destroy the germ
when it reaches it. By reason of the complexity
of the subject, no satisfactory routine test has
yet been devised to measure penetration.

The high germicidal values given to certain
substances, notably salts of mercury, by earlier
observers have been considerably modified recently.
Previous fallacious results were mainly due to
the carrying over of traces of the powerful germi¬
cides into the sub-cultures, the great difference
between an antiseptic and a disinfectant dose
not always being allowed for. This difficulty
which also arises in using resistant spores as test
organisms can be overcome in the case of simple
chemicals, such as metallic salts, by the addition
of suitable precipitants to the cultures, but
the traces of the more complex phenol derivatives
cannot be so certainly removed.

THE REDUCTION OF

INFANT MORTALITY,

DY BETTER MANAGEMENT AND CONTROL OF THE MILK
SUPPLY, (a)

By HENRY KENWOOD, M.B., D.P.H.,

Profmtor of Publlo Health, University College, London.

A very large percentage of infant deaths from
zymotic diarrhcea has been attributed to artificial
feeding, and condensed milk has been held to be much
more dangerous than raw cows’ milk. These conclu¬
sions have been arrive! at from a statistical com¬
parison of the infant deaths from zymotic diarrhoea
on the basis of the method of feeding prior to death.
Incontrovertible as these facts are as statistical state¬
ments, they do not, of course, afford a true quantita¬
tive expression of the extent to which milk alone is the
determining factor of the higher mortality among those
who have been artificially fed, because other important
factors capable of variation in the two classes com¬
pared are ignored.

Any mere statistical comparison, on the basis above
referred to, may be equally misleading when it is used
to demonstrate the extent of the value of municipal
milk dep6ts, as agencies in the reduction of infantile
mortality; for our experience in Stoke Newington
points clearly to the fact that the hand-fed infants,
as compared with the breast-fed, are generally more
handicapped by other circumstances that largely deter¬
mine the matter of the survival of the infant. I refer
to a lesser degree of maternal care (and, in conse¬
quence, a greater neglect), and to those circumstances
associated with extreme poverty (including insufficient
food, neglect to seek and obtain medical advice, in¬
sanitary environment, etc.). It is therefore extremely
difficult to gauge the true proportion of those deaths
that are due to hand-feeding per se ; but there can be
no doubt that the number is very considerable, and
that it constitutes an appalling annual toll exacted by
maternal ignorance and dirty milk.

But, despite all our efforts to foster breast-feeding,
a large proportion of infants will continue to be arti¬
ficially fed, and public health interests demand a
guarantee of healthy cows, a sufficient standard of
cleanliness of milk and the discontinuance of the very
general practice in summer months of drugging it with
chemical preservatives.

The milk trade does not realise to the full that theirs
is unique amongst trades, inasmuch as it deals with a
necessary article of food which forms the almost
exclusive diet of a large proportion of the most sus¬
ceptible units of the population (the infants and
invalids), and that milk is unique, as an article of
food, in its powers of collecting and fostering micro¬
organisms which are injurious to health and may be
fatal to the infant consumer. It is an extremely re-

( a) Abstract of paper read In the State Medicine Section at the
Exeter meeting of the British Medical Association, August, 1907.

sponsible trade, and it is an exceptionally difficult one
to conduct. But the public, enlightened and stimulated
by those who guard their health interests, are demand¬
ing, with increasing concern, that those engaged in the
milk trade shall do more to protect them. It is not an
unreasonable demand, and those who fail to respond
to it not only neglect an obvious duty which they owe
to the community, but it is inevitable in the near future
that they shall suffer from the consequences of their
neglect. It is the fit alone who will survive, for the
milk trade will have to be raised to a much higher
standard of ideal and accomplishment. It is, more¬
over, greatly in the interest of the trade that the milk
supply should satisfy a legitimate demand for the
greatest possible purity, and that it should cease to be
regarded as a not infrequent danger to infant health
and life.

The greatest difficulty which has to be confronted is
the ignorance at the fountain-head—the average
country dairy farm. The majority of dairy farmers
have made little educational advance during recent
years in their appreciation of the necessity of greater
care and better provision for guarding the cleanliness
of milk, and the actual milkers have rather deteriorated
than improved with the greater difficulty experienced
in obtaining that class of labour. During a recent
visit to Denmark I was struck with the greater intelli¬
gence and the better supervision exercised over the
milkers by the Danish dairy farmers compared with
what has been my general experience in this country.
The more backward British dairy farmer will, like the
Dane, improve under the stimulus of a sufficient super¬
vision and inspection, and by the insistence among
those whom he supplies of a higher standard of clean¬
liness of the milk.

It would be a good thing if a simple limit of dirt
could be fixed, which when exceeded would warrant
the condemnation of the milk as dangerous for use;
the consignee would return any milk which does not
reach the standard, and the farmer would then soon
learn the lesson of the necessity for greater cleanliness,
and where neither he nor any member of his family
assisted in the milking operation, he would find it in
his interest to at least exercise the necessary supervision
over those who do the work. To put it mildly, too
often only the most rudimentary precautions are taken
at the fountain-head, and the slovenly methods of the
past must make way for more cleanly ones, which
involve the minute attention to detail which comes
with an educated cleanliness. The state of filters and
separators after use is eloquent testimony to the need
for reforms. The suggestion for a diet standard
(based on pus or blood cells and the volume
of dirt that can be separated) has met with a wide
approval, and is one of the possibilities of the near
future. Excessive bacteria generally imply excessive
dirt, and dirt is as bad as adulteration, if not worse.

I realise that under no conceivable conditions can
we hope in general practice to collect milk which is not
planted with many hundreds of micro-organisms to
the c.c. ; but the fact remains that by greater efforts
to reduce the number of extraneous organisms which
now get into the milk at the time of collection, and by
preventing those from unduly multiplying in the
interval of collection and distribution to the public,
we should achieve a valuable and vital improvement
in the purity of the milk. It is this improvement at
the source which is so much demanded, for the exces¬
sive contamination there either handicaps or nullifies
all the subsequent precautions which may be taken.

It is to the dicta of their trade organisation that the
country dairymen and dairy farmers will turn the most
willing ear. The better class dairymen have done much
to educate their own farmers, and would not the Dairy
Association do valuable work by publishing detailed
dairy rules, somewhat of the nature of those issued by
the United States Department of Agriculture, 1900.
and founded on the advice offered in the published
leaflets of our own Board of Agriculture?

It has often impressed me as a most discreditable
circumstance in our sanitary administration that the
legal powers which it is competent for any rural
sanitary authority to execute have either been so
ignored or badly administered that in the rural dis¬
tricts, where the bulk of our milk comes from, there

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ORIGINAL PAPERS.

The Medical Press. 195

exists practically nothing worthy of the name of a !
sanitary supervision of dairy farms. By consequence
the larger milk dealers have had to step into the
breach, and in order to protect themselves and their
customers from the consequences of the neglect of the
proper authorities, have taken upon themselves these
duties ; and it is no exaggeration to state that the re- !
quirements and conditions imposed by up-to-date milk \
vendors under their contracts with the farmers, furnish
an object-lesson of what can and ought to be done,
xo the best organised and most advanced rural sanitary
authority in this country. But this is an unfair tax
upon the milk trade, and if rural sanitary authorities ,
did their duty it would be unnecessary. From in¬
formation obtained in 1903 by the British Medical
Journal from Medical Officers of Health of counties
and of combined sanitary districts, it appeared that m
England and Wales, as a whole, some 30 per cent,
of the sanitary authorities had made no regulations
under the Dairy and Cowsheds’ and Milkshops’ Order,
1885; that very few of those who made regulations
had provided efficient means for the supervision which
is necessary to ensure that they are carried out; and
that under the Order of 1889 (for dealing with tuber¬
culosis of the udder) only four had arranged for any
measure of veterinary inspection of milch-cows.

This year Mr. Burns made a statement in the House
of Commons to the effect that there are at present
some 20 per cent, of authorities without the regulations
empowered in 1885—20 years ago!

All local authorities should be compelled to adopt
and enforce suitable and sufficient regulations, and the
Local Government Board should appoint inspectors to
see that these are enforced. Moreover, a Bill should
be drawn up for the purpose of empowering the
County Councils to supervise the execution of the
regulations and to take over and execute the powers
of defaulting authorities and to charge the expenses
to defaulting districts.

It is clear that the fundamental difficulty in obtain¬
ing these most necessary reforms is that the sanitary
authority who administers the law in rural districts
generally consists of those who have the least interest
in making it effective, and who often deliberately make
it lax, because the adoption and proper enforcement
of the existing powers at their disposal would affect
their pockets. It is this circumstance which gives great
weight to the plea for making the responsibility for
the necessary control and inspection of the milk
industry a central and national one; and a further
argument is the circumstance that otherwise the con¬
ditions imposed will vary in their stringency in
different districts, and thus affect the trade unequally
and unfairly. In default of such a national control
the County Councils and County Boroughs must be
charged with special powers and duties in this con¬
nection—an alternative which, while presenting advan¬
tages over existing conditions, is immeasurably inferior
to a central control for the whole country. Why, in
any event, should not the execution of the above-men¬
tioned powers be subject to more supervision by a
Government Department? They transcend in their
importance to the public health the legislation dealing
with the sale of food and drugs, yet in this matter the
central authority keeps in close touch with all local
authorities, frequently making representations with
reference to the administration of the Acts, and giving
advice upon the difficulties encountered ; but our milk •
supply is comparatively neglected by them.

You will agree with me that another very necessary
reform is the annual licensing of all premises where
milk is either sold or collected or prepared for the
purpose of sale. This has already received legal
sanction in the Liverpool Improvement Act, which
dates as far back as 1867. The conditions of the initial
grant of the licence must be the suitability of the pre¬
mises and the sufficiency of the general arrangements
for the important purposes to which they are put, and ]
the annual renewal must be conditional upon the main- 1
tenance of these at a satisfactory sanitary standard.
There is another precedent for this in the annual 1
licensing of slaughter-houses, and none will dispute
the greater claims which may be urged in favour of ,
licensing dairies and shops where milk is sold. The j
provision would, of course, apply to dairy farm pre- !

raises, none of which should be licensed unless ade¬
quate arrangements exist for cooling the milk ; and
under its operations it is to be hoped that milk will
no longer be sold in shops fully exposed to dust and
flies, and more particularly in such places as chandlers'
shops.

Such a requirement would not hit anyone who was
conducting the business with due regard to the bare
necessities of the case, but it would eliminate a few
from the trade who should not be allowed to continue
to carry it on to the public danger. It is not necessary
that the premises licensed should be structurally
elaborate; elaborate cleanliness is what is wanted :
and the means for securing this, and the evidence of
a conscientious and intelligent effort to maintain it,
should determine the granting and renewal of such
licences.

The arguments in support of the frequent veterinary
inspection of cows the milk of which is used for
human consumption (whether as milk, cream or butter)
is overwhelming.

I believe that you will agree that such an inspection
cannot be provided by the rural and small urban sani¬
tary authorities, for many reasons, and it certainly
would not be fair to saddle all the expenses involved
upon the dairv districts. Failing these authorities,
the duties would devolve upon the County Councils,
and, failing them, upon the Local Government Board
or the Board of Agriculture. Personally, I should
favour a system of quarterly inspection under one of
the latter boards, but it might be undertaken by the
County Councils and the County Boroughs, and I
would give them power to act quite independently of
the local sanitary authorities. But some fair measure
of compensation should be provided (as under the
London County Council (General Powers) Act, 1904),
when animals infected with tuberculosis have to be
removed from the herd and slaughtered. I am out of
sympathy with the antagonism evinced in many
quarters against a fair measure of compensation in
such a scheme. The cost, having regard to the im¬
portant issues at stake, and to the fact that it would
remove the formidable barrier which trade opposition
can erect against legislative action, is small, and would
tend to grow smaller year by year, and without it the
scheme of veterinary inspection will be under a great
disability. Under most milk contracts with farmers
the farmer is exempted from any loss which might
result from his giving prompt information of the
existence of infectious disease in anyone connected
-xtnith the cows and the milk. This is found to be a
valuable concession as guaranteeing that the necessary
information will not be withheld ; it is for a similar
reason that I advocate compensation for the compul¬
sory slaughter of the milch cows, and my advocacy is
strengthened by the circumstance that the clinical
diagnosis of tuberculosis is often very difficult. I
would not advocate a full measure of compensation,
for some loss upon a tuberculous animal will serve as
a stimulus to many farmers to be more careful what
they buy, and to do more (especially in the matter of
the ventilation of the sheds) to keep cows free from
this disease. To further the ends of this necessary
veterinary inspection, the Board of Agriculture should
make tuberculosis in milch cows a notifiable disease,
and it is not too much to require that farmers should
be compelled, under a penalty, to notify any udder
diseases in a milch cow, and to refrain temporarily
from selling the milk of cows so affected, pending the
veterinary inspection. The scope which at present
exists for reduction of tuberculosis in bovines, without
seriously interfering with the conduction of the trade
or increasing the cost of the milk to the public, is
demonstrated by the operation of the L.C.C. and Man¬
chester Milk Clauses, the latter Act having led to a
reduction of the number of tubercular samples sold
by over 40 per cent.

But all along the line there is need for re
form, and for many reforms which the trade
itself should do more to promote. Time, how¬
ever, demands that I should conclude my opening
remarks within a few minutes, and those I propose to
devote to a very important issue of the milk question.
Although I am confident of great advances in the near

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ORIGINAL PAPERS.

Aug. 21, 1907.

future, I do not expect to see such a measure of im¬
provement as would lead me to recommend the feeding
of infants with raw milk in the summer months, when
Pasteurisation appeals to me as a measure of enormous
public health value, as much preventable disease would I
thereby be prevented, and we should have no more
drugging of milk with chemical preservatives. And as 1
the contamination of the milk in the home is a cir¬
cumstance which is responsible for much of the evil
consequences of the consumption of raw milk in the
summer months, I am confident that before long all
milk will be sold in bottles. This represents an im¬
portant advance in the right direction, when the proper
means are provided for thoroughly cleansing the
bottles by steam under pressure, and for filling them at
headquarters. The bottle protects against the access
of dust and flies before and after the milk reaches the
home, and it is almost a guarantee of unwatered milk
and of full measure.

I believe that in no other civilised community is
raw milk consumed in such proportion as in our own
country, and yet practically all leading authorities in
this and other countries inveigh against its use,
especially in the summer months. Is it not clear, then,
that in the interests of preventive medicine we should
make the dangers of artificial feeding the argument for
obtaining breast-feeding whenever possible ; but, fail¬
ing that, we should discourage the employment of raw
milk for infant-rearing until we attain to (if it is
attainable in general practice) an absolutely pure milk
supply? But although we shall certainly much reduce
the dirt in milk, it is inconceivable that we shall ever
do away with it entirely. Even with a much-vaunted
supply in Copenhagen, I was astonished to see the
large amount of dirt present in the milk arriving at
the depfit. Now the alternative to raw milk is to heat
it to a temperature which represents Pasteurisation or
to the far higher temperature of sterilisation.

With regard to the prolonged use of sterilised milk,
it is conceded that some danger exists, but there is a
tendency to a great exaggeration of the danger in this
country. This is the view of many competent authori¬
ties with whom I have discussed the subject, and the
following facts support the view.

What is the experience in this country? There are
each year many thousands of infants up and down the
country who are fed upon sterilised milk, and there
has been for some years a large market for such milk;
the -use of (sterilised) condensed milk for infant feed¬
ing is also a very extensive one ; yet the testimony to
its evil effects is trifling. The bulk of the milk supplied
at institutions to infants in this country is either steri¬
lised or Pasteurised, and wherever sterilised milk has
been given out in infant milk depfits there has been
no mention of infantile scurvy. But the Registrar-
General’s reports afford perhaps the best justification
for the pronouncement in favour of the harmlessness
of sterilised milk, for, despite the extent to which it
is used at the present day in this country, we find that
only ten deaths occurred from scurvy among infants
under one year of age in the vast community of
London during the three years 1903, 1904, and 1905,
whereas for every such death about 800 deaths were
certified from diarrhoea (stated to be due to food),
epidemic diarrhoea and infantile enteritis, and
diarrhoea (not otherwise defined).

What is the experience abroad? In America, Den¬
mark and France, each with an extensive experience
covering many years, the verdict is favourable
to sterilised milk. Dr. Variot, whose experience is
unique, since his feeding experiments at the “ Goutte
de Lait, ” at Belleville relate to over 3,000 healthy as
well as unhealthy children who were closely observed by
him for many months, has seen nothing of infantile
scurvy resulting from the use of sterilised milk. The
facts collected from the experience of other such
institutions abroad, and from the Consultations des
Nourissons in France, are further testimony to the
almost absolute harmlessness of sterilised milk. On
all sides the general experience is that extremely little
scurvy results from the use of such milk, and the late
Professor Budin, whose “ Consultations ” are now
established all over France, and were first started in
1892 with the object of advising and helping French
mothers in the healthy rearing of children, wrote to

me under date April 6th, 1906, that as the outcome of
his wide experience he had not seen a single case of
infantile scurvy resulting from the use of sterilised
milk.

This is not the place to discuss the etiological rela¬
tionship of the prolonged use of sterilised milk to
scurvy in the infant, but the absence of that unknown
quantity, “the anti- 9 Corbutic principle,” can only at
most affect those patients with a very rare idiosyncracy.
But although it is granted that the use of sterilised
and boiled milk occasionally harms a child (for this is.
testified to by those whose findings are authoritative
and beyond dispute), it cannot be in the public interest
to discourage its use in face of the overwhelmingly
greater dangers of raw milk. If one sets the danger
of sterilised and boiled milk against that of the raw
article, the former danger sinks into insignificance by
the side of the latter. Those who rail against the use
of sterilised milk say, in effect, that rather than one
child should suffer from scurvy, some hundreds may
be left to die of zymotic diarrhoea, etc. There is,
however, practically no evidence that Pasteurised milk
has caused infantile scurvy, and it possesses the addi¬
tional advantages over sterilised milk that its taste is
unaltered, the physical changes brought about by
Pasteurisation are practically nil, and the digestibility
is not impaired ; and, furthermore, Pasteurised milk is
consumed in a fresher condition than sterilised milk.

As to the provision of municipal milk depfits, I am
not, I must confess, enthusiastic. That they are
valuable object-lessons to the community (including
the trade) I have no doubt, but I believe that educa¬
tionally and sociologically the provision of infant
consultations, as inaugurated by the late Professor
Budin, are to be preferred. Such provision was made
a little more than a year ago at the St. Marylebone
General Dispensary, London, and the results appear to
be (so far as one can judge from statistics) at least as
good as those obtained from the Metropolitan muni¬
cipal milk depfits. Through the efforts of Dr. Sykes,
“ A Mothers’ and Babies’ Welcome,” with similar aims
to those of the “Infant Consultations,” has recently
been established in St. Pancras, London, and is doing
excellent work. I am of opinion that the mothers
should be left to obtain the milk through the ordinary
commercial channels, and that those milk vendors
should be recommended who are willing to conform
to the conditions imposed by the directors of the
Consultation.

In conclusion, I know that there is among medical
men a general agreement with my main contentions,
and yet in this, as in other matters, we muddle along
and delay the day when the full beneficent results of
our knowledge will be reaped.

The President of the Local Government Board has
stated that he proposes to make legislative proposals
on his own account next year. At the risk of being
judged presumptuous, I would suggest that what is
wanted more particularly is stringent legislation,
embracing, above all, a scheme of efficient inspection of
dairy farms and milch-cows; and, with reference to
certain matters that do not lend themselves to effective
legislation, an authoritative pronouncement by the
Local Government Board. As to the matters referred
to in the latter category, let me remind him that in
other countries neither the public nor the trade is left
in doubt that what is the correct thing to do is to avoid
the use of raw milk, at least in the summer months,
and Pasteurisation and sterilisation is encouraged.
Those responsible for the public health in New York
and some other American States have made no secret
of their preference for Pasteurised milk. The conse¬
quence is that the trade has responded, and a consider¬
able reduction in infantile mortality is claimed as the
result of its very general use. In France they have
made up their minds on the subject, and the French
Minister of Public Instruction has advocated the use
of Pasteurised, boiled or sterilised milk as a precaution
against disease. The central authorities in Denmark
and Germany have also given advice on the subject.
But in this country no such lead is given. If the
public were informed by a Government department
what it is they ought to demand, the trade (at present
distracted by all sorts of conflicting views and state-
I ments) would the sooner fall into line.

Aug. 21, 1907.

CORRESPONDENCE.

OP£RATING THEATRES.

KING’S COLLEGE HOSPITAL.

Operation for Ruptured Gastric Ulcer.—
Mr. Peyton Beale operated on a coachman, aet.
about 35, who had been admitted, under the following
circumstances: at two o’clock in the afternoon, having
had no food since breakfast, he was seized with
sudden and very severe pain in the abdomen ; it
started in the lower part in the region of the bladder,
then extended to the right iliac region and right loin,
and when he was admitted at about 3 p.m., was found
to be most severe in the gall bladder region. There
was a history of rheumatic fever, and the man had
aortic and mitral murmurs. His chief complaint
was difficulty of breathing. The pain was so severe
that he was obliged to sit up, and he was sweating
profusely. He was admitted and ordered to be kept
very warm, and fomentations were applied over the
abdomen. He vomited once only, bringing up some
bile-stained fluid. There was practically no dis¬
tension of the abdomen, but there was very well
marked dulness in both flanks. At 8 p.m., about
five hours after admission, his condition was as
follows : pain localised to the epigastrium, slight
abdominal distension, marked dulness in both flanks,
no vomiting, temperature 99, and tending to rise,
pulse 120, considerable respiratory difficulty except
when sitting up. He had given an old history of
indigestion extending over some months, but at no
time had he suffered from ha-matemesis or from
melaena. It was considered advisable to explore
the abdomen at once, so, the usual preparations having
been made, the abdomen was opened in the right
linea semilunaris. A quantity of turbid fluid at once
escaped, and there was little doubt that this came
from the stomach. On inserting the hand into the
abdomen and exploring the stomach, a perforated
ulcer about the size of a threepenny piece was detected
in the smaller curvature of the viscus close to the
pylorus. This was with some difficulty brought to
view, its edges were rapidly excised and several
sutures introduced in order to approximate the borders;
more sutures were then used to bring together the
peritoneal covering of the stomach and thus to close
over the line of previous sutures. The stomach was
next explored, but no other ulcer could be detected.
The abdominal cavity was then washed out very
freely with hot sterile salt solution and the abdominal
wound closed, two gauze drains being inserted at
each extremity. The patient was put to bed and
ordered to be given as much morphia as might be
necessary to keep him absolutely quiet. The whole
operation lasted about twenty minutes. Mr. Beale
said that in his experience the elements of success
in these cases rested upon the carrying out of the
following conditions : First, to operate at the earliest
possible moment, even though there was considerable
doubt as to the diagnosis, confirmation of the diagnosis
often not being obtained until general peritonitis was
well advanced, to wait until this occurred was, of
course, in most cases fatal; secondly, to operate as
quickly as possible, and not to insert more sutures
than were absolutely necessary to approximate the
freshened edges of the ulcer. If the ulcer were larger
than a threepenny piece, it was always wiser and
really quicker in the end to open the stomach freely
on its anterior aspect and sew up the ulcer from
within, subsequently closing the stomach incision
with a continuous suture ; this procedure was, of
course, always necessary when the ulcer was situated
at all posteriorly. The process of dragging the

The Medical Press. 19 7

stomach up in order to reach the ulcer in the ordinary
way was, he considered, very dangerous. Thirdly,
to operate in a very hot room or theatre, to have all
instruments and lotions as hot as possible, for he
was perfectly convinced that the greater part, if not
the whole, of the shock subsequent to abdominal
operations was due to exposure to cold ; fourthly, to
keep the patient fully under morphia for two or
three days after operation, that is to say, to ad¬
minister sufficient morphia to keep the patient
perfectly quiet.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Pari*. Aug. 18 th, 1907.

Exophthalmic Goitre.

Numerous are the theories put forward relative to
the cause of exophthalmic goitre, but only two of the
group claim attention—nerve and thyroidian theories.
The former incriminates either an affection of the bulb
of of the sympathetic system.

Authors who pronounce in favour of disorders of
the bulb invoke the co-existence of cardiac troubles,
vaso-motor troubles on which might depend the goitre
(congestion of the thyroid), and exophthalmia and
the trembling, from paralysis of the cranial nerves.

The theory which attaches Graves’ disease to a
lesion of the cervical sympathetic is based on the
theories of Claude Bernard and more particularly
those of Abadie. For Abadie, there existed a per¬
manent excitation of the vaso-dilating fibres of the
cervical sympathetic or of their nuclei. The origin of
the vaso-constrictors being abolished, the carotid
arteries and those of the thyroid gland, dilate, and
the result is hypertrophy of the gland from turgescence
of its arteries, hence goitre ; the vessels of the bulb
dilate also, hence exophthalmia. As to tachycardia,
it is the direct result of the disturbance of the great
sympathetic. Thus, the three great symptoms of the
malady are easily explained.

Plausible though it be, this theory is being gradually
abandoned as lesions of the sympathetic are far from
being constant in Graves’ disease, and, according to
Francois Franck, the sympathetic exercises no vaso¬
dilating action on the thyroid body. Yet the con¬
ception of Abadie deserved mention, as it had as a
consequence, originated the surgical treatment of ex¬
ophthalmic goitre by section of the cervical sympa¬
thetic.

Much more important would be the thyroidian
theories, which are two in number, one sustained bv
Ganthier, incriminating perversion of the secretion of
the gland, the other exaggeration of this secretion
(Mobius).

The last-named is based on clinical facts. In
myxoedema, which results from thyroidian insufficiency
symptoms are observed (atrophy of the thyreid body,
sensation of cold, lowering of the central temperature,
dryness of the skin) which are exactly the reverse of
the symptoms of Basedow's disease. On the other
hand, MM. Ballet and Enriquez reproduced, by in¬
jecting thyroid extract into sheep, a certain number
of signs of exophthalmic goitre.

For M. Boix, neither of these theories should be
considered absolute, as we have not yet arrived at a
perfect knowledge of the nature and cause of the
malady.

Treatment.

The treatment is either medical or surgical. The
medical treatment is very important, and can, if pro¬
perly carried out, cure the patient. Absolute rest in
bed should be prescribed, where the symptoms present
the slightest gravity ; this means alone are sufficient
to moderate the cardiac palpitations and the nervous
agitation. In every case, the patient should be

Digitized by GoOgle

jg8 The Medical Press.

CORRESPONDENCE.

Aug. 2i, 1907.

guaranteed from all excitement and brain worry.
Country air is very beneficial, but a sojourn at the sea¬
side is counter-indicated.

As to medical treatment proper, digitalis has been
prescribed for palpitations.

Trousseau recommended it in large doses until
symptoms of intolerance set in, while Jouffroy recom¬
mended strophan thus. But Dieulafoy considered either
of these drugs as more or less hurtful, and they should be
reserved for cases of weakness of the cardiac muscle,
with dilatation of the cavities and a tendency to
asystolia. He prescribes, on the other hand, ipeca¬
cuanha.

Hippo powder, 1 gr.

Digitalis, 4 gr.

Ext. of opium, 1-loth gr.

For one pill. Two, three, or four daily, and con¬
tinued for months.

Agitation and insomnia are best treated by bromides
or valerian and febrile attacks by antipyrine (Huchard),
salicylate of soda (20 gr. four times daily) gave good
results in the hands of Chibret and Babinski.

Hypertrophy of the thyroid body has been treated
by iodine and iodides, but, according to Dieulafoy
they do more harm than good. The same might be
said of ferruginous preparations.

Among physical agents, hydrotherapy procures
frequently excellent results. The cold douche may be
ordered, but in order to accustom the patient to the
cold water, warm douches might be given for the first
two or three days.

Electricity is one of the best therapeutical agents ;
it is local and consists of two great methods—that of
Eichorst, utilizing galvanisation, and that of Vigouroux,
employing Faradisation ; they may be associated.

The seance may be commenced by galvanisation,
one plate on the tumour, the other on the back of the
neck. The seance should be from one to ten minutes,
according to the tolerance of the patient. Then Fara¬
disation of the orbicular region, the sides of the neck
and the precordial region should follow.

The duration of the electric treatment is from three
to four months. Decrease of the goitre, attenuation
of the trembling, improvement of the general condition,
are frequently observed after the first few seances.
According to Delherm, improvement in the palpitations
and the exophthalmia is much slower.

As to opotherapy, it has but little place in the treat¬
ment of exophthalmic goitre ; iodo-thyrine would be
only beneficial where the malady depended on defect
of the secretion of the thyroid gland, which is far
from being proved.

Gilbert Ballet and Enriquez imagined an immu¬
nising serum taken from the horse or the sheep, from
which they had previously removed the thyroid gland.
Mixed with glycerine and given at the dose of three
teaspoonsful a day, it has given encouraging results.
All the symptoms improved rapidly—goitre, palpi¬
tation, exophthalmia and trembling.

The surgical treatment consists in total or partial
thyroidectomy, resection of the cervical sympathetic,
operations which may be regarded as generally useless,
and should be only counselled as a last resource.

The treatment of Graves’ disease requires great
atience, and the physician should know how to vary
is treatment according to the particular case. But
if intelligently applied, the treatment procures in the
large majority of cases, if not a complete cure, con¬
siderable improvement and prolonged remissions.

GERMANY.

Berlin. An*. 18 th. 1907.

At the German Society for Surgery, Hr. Kausch,
Berlin, discussed the subject of

Contracted Bladder and its Treatment.

He first described the various causes of the abnor¬
mally small bladder (congenital, neuroses, affections
running their course outside bladder, inflammatory
growths, tumours lying within the bladder, and calculi ;
concentric hypertrophy). By far the most frequent
cause was interstitial cystitis with disappearance of

the muscular walls (contracted bladder). The con¬
dition of the severe cases in which the bladder capacity
fell to 10-20 ccm was intolerable ; at last all the patients
died with ascending inflammation.

The treatment consisted in dilatation of the bladder ;
this, however, when inflammation was present or
when it supervened was out of the question and did no
good. In one case a suprapubic fistula was formed and
the sufferings of the patient were very much diminished.

The speaker in one case, that would be more fullv
related, nad totally disconnected a loop of small intes¬
tine and brought it into connection with the bladder,
the capacity of which was only 20 ccm. The patient
was discharged cured, continent, with a capacity of
200 ccm. The procedure might be advisable in cases
that could not be relieved in any other way or in which
the bladder had been totally or almost totally extir¬
pated.

Hr. Schmitt, Munich, observed that none of the
operations at present employed secured complete
continence. Maydl’s method of implanting the ureters
into the bowel still gave the best results.

Hr. H. Jacoby, Berlin, showed apparatus for stereo¬
cystoscopy and stereoevsto-photography and also
photographs produced by them.

Hr, Ringleb, Berlin, believed that vision was not
stereoscopic with the apparatus shown, but that with
Nitze’s instrument it was easy with practice. It was
not to be denied, however, that stereocysto-photo-
graphy was an important advance.

Hr. Korte, Berlin, had performed Maydl’s operation
in one case, continence was not complete, but the
patient was very much improved.

Hr. Kiimmell, Hamburg, greeted Rovsing's method
of performing total extirpation of the bladder as an
important advance. Total extirpation of the bladder
for carcinoma was always very fatal. In two non-
carcinomatous cases the results were better ; in one
case death took place 4 years after from ascending
disease ; in the second case, that of a boy, death took
place in a year.

Hr. Riedel, Jena, had been successful in one case ; a
second one died of ascending pyelitis.

Hr. H. Stettiner, Berlin, showed a case of
Multiple Intestinal Atresia.

*lhc patient, an infant aet. 13 months, presented
the deformity of Atresia ani urethralis or Atresia ani
et communicatio recti cum parte prostatica urethrae as
Sticda called this form of malformation. The first
operation was performed on the second day after the
birth of the child, and consisted in making an opening
to the blind end of the rectum and suturing it to the
place where the anus should have been. The second
operation was performed four weeks afterwards, the
object of which was the abolishment of the communica¬
tion. Here also the operation was performed from
the perineum. The urethra tore at the point of com¬
munication and a N^laton’s catheter had to be sutured
in. The opening in the rectum was also closed and the
operation concluded with a proc.to-plastique. A
perineal urinary fistula formed at first but closed later.
Urination was now normal, the bowel function was
not perfect but satisfactory. Communications of the
blind end of the rectum with the urinary organs were
met with at three spots, most rarely at the summit ot
the bladder, most frequency at the base, and thirdly
at the prostatic part of the urethra. Whilst the first
named malformation required laparotomy, separation
of rectum and bladder, suture and pushing down of the
blind sac to the perineum with proctoplastiquc, such a*
I.otsch had lately carried out successfully in a case,
with deeper seated communications the operation
should be carried out from the perineum. He would
do the operation at two separate sittings but w’ould
not put off the second to a later age, but at the most
for two to six weeks after the first part.

He also showed the bowel of a child with multiple
stenoses on which the operation for artificial anus had
been performed 24 hours after birth, but which diet!
60 hours after the operation. At the post-mortem it was
found that the small intestine ended in a blind sac 7 $ cm.
below the pylorus. This blind end lay in a tangle ol

zed by Google

Aug. 2 i, 1907 -

CORRESPONDENCE.

The Medical Press. I 9 Q

matted loops m which the blind end of the further
portion of the small intestine lay. This was at first
much dilated, and it was here th?.t the artificial anus was
made. Next to this was a mass of thin twisted serpen¬
tine loops, then the normal colon with a large ver¬
miform appendix and the rectum only the size of a
pen holder. There was also a good deal of peritonitis
robably secondary. It would have been better to
ave operated lrom the abdomen so that the require¬
ments of the case could have been met.

AUSTRIA.

Vienna, Ah*. 18th. 1907.

A New Function of the Pancreas.
Professor Loewi, in a long paper read before the
members of the Gcsellschaft, raised a new point in
connection with diabetes mellitus, which had been
excited in his own mind by the experiments of Eckhard,
who demonstrated a short time ago that, if the sym¬
pathetic could be inhibited, irritation of the nerve,
cither centrally or peripherally, would produce sugar
in the urine by the transformation of glycogen. If
the pancreas possesses this function alone of irritating
the sympathetic which has been proved to cure the
diabetes in some experiments, by its removal, we have
in our hands a speedy remedy for the disease. With
this argument in view, Loewi commenced the exami¬
nation of the hypothesis from another point. The
dilator muscle of the pupil of the eye is the best index
of the sympathetic at our command. If adrenalin be
dropped into the normal eye no mydriasis will appear,
as this drug stimulates the motor fibres of the sym¬
pathetic ; but if the cervical ganglion be removed
twenty-four hours before dropping in the adrenalin,
mydriasis will appear. Now of 18 diabetic patients to
whom Professor Loewi administered the adrenalin to,
10 of them suffered afterwards from mydriasis.
Of 28 other patients suffering from other diseases,
only two had mydriasis, viz., one suffering from
occlusion of the pancreatic duct according to cliaical
diagnosis, but no glycosuria was present. From this
he assumed that the two functions of the pancreas can
be separated. The other case that acted was one
suffering from morbus Basedowi, which from this re¬
action may have some close connection through the
sympathetic nerve system.

Freund thought this an important contribution to
our knowledge on a very abstruse and obscure subject
in medicine. From a chemical standpoint, Professor
Loewi’s theory was interesting. We have a series of
clinical observations very conflicting when an attempt
is made to reduce them to order but if a chemical
insufficiency in the hepatic cells be accepted this
would interfere with the function of the organ and
prevent the sugar being converted into glycogen. In
1902 he had a considerable amount of discussion and
examination of cases which resulted in the opinion
that different forms of diabetes mellitus were due to
vascular paralysis, supposed to be due to central
irritation as well as peripheral, causing a dilatation of
the .vessels that had no power to contract. Toxins and
antitoxins possessed the same property of paralysing.

Falta thought that Professor Loewi’s theory had a
wider interpretation as it could be extended to the
Naunyn school, which believed in the disturbance of
glycogenic circle by the loss of power in the lung to
burn up the superfluous grape sugar. Freund’s
chemical theory might be true of slight or simple forms
of diabetes mellitus, but in severe cases no clinical
argument could support it; indeed, experimental
pancreatic diabetes contradicted it. The burning up
metamorphosis seems to have more clinical support
than ever. At this point Freund reminded Falta that
Kfilz founded the whole of his chemical theory of dia¬
betes on purely clinical evidence, and not on labora¬
tory experiments like these of Loewi’s.

Loewi replied that his experiments with the stimu¬
lation and inhibition of the different fibres of the
sympathetic were not stimulation and inhibition of the
vascular nerves nor on the consumption or expenditure
of oxidisable material, but rather a physiological func¬

tion in the nerve system existing between this and the
spleen. His theory is purely experimental, although,
curiously enough, the 28 cases given above support the
theory in the sugar metamorphosis.

Injury to Neck W'ith Paralysis.

Heyrovsky presented a case of some interest from
its subsequent development. The patient was aet. 62.
and in January', 1906, received a stab in the left
posterior side of the neck. The external jugular vein
was slit open for some distance, but beyond that no
other untoward circumstance was present.

The wound healed kindly in a very short time, but
suddenly one day an unusual sequence was discovered in
paralysis of the left recurrent nerve from a probable
injury of the left vagus which appears to have in¬
volved the left sympathetic as myosis and enophthal-
mos were present. On closer investigation it was
ascertained that the myositos and enophthalmus .or
contraction of the pupil and retraction of the eye-ball
were noted immediately after the accident, but it was
expected they would recover on the wound healing ;
but instead of disappearing ihey have become more
accentuated.

The question arises concerning the real site of the
lesion. Injury to the recurrens or vagus will affect
the vocal cords as it has done in this case, but the
sympathetic is also involved. The respiratory signs and
frequency of pulse are absent, which usually' accom¬
pany injury to the vagus, but the paralysis of the left
vocal cord is present, which would indicate that the
recurrens and sympathetic alone are injured.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

THREE TERM SESSION IN EDINBURGH
UNIVERSITY.

The King in Council has approved a new ordinance
which will effect very important changes on the
Edinburgh medical curriculum. The question of a
three term session, with corresponding alteration of
the dates and sequence of the professional examina¬
tion has been under the consideration of the various
governing bodies of the Association for some years
back. The originator of the reform, which has now
been accomplished, was Professor R. J. A. Perry',
now of Melbourne, and the new arrangement will, it
js believed, lighten the burden of the student by-
enabling him to take his classes and examinations
in a more convenient order, and will not lessen his
work, but allow of its being expended with more
profit to himself. The ordinance has been delayed
through the opposition of the Universities of Glasgow
and Aberdeen ; the tradition has been that all the
universities toe the line together, and the pace of
progress is that of the most conservative and slow-
moving. Even were the ordinance in itself trivial,
it would be important in the. earliest step towards
autonomy on the part of any one university, for it is
the first ordinance in which one university has struck
out a line of its own, and has not waited for conjoint
action with its fellows.

The new arrangement will remove one anomaly,
namely, that materia medica will no longer be studied
before pathology, and then the student will know
something of disease before he comes to its remedy.
An outstanding feature is the division of the winter
session into two half sessions—October to Christmas
and January to March. Professional examinations
will now be held thrice yearly—December, March,
July, at the end of each term. At present there is no
professional examination at the end of the second year,
consequently slackness is engendered among the
students, and the third year is burdened by arrears.
Now an examination in physiology is provided at the
end of the second year. In order to leave more time for
clinical and practical work the examination in anatomy
may be taken three months earlier than before. The
examinations in materia medica and pathology have

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CORRESPONDENCE.

Aug- 21 , 1907.

been transposed, so that the latter now precedes the
former. The final examination may now be taken
in four parts. Forensic medicine and public health
may be taken at the end of the summer session pre¬
ceding the final winter, and midwifery at the following
Christmas. In March, at the end of the final year,
systematic medicine and surgery can be taken, and
clinical medicine and surgery in the summer there¬
after. The present final drags a weary course of
two months, all subjects being taken at once, this
involving about eighteen separate appearances for
examination. Being now allowed to distribute his
work over a larger period greater proficiency and a
higher standard should be attained and ought to be
exacted. The new regulations will apply to all
students, future and present, and take effect in October.

TYPHOID FEVER AT PETERHEAD.

A somewhat extensive epidemic of t yphoid fever
fortunately of a mild type, has been in full swing in
Peterhead for the past month, during which period
nearly 200 cases have been notified. The source of
infection has been found in one of the reservoirs,
the water of which has accordingly been cut off. In
the herring season especially, this deprivation of
part of the usual water supply has been greatly felt,
and the Government authorities are helping the town
as much as possible from their special supply used for
the convict prison, having placed at their disposal
between 30,000 and 40,000 gallons per day. The
epidemic was at first thought to be connected with
the milk supply, but Dr. Dittmar found that it was
too extensive to be accounted for by this, and traced
it to the water. He states that a purer and larger
water supply is required by the town, which has out¬
grown the present sources. The present springs
require protection from pollution, and stream and
surface water should be excluded. Since the epidemic
began there have been 216 cases with only 12 deaths.
Fortunately for the prosperity of the town, the
population of which has swollen from 13,000 to 18,000
during the fishing period, this industry has not been
interfered with by the epidemic, and no strangers
have been among the patients. A fresh water supply
has been under consideration for some years, and a
scheme is now being adjusted which will give the
town an abundant supply for the next quarter of a
century at a cost of about /io.ooo.

BELFAST.

Bangor Nursing Society. —The annual meeting
of the Bangor (Co. Down) District Nursing Society'
was held last week, the president of the Society,
the Dowager Marchioness of Dufferin and Ava, in
the chair. In recounting the year's work the president
said that their nurses had had 260 cases under their
care, and had paid 5,645 visits. The Society had
also given help in the form of food and clothing to
many necessitous cases. Professor Sinclair, F.R.C.S.,
moved the adoption of the report. After speaking
of the need of such societies as this, and the amount
of human misery which they relieved, he dealt at
some length with the subjects of infantile mortality,
medical inspection of school children, and the physical
degeneration of the race. He pointed out that in
dealing with all these important problems the district
nurse had a part in the work. Lady Helen Munro-
Fcrguson also spoke, and told the ladies present
•• that while they looked after the work of their Society
among the poor, it was also their duty to see that
their nurses were properly remunerated, had pro¬
vision made not only for the present, but also for
the wants of old age, did their work under the best
conditions, and had that recreation and change
which ensured the maintenance of their good health
and. what was equally necessary to that success,
their good spirits.”

Up to August 14th, 132 cases of cholera were re¬
ported to have occurred in Samara, 36 of them ending
fatally. Twenty-five cases and six deaths occurred
in Astrakhan. Two deaths from cholera are reported
from Yaroslavl.

LETTERS TO THE EDITOR.

MILK AND TUBERCULOSIS.

To the Editor of The Medical Press and Circular.

Sir,—I have yielded to the suggestion of “ A
Family Doctor,” and I have very carefully read
(but not without some impatience at the absence of
fact ) this paper to which he refers me. From the
beginning to the end I do not find a single fact that
can be regarded as evidence in support of the view
of the writer. It is all pure assumption, and the
following sentences condemn his views beyond the
hope of reprieve: ” This disease (tuberculosis) is
insidious in its approach; its period of incubation
is unknown ; the signs of its presence are for a con¬
siderable time indistinguishable from those of other
ailments ; and the means of tracing its probably
remote origin are not available. Hence the impossi¬
bility tn the present state of our knowledge of presenting
evidence of the extent to which the disease may be attri¬
buted to milk or any other individual cause.” I
endorse his quotation, viz., ” If there be anything
like the danger from the meat and milk of tuberculous
cattle that medical officers of health say there is, we
should all have been dead of tuberculosis long ago.”

In spite of what the writer of the paper says, viz.,

“ That the cowhouses in the rural districts are as
insanitary as ever,” and of all the causes that are at
work in the production of this disease, it is an incon¬
testable fact that the disease is becoming less pre¬
valent under the improved conditions of life at present
existing.

If, then, I fail to find anything in the paper with
the slightest pretence to evidence, and the advocates
of the theory involved fail to produce one solitary
instance in which there was even a suspicion that the
disease had been communicated to a human subject
by means of milk, I must continue to hold my present
views in which I feel myself fully justified, and I am
not in a position to confess that they can no longer
be maintained.”

” A Family Doctor ” appears to accept statements
that are not supported by any evidence. I am not
in that frame of mind.

I am, Sir, yours truly,

George Granville Bantock.

August 17th, 1907.

THE NEW ADVANCE AT THE INTERNATIONAL
, . CONGRESS OF SCHOOL HYGIENE.

To the Editor of The Medical Press and Circular.

Sir. —As a slightly incorrect statement has been
published it would be as well to explain in some detail
the important new move in the matter of School
Hygiene which was taken at the closing meeting of the
recent International Congress. The permanent Inter¬
national Committee consisting of about sixty members
selected from almost every country has hitherto only
met during Congresses. Arising out of the question of
whether it would not be a proper thing to establish a
Bureau, with a permanent star, library’ and museum,
and so on, in some central but neutral spot, such as a
Swiss or Dutch town, it was decided, as explained by
Drs. Mathieu, Burgcrstein and Kerr, that it would
probably lead to greater progress if such Bureau was
not localized, but if each country had its own centre
lor the diffusion of knowledge, and to act as a clearing
hou'ie in the matter of School Hygiene statistics laws
and regulations. Finally, to supervise in scientific
matters and generally to do all that is possible at all
times or places to forward the human interests which
are bound up in the special lines of knowledge included
in School Hygiene, the International Committee has
formed a small Council.

This Council has all the powers of an ordinary
Committee. It can form sub-committees of experts
on special enquiries. The usual Committee procedure
is to sit round a table and discuss matters, but this
Council will deal with the various subjects that arise,
submitting the different topics by correspondence.

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OBITUARY.

The Medical Press. 201

collating the answers, and, finally, making pronounce¬
ments in urgent matters after a meeting of the Council.

It is obvious that for efficiency such Council should
be small and yet have in the elements to secure per¬
manence, and, at the same time, possibilities of slow
bat constant change. This has been done by deciding
that it shall consist of the president of the past Congress,
the president of the Congress which has just been held,
and the president of the next Congress. Nine other
members are to be elected, of whom three arc to be
from the country where the Congress was last held, and
three from the country where it will be held next,
three being selected from other lands.

Certain matters for instiince will almost at once
come under the consideration of this Council. Such
might be quoted as :—

" The question of how medical inspection of schools
can best be carried out with the maximum of efficiency
and minimum of cost.”

“The question of how far the laws of health can best
be imparted to the coming generation, so that later
they will know how to care for themselves and those
dependent on them.”

"Ihe best systems or methods of physical training
for both sexes at various ages.”

“ The feeding of children requiring proper nutrition ,
so that it shall be done without developing pauperism
and with regard to those upon whom the cost falls.”

These four matters are being dealt with practically
in a great variety of ways, and this Council should be
able to collect and analyse known facts to show which
methods are best for any town or State.

It is obvious that information thus digested will
have a very great value politically as well as educa¬
tionally, and this Council may in time come to be
officially regarded as quite analogous in matters of
School Hygiene, to that other Congress of Peace now
in session at the Hague.

I am, Sir, yours truly,

Lauder Brunton, President.

E. White Wallis,
James Kerr,

Hon. Gen. Secs.

QUACKERY IN DRUGS.

Tu the Editor of The Medical Press and Circular.

Sir,— One of the best plans of scotching the quack
medicine trade would be for all retail chemists to
write and refuse point blank to stock such articles,
and in addition, if all medical men would begin again
to write prescriptions, as in the past, the difference
would soon be felt, if only by the inconvenience
experienced in endeavouring to obtain the articles so
largely advertised bv those who will not pay a doctor,
but prefer self-medication. The gain eventually to
both retail chemists and medical men themselves
would certainly be appreciated.

I am, Sir, vours truly,

Alexander Duke.

London, W.

P.S.—The curse of the nation is self medication.

OBITUARY.

W. H. BROWN, M.Sc., F.R.C.S.I.

We regret to announce the death of Dr. W. H.
Brown, the well-known Leeds surgeon, which took
place at Headinglev, Leeds, on August 15th. Two
years ago, while performing an operation, Dr. Brown
contracted blood poisoning, and up to the time of
his death he never succeeded in completely throwing
off the effects of that illness. For some time past
his condition has been serious, and the announcement
of his death was not unexpected by his friends.

Dr. Brown spent practically the whole of his life
in Leeds. He received his early training at the
Leeds Grammar School, and subsequently studied
medicine at the Leeds School of Medicine. He ob¬
tained his M.R.C.S. (England) degree in 1878. and
almost continuously from that time to his death

Dr. Brown was connected with the Leeds General
Infirmary. After filling the position of resident
house surgeon he was appointed resident surgical
officer. In the year 1884 he became hon. assistant
surgeon, which office he held until 1890. In that
year he was appointed to the full staff, fulfilling his
duties until his resignation in December, 1906, on
account of ill-health. He was then appointed hon.
consulting surgeon. On his retirement the Weekly
Board placed on record their high appreciation of the
great services Dr. Brown had rendered to the institu¬
tion. Dr. Brown for some time was house surgeon
at the West London Hospital. He was also a demon¬
strator of anatomy at the Yorkshire College—now
the Leeds University—subsequently being lecturer
in clinical surgery. He became a Fellow of the Royal
College of Surgeons, Ireland, in 1887, and M.Sc.
(Leeds) in 1905. He was a medical referee under
the Workmen’s Compensation Act, and late hon.
surgeon to the Leeds Public Dispensary. In March
of 1905 Dr. Brown called the attention of medical
men and the public to the dangers of the primula
obconica, as illustrated by the death of a Leeds
lady who, when recovering from an attack of influenza,
aqcidently scratched her nose while smelling the
flower, death ensuing within a week.

Dr. Brown was an ardent supporter of the Leeds
Choral Union. From its inauguration he took a
keen interest in the work of the society, having
occupied the position of president. At the time of
his death he was a vice-president of the union. Al¬
though taking little part in the public affairs of the
city, Mr. Brown was a well-known figure. A man
of striking personality and genial presence, he made
many friends during his professional career, and his
death will be mourned by all who knew him.

MALCOLM L. MARGRAVE, M.R.C.S., L.R.C.P.

We regret to announce the death from morphia¬
poisoning of Dr. M. L. Margrave. The news of his
tragic death aroused deep sympathy in his native
town of Llanelly, where he and his family are held
in high esteem. The deceased gentleman was the
youngest son of Mr. Robert Margrave, J.P. He
was educated at Llandovery College, and thence pro¬
ceeded to Edinburgh. He received his medical
education at St. Bartholomew’s Hospital, London.
After acquiring his diplomas of M.R.C.S. and L.R.C.P.
(London), he held the posts of house physician and
house surgeon at the West London Hospital. After
holding many and various appointments in private
work, he travelled abroad, and for some time acted
as surgeon in the service of the British India Steam
Navigation Company, in which capacity he made
several voyages to the East. He eventually settled
down at Newton Abbott in partnership, and it was
here that his health broke down. Later on serious
heart mischief made its appearance, and it became
imperative that he should seek a more bracing climate
to live in. He was advised to remove to Scotland,
and less than twelve months ago he went into practice
at Moffat.

Apart from his purely professional attainments.
Dr. Margrave was a man of wide culture and versatile
talents. He was one of the finest tennis players
in West Wales, and as an athlete generally he ex¬
celled. He was also a great reader, his knowledge
of English literature being extensive.

CHARLES WILLIAMS, M.R.C.S., F.R.C.S.Edin.

We regret to announce the death of Dr. Charles
Williams, M.R.C.S., F.R.C.S.Edin., who had for many
years practised in Norwich, and at the time of his
death was senior surgeon to the Norfolk and Norwich
Hospital. Dr. Williams received his training at the
infirmary in that city and at Charing-cross Hospital.
He had an extensive private practice, and was con¬
sulting surgeon to the Norfolk and Norwich asylums.
Dr. Williams was an authority on the life and writings
of Sir Thomas Browne. He possessed a fine collection

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202 The Medical Press.

NEW PREPARATIONS.

Aug. 2i. 1907.

of early editions of Browne’s works, and was the
author of pamphlets on “ The Measurement of the
Skull of Sir Thomas Browne.” “ The Portraits of Sir
Thomas Browne,” "The Bibliography of the Religio
Medici,” and " The Pedigree of Sir Thomas Browne.”
He also published interesting facts about " The Treat¬
ment of the Sick in Norwich during the 17th century,”
and “ The Barber Surgeons, of Norwich.”

SPECIAL ARTICLE.

THE REPORT OF THE LOCAL GOVERNMENT
BOARD FOR IRELAND FOR 1906-7.

Tuberculosis in Ireland.

The Annual Report of the Local Government
Board, which has just been issued, supports very
fully the opinion put forward by the Registrar-General
with regard to the prevalence of tuberculosis in
Ireland.

The present report dwells on the fact that in 1905
close on 12000 deaths in Ireland were due to tuberculous
diseases, and particularly to pulmonary tuberculosis
and that the death rate from this particular form of
disease stands at a far higher figure in Ireland than
in either England or Scotland. Referring to the
feeling that has been aroused on the subject, the
Local Government Board say that they are glad
to state that the question has aroused very general
interest, and that some of the sanitary authorities
in and about Dublin, where the death-rate from
tuberculosis is especially heavy, are taking steps
to combine in a scheme for the establishment of a
joint sanatorium for consumptives.

The Board fully recognise, they say, that it is a
tedious and difficult task to secure co-operation
among sanitary authorities for the establishment
of sanatoria. The cost is for the most part too great
to admit of one authority undertaking the erection
of a sanatorium single-handed, and consequently
a united district and a joint board of several authorities
has to be constituted by Provisional Order, involving
delay and considerable trouble in securing the consent
of the various local bodies affected. On this point
by way of a solution of the difficulty, the Local,
Government Board say :—

“ If the matter remains in the hands of existing
-sanitary authorities, a long period is likely to elapse
before there is proper accommodation for the treat¬
ment of consumptives throughout Ireland. We con¬
sider, however, that many of the difficulties at present
experienced would be overcome if power were given
to County Councils to establish and maintain, either
singly or in combination, suitable institutions for
the treatment of consumptives.”

The Board state further that in the opinion of their
medical department the prevention of consumption
should be dealt with on a systematic plan, consisting
of these four elements :—

(1) Advanced cases should be accommodated apart
in hospitals, the mere segregation of highly infectious
patients from healthy persons being in itself a great
safeguard against the spread of the disease.

(2) Where the disease is iD an incipient stage and
is capable of being cured or arrested, sanatoriums
should be provided, where persons affected could be
sent for proper treatment.

(3) In large centres of population, dispensaries
where advice can be obtained, and where the latest
methods of treatment can be tried, have proved very
successful in other countries, especially in France,
and might be established in Ireland with advantage.

(4) Lastly, local committees appointed by sanitary
authorities to deal with the question of consumption
would be very beneficial. The functions of such
committees would be educative. They should en¬
deavour to personally convey information to sufferers
and also circulate leaflets and literature relating to
this disease. Much might be done by active com¬
mittees, who would advise their neighbours on the ad¬
vantage of simple sanitary precautions in their homes.

Something more even than this, however, is needed

in the opinion of the Local Government Board'
They say, specifically:—

” We are of opinion that compulsory notification
of pulmonary tuberculosis should be carried out by
special legislation, and that safeguards should be
provided to ensure that no unnecessary restraint
is placed on the liberty of consumptive patients.
If notification is used merely for the purpose of gaining
information as to the locality of the disease, and
helping the sufferer by giving assistance and advice,
which would be useful in protecting other members
of his family from contracting the disease, we con¬
sider that it would, under efficient and sympathetic
administration,be a most useful public health measure.”

The Board report that the Guardians of the South
Dublin and Belfast Unions have shown a keen desire
to improve and enlarge their accommodation for cases
of consumption. The former, we are told, are making
an extension of their female consumptive department
for twenty additional patien ts. The Belfast Guardian s
it appears, have, during the past year, opened four
pavilions at the Abbey Sanatorium, in which there
were 112 patients on March 31st last, and the large
hospital, which is rapidly approaching completion,
will accommodate about 150 of the less hopeful
cases. With the completion of this building, the
Guardians will have spent about £34,000 on the
purchase of the site and the erection of the buildings.
The sanatorium will then have accommodation for
about 265 patients with space for further extensions,
which, however, will cost considerably less per bed,
as the ground and the administrative arrangements
are already provided.

Speaking generally of the country, the Board say
that the subject of the treatment and segregation of
cases of pulmonary tuberculosis in workhouse in¬
firmaries continues to receive constant attention,
and the nature of the disease being now more fully
recognised, Boards of Guardians are evincing greater
willingness to make provision for the care of patients
suffering from it.

NEW PREPARATIONS.

ROGERS’ MUSCATOL IN INSECT BITES.

Under the title of “ Muscatol ” Mr. Frank Rogers,
the well-known chemist of Oxford Street, London,
has introduced a pleasant preventive of insect bites.
There is plenty of room for a good preparation of the
kind, and Muscatol, so far as we nave been able to
judge, fulfils its purpose in a safe and efficient way.
Who that has travelled would not often have given
almost anything in his possession for a boon of this
kind ? Imagine what it would be to be able to
defy the mosquitoes, say, when lying in harbour in
Singapore, or in a West Indian port ? Beyond the
mere annoyance of mosquito bites there is, of course,
the far more serious point of the malaria that is con¬
veyed in that way. In future, however, the traveller
or the sportsman can carry about with him protection
in the shape of one of Mr. Rogers’ bottles of Muscatol,
sold at prices varying from a shilling to a guinea. It
can be applied by a dropper or by a convenient little
spray, and may be applied to clothing, bedclothes, or
the skin-surface, generally or locally. If Mr. Rogers,
by his timely remedy, can protect the patient fisher¬
man at home and abroad, and the equally patient
artist, from the bites of gnats and other noxious flies,
he will be entitled the enduring gratitude of a great
many of his fellow beings in all parts of the world.

BURROUGHS WELLCOME’S TABLOID “ GINGA-
MINT.” (Soda Mint Compound.)

This new preparation of Messrs. Burroughs Well¬
come, claims to be a valuable antacid and stomachic
for the relief of dyspepsia, nausea, heartburn, and
flatulence. It is said to promote appetite and diges¬
tion, while at the same time it relieves griping and
produces a diffusible stimulant effect. The compo¬
sition is as follows : Each contains sodium bicarbonate,
gr. 5 ; ammonium bicarbonate, gr. 1-12 ; with
1 gingerine, saccharine, and oil of peppermint. k .

Aug. 2i . 1907.

WEEKLY SUMMARY.

The Medical Press. 203

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press ahd Circular.

RECENT SURGICAL LITERATURE.

The Treatment of Detachment of the Retina.—

Professor Deutschmann (Ophthalmoscope. July, 1907)
advises that operative treatment for detachment of
the retina should be resorted to earlier than is usual,
as much time is wasted in pacific treatment which
gives such bad results. Prof. Deutschmann considers
that his operative treatment gives better results than
such procedures as (t) simple scleral or sclero-chori-
oidal puncture, or puncture of sclera with a galvano-
cautery ; (2) puncture of detached retina ; (3) per¬
manent drainage ; (4) electrolysis; (5) intra-ocular
injection of iodine ; (6) cauterisation of sclera with
or without sub-conjunctival injection of sodium
chloride solutions. The author’s operations are two in
number. One he calls “ bisection,” the other consists
of the injection of sterile animal vitreous body into
the diseased eye. In performing the bisection operation,
a double-edged knife is inserted tangentially to the globe
downwards and outwards, passed horizontally across,
making the counter puncture directly opposite, i.e .,
downwards and inwards. The counter-puncture in¬
volves the sclera only, the conjunctiva being spared.
In withdrawing the knife it is given a half-turn, which
allows the sub-retinal fluid to escape. The eye is
atropinised, and both eyes are bandaged for twenty-four
hours, the patient being kept in bed seven or eight
days. If necessary, the operation may be repeated in
ten to fourteen days, and be done as often as ten or
twenty times. The operation may be considered to
be devoid of danger. The mischances one has to con¬
sider are the wounding of a large retinal vessel, or the
lighting up of a previously existing inflammatory
process. The injection of animal vitreous appears to
be reserved for desperate cases, and need not be re¬
lated here. M.

Scoliosis: Its Prevention and Treatment. —M'llhenny
[Lancet-Clinic, July 20th. 1907) divides scoliosis
into postural and structural. He believes that
rickets holds a more important position in the
a tiology of scoliosis than is generally conceded to it.
The family physician is the person on whom the re¬
sponsibility of preventing this condition rests, for it
is he who has the opportunity to recognise deformities
in their incipiency. The fundamental points in treat¬
ment are two : First, to correct the deformity and
limber up the vertebral column as much as possible ;
and, second, to develop the muscles of the back so
that they may be able to support the spine in the proper
position. In the treatment of postural scoliosis, where
no changes have taken place in the bones or soft parts,
it is merely necessary to correct the faulty position
and build up the weakened muscular system with
massage and gymnastics without the aid of corsets
or braces. Every case is first treated with hvperaemia.
The patient sits with the back to a pentagonal cabinet
which has an opening, eval in shape, cut in each side
just large enough to allow the bared back to fit into
it from about the sixth cervical to the fifth lumbar
vertebra, and about three inches on each side of the
spinous processes. In the centre of the cabinet there
is a gas Dumer. The temperature is raised from 120°
to 230° F., and the application lasts from fifteen to
twenty minutes. After the patients have had the hot
air application and their backs massaged for ten to
fifteen minutes, they are then put through a course of
simple gymnastics for half an hour. The less com¬
plicated the exercises are the better. The main point
is to educate the body to involuntarily maintain the
proper position. The treatment of structural scoliosis
is more difficult as changes in bones, muscles, and liga¬
ments have taken place, and motion is limited. While

obtaining as much extension as possible in an extension
frame, a plaster-of-Paris corset is applied. No padding
is used, and the corset is well moulded over the
hips and shoulders, the latter being incorporated.
When the plaster sets the corset is cut down in front,
removed and trimmed. When reapplied, it is laced
up in front over shoe-hooks with elastic lacings, which
causes constant pressure laterally. The author
places a thin pneumatic cushion under the corset
posteriorly, and one over the anterior opposite pro¬
jection. By so doing the pressure on these parts
is increased, and there is a tendency to untwist the
rotation, besides correcting the lateral displacement.
After the corset is finished the patient has a daily-
application of hyperemia for twenty minutes, and then
goes through the exercises. The first and most im¬
portant exercise is a form of crawling on the floor,
which is described in detail. The benefit of this exer¬
cise depends on the fact that when the limbs on one
side of the body are well approximated in crawling,
the spine becomes well bent with its convexity in the
opposite direction. After the exercises the patient
rests for twenty minutes in a correcting frame devised
by the author. The corset is worn night and day for
six weeks, being only removed for exercises and hygienic
reasons. Fresh corsets are made about every two
months with the patient in the best corrected position.
These are used only during the day. It is a great
mistake to keep a brace or corset on too long, for the
muscles after a time rely on the artificial support, and
atrophy consequently sets in. S.

Inoperable Sarcoma. —Coley (Medical Record, July
27th, 1907) makes a further report of cases suc¬
cessfully treated with the mixed toxins of ery¬
sipelas and bacillus prodigiosus. The author has him¬
self successfully treated 42 cases, and 60 cases have
likewise been successfully treated by other medical
men. Of his 42 cases, 17 were round-celled sarcoma.
17 spindle-celled sarcoma, 2 mixed-celled sarcoma,
i*■ chondro-sarcoma, 1 epithelioma. In 4 no micro¬
scopic examination was made ; yet the clinical features
of the cases, such as recurrence after operation, rapi¬
dity of growth, size, and inoperability of the tumours,
left hardly any doubt as to the diagnosis. The late
results in‘these cases are as follows:—21 well from
5 to 14 years, 26 well from 3 to 14 years, 10 well from
10 to 14 years. Twelve cases are reported in detail.
Coley finds that Dr. Tracy’s method of preparing and
standardising the toxin is the most satisfactory. It
consists of: Streptococcus culture in broth, three
weeks’ growth 100 c.c. Prodigiosus suspension, con¬
taining 750 milligrams of prodigiosus proteid, 30 c.c.
(sterilized one hour at 75 0 ), glycerine. 20 c.c. After
mixing and bottling the toxines the mixture is again
sterilized two hours at 75 0 . One minim contains about
3 mgrs. of prodigiosus. It is most important in every
case to begin with a very small dose, not over J minim
(diluted with a little boiled water to ensure accuracy
of dosage). If the tumour in question is highly vas¬
cular it is wiser to begin the injections remote from the
same, until the susceptibility of the patient to the
toxins has been ascertained. As a rule, when giving
injections into the tumour, only about one-fifth of
the dose used for injections remote from the tumour is
required to produce the same reaction. The best
results are obtained by doses sufficiently large to pro¬
duce severe reaction, say a temperature from 102 3
to 105°. The frequency of injection must depend
entirely upon the strength of the patient, some being
able to bear daily injections, while in others it may be
unwise to push the treatment beyond three or four

204 The Medical Press.

WEEKLY SUMMARY.

Aug. 2i, 1907.

injections a week. In successful cases the effect is
usually very promptly noticeable. The tumour
becomes smaller in size, much more movable, and
very much less vascular. These changes appear
quickly, often within two or three days. The action
of the toxins is both local and systemic. Sometimes
the best results are obtained by giving injections
alternately into the tumour and remote from the same.
In intra-abdominal sarcoma, &c., a perfect cure may
he obtained by systematic injections entirely.

Partial Perforation of the Bowel Simulating Appen¬
dicitis. —P. Blumer records a case ( Lancet, July 20th,
1907) of a coal worker, who, while pushing a heavy
object with his foot, felt something give way inside
himself, but for several hours felt no pain, then severe
pain began in the right iliac fossa, the bowels acted,
and the desire to pass water became very urgent, his
temperature and pulse rate at this time were normal.
On nis admission to the infirmary a few hours later,
he presented all the appearances of a man with an
acute attack of appendicitis, temperature now being
102, and pulse about 80, he had no history of any
previous attack of a similar nature. The pulse soon
afterwards rising in frequency to 104, the abdomen
was opened, and in the midst of a good deal of inflamma¬
tory lymph about the ca-cum, a small tear of the
muscular and serous coats of this organ was found.
The lesion was about two inches from the butt of the
appendix, and through the rent the inner coat was bulg¬
ing out. The walls of the bowel were closed and the
patient made a complete recovery. On account of the
slight violence which caused the rupture of the bowel,
and the close manner in which it simulated appen¬
dicitis, the case possesses considerable interest. G.

The Treatment of Snppnrative Pyelitis by Lavage

of the Renal Pelvis. —W. Ayeres gives an account of
six cases ( International Jour. Surg., May, 1907) of
pyelitis, which he had treated by local applications to
the renal pelvis; in all the cases the infecting cause
was the gonococcus. When no real kidney substance
was felt, only slight improvement occurred, but when
the suppurative process had only affected the kidney
itself, to a small extent, rapid improvement or recovery
followed. The solutions employed were argyrol and
silver nitrate, the latter usea at a strength of about
1 in 7,000, the ureter being catheterized through
cystoscope in the usual manner. Of these six cases
two were failures, and nephrectomy had later on to be
done, the remaining four were satisfactory, one being
much improved and the other three completely cured.
In one of these cases the flushing out of the pelvis of
the kidney had only been done four times when all
pus ceased coming from the ureter. In this case gono¬
cocci, although suspected, were not actually found,
and this may account for the rapid cure.

Renal Calculus: Its Etiology and Treatment.—P.

Horowitz (Post Graduate, July, 1907), in a paper,
illustrated by numerous cases, on this subject, deals
very fully with the over-production of uric acid, drawing
the following conclusions : 1. Renal calculus is the
result of faulty metabolism. 2. The uric acid type, is
the most common form. 3. The action of the calculus
on the genito-urinary tract is purely mechanical.
4. Small loose stones in the pelvis and ureter cause the
most symptoms. 5. There are cases of a single large
stone occupying the pelvis and calices of the kidney
without any symptom. 6. The most important
symptoms are, pain, colicky in nature, starting in the
region of the kidney or the loins, radiating down the
ureter to the bladder and thigh, and to the penis and
testicle in the male, and to the labia in the female.
Haemorrhage, beginning usually with the passage
of the stone into the bladder, may be slight or ex¬
cessive. Frequency of micturition, or occasionally
calculous anuria. 7. The diagnosis is often uncertain
unless the stone can be palpated, or be shown to be

present by the X-rays. 8. Indican is an index to the
condition of the digestion, therefore, pointing out the
possibility of an existing suboxidation, and therefore
the possibility of this condition being present also.
9. The Paquelin cautery is a valuable aid for relieving
the congestion of the kidney, and thus aids in breaking
up an existing anuria. 10. Carbolic acid stops the pain
> of renal calculus very quickly, and prevents recurrence
by changing the over-produced uric acid into urate of
sodium. 11. Attention to diet is of great importance
in the treatment of renal calculus. Fruits must
be excluded. G.

A Cause of Podalgia. —F. Bird, in an article illustrated
by X-ray photographs (Intercolonial Jour., June,
1907). gives an interesting account of four cases of
podalgia, all of which had been treated by the ordinary
methods without success, two of the cases were believed
to be gout, yet on taking X-ray photographs of the
os calcis in each case a spur-like process of bone was
found growing from the under surface of that bone,
the spur growing forward and running parallel with
the sole of the foot; in one of the cases a similar process
was found going on at the insertion of the tendo-
Achillis. The author suggests that the condition present
in these cases is a slowly progressing osteo-penostitis.
There is no clear connection between these cases and
cases of inflammation of the plantar fascia. In each
case the same treatment was adopted, an incision
made parallel to the sole of foot was carried down to
the calcaneal tuberosity, the position of the bony spike
having been determined by the finger a gouge was intro¬
duced and the offending portion of bone removed,
the wound closed without drainage, the patient only
kept in bed for three or four days. In all the cases the
relief from pain was immediate, and has,, up to the
present, been nermanent. G.

Rhinoplasty by Means of One of the Fingers.—

Finney (Surgery, Gyneecology, and Obstetrics, July,
1907) describes the operation which he has performed
successfully in two cases as follows : T he ring finger
of the left hand is selected. The nail and matrix are
completely removed, the dorsum of the finger up to
the distal end of the first phalanx denuded of skin.
The top of the finger, throughout its entire circum¬
ference, is also denuded of skin for about the distance
of 1 cm. from the end, leaving the distal phalanx
exposed, but not completely so. The skin covering
the nose which is retracted and deformed owing to
cicatricial contractions, is then freed carefully from
its attachments below without making any external
scar. The skin of the nose is then stretched carefully
and thoroughly. The soft parts are next freed from
the nasal process of the frontal bone. The inner
surface of the skin forming the nasal covering should
be denuded on the inner side of the middle line, in
order that a raw surface may be opposed to the denuded
surface of the dorsum of the finger, which is now in¬
serted into the nasal opening, until the tip of the
distal phalanx rests upon the nasal process of the
frontal bone. The finger is held in place by suture
through the free border of the tip of the nose and the
edge of the skin over the dorsum of the first phalanx.
The hand is held in this position for two weeks, after
which time the finger is disarticulated at the metacarpo¬
phalangeal joint and left for another week; at the
end of this time the tissues over the nasal spine of
the superior maxilla are split, and the finger flexed to
a right angle at its proximal-phalangeal joint. The
free end of the first phalanx is inserted into this opening
and held there by stitches through the soft parts. The
first phalanx forms the columna of the nose, while
the second and third phalanges form a very satisfactory
support for the dorsum. Later, smaller operations,
under cocaine, are performed to improve the appear¬
ance of the columna. It is well as a preliminary
operation to stiffen the last phalangeal joint of the
finger in order to prevent a slight tendency to sagging
of the bridge of the nose. S.

fAVG. 21 , I907.

MEDICAL NEWS IN BRIEF.

The Medical Press. 205

Medical News in Brief.

The King and India.

The India Office has issued the following letter
which His Majesty the King has addressed to the
Governor-General of India :—

Buckingham Palace, August 13th, 1907.

“ My Dear Viceroy, — I have followed with anxious
interest the later course of that epidemic of plague
by which India has for eleven years past been so sorely
afflicted.

“ The welfare of my Indian subjects must ever be
to me an object of high concern, and I am deeply
moved when I think of the misery that has been
borne with such silent patience in all those stricken
homes.

“ I am well aware how unremitting have been
the efforts of your Excellency’s predecessors and
yourself to make out the causes of the pestilence
and to mitigate its effects.

" It is my earnest hope and prayer that the further
measures now being prepared by your Excellency
in consultation with zealous and able officers, may be
crowned with merciful success.

“ I desire you to communicate this expression of
my heartfelt sympathy to my Indian subjects.

“ Believe me, my dear Viceroy, sincerely yours,
(Signed) Edward R. and I.”

Progress of the Plague Measures.

A Reuter’s telegram from Simla states that a
Gazette Extraordinary has been published there,
containing the above letter, and also a letter from
the Viceroy to the local Governments and one from
the Indian Government. The Earl of Minto states
that the difficulties in the way of eradicating the
plague are enormous, chiefly owing to the inability
of the people to understand sanitary and hygienic
measures.

In the third letter the Government of India states
that the Plague Commission believed, first, that the
bubonic plague is spread bv rats ; secondly, that the
vehicle of contagion is the rat flea; and thirdly,
that the life of the plague germ in soil, floors, and
walls is of short duration. The Government recom¬
mend the destruction of rats, the improvement of
the construction of houses, the reduction of the food
supplies of rats by the protection of grain stores,
the removal of people to temporary dwellings, and
inoculation, while avoiding any action calculated
to excite the opposition of the people.

Aanaal Dinner of the Caledonian Medical Soctety.

This Society met on August 1st in Bradford, under
the presidency of Dr. Andrew Little, of that town.
There was a good attendance from far and near.
The membership, which consists of Highlanders,
University medical graduates, now numbers 240,
and they are spread all over the world. The great
majority are graduates of Edinburgh. Glasgow and
Aberdeen, in almost equal numbers, together furnish
about half the membership, and there are a few from
Oxford, Cambridge, and St. Andrews, and from the
Royal University of Ireland.

The meeting took place at the Royal Eye Hospital,
an extremely handsome and convenient building,
of which Dr. Little is surgeon, and of which another
Scot, Dr. John Bell, was founder. The latter it was
who first declared that the “ wool-sorters’ disease ”
was due to a living germ, and made several valuable
suggestions for its prevention, which were subse¬
quently embodied in Acts of Parliament. He was
also the pioneer of operation upon the eye for cataract
and other diseases.

Sympathetic reference was made in the secretary’s
report to the deaths within the last few months of

Dr. Alexander Macbain and the Rev. John Watson
(“ Ian MacLaren.”)

The Dinner.

At the dinner in the evening at the Midland Hotel
there was a large gathering of members and guests.
The President proposed the loyal toasts. The toast
of “ The Caledonian Medical Society ” was proposed
by Dr. Swanson, of York, and responded to by Dr.
S. R. MacPhail, of Derby ; “ The Universities,” by
Sir William Sinclair, of Manchester, and responded
to by Dr. MacKenzie, of Burnley ; ” Caledonia,” by
Dr. Rabagliatti, of Bradford, who claims his Highland
right because he is married to a daughter of the late
Mr. Bright MacLaren, the well-known Member of
Parliament.

Among other members present were :—Drs. Mackin¬
tosh. Stirling ; MacGregor Sinclair, Burnley ; Menzies,
Mitchell, Dunlop, Munro, Clow, Beatton, Bonar,
Gray, Hall, Baldwin, Dunlop—all of Bradford ;
DiD MacGregor (a son of the late “ Alastair Ruadh ”
of Inverness) ; Dr. MacNaughton, Stonehaven ; Dr.
Cameron Gillies, London ; Dr. Stewart, Bacup ; Dr.
Blair, I,ancaster ; Dr. Bonner, Shipley ; Dr. Angus,
Bingley; Dr. Gordon Little, Blundellsands; Dr.
Logan, Harrogate ; Dr. Gairdner, Burnley ; and quite
a number of friends as guests.

The dinner was done in thoroughly good Highland
form. There was a gorgeous piper, in the full Stewart
dress of the old time. There, was haggis and other
things, and hearty good-fellowship.

Dr. Dunlop invited the members to his house, and
among the relics exhibited was half a banner of the
Clan Fraser that was at Culloden. The following
is the history of this banner :—

“ The complete colours were given to a Dr. Mackin¬
tosh, of Inverness, a great antiquarian, by the then
Fraser of Lovat. In 1827 Dr. Mackintosh divided
the colours into two parts—one he kept himself, and
the other part, the history of which is now being
traced, he gave to Mary Stewart, spouse to Dr. Mac-
Laurin, of Culloden, Inverness, and afterwards of
Bradford, Yorks. Mrs. MacLaurin died in 185-,
bequeathing the colours to her daughter, Mary Miller,
spouse to Jonathan Beattie, in 18S3. The colours
passed into the possession of their daughter, Agnes
Paterson, spouse to John Dunlop, M.D., of Bradford.—
(Signed), Agnes Paterson Dunlop.

"May 20th, 1883.”

The motto of the clan is given in English, “ I am
ready," but only the letters “ I am re—” are on this
half. It would be interesting to know if the other
half of the banner is in existence.

Prevent Jtlon to a Medical Man

The guardians and officials of the Willesden Union
have presented to their medical officer, Dr. Walter E.
Turner, a handsome cabinet of table cutlery and fish
carvers on the occasion of his marriage to Miss Jessie
Powell, of Tregaron, Cardigan. Some of the inmates
of the workhouse also presented the doctor with a
beautifully-worked drawn-thread teacloth.

School ol Tropical Me Heine—Further Grant.

In the House of Commons on August 15th, Colonel
Seely asked the Under Secretary for the Colonies
whether, in view of the work already accomplished
by the Liverpool School of Tropical Medicine in
combating tropical diseases, he could arrange for an
increased grant to be made in order that the work
may be further extended. Mr. Churchill said a
further grant will be made, of which the Secretary of
State will be able to specify the amount after con¬
sultation with the Treasury.

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206 The Medical Press. NOTICES TO CORRESPONDENTS.

Aug. 2i, 1907.

NOTICES TO
CORRESPONDENTS,

ffc.

Correspondents requiring a reply in this oolumn are par¬
ticularly requested to make u*e of a DUtinctive Signature or
Initial, and to avoid the praotioe of signing themselvea
• Reader,” “Subscriber,” “Old Subscriber,” etc. Much con¬
fusion will be spared by attention to this rule.

SUBSCRIPTIONS.

Subscriptions may commence at any date, but the two volumes
each year begin on January 1 st and July 1 st respectively. Terms
per annum, 21s.; post free at home or abroad. Foreign sub-
scriptiona must he paid in advance For India, Messrs. Thacker,
Spink and Co., of Calcutta, are our officially-appointed agents.
Indian subscriptions are Rs. 15.12.

Rbprints.— Reprints of articles appearing in this journal can
be had at a reduoed rate, providing authors give notioe to the
Publisher or Printer before the type has been distributed. This
should be done when returning proofs.

Original Articles or Letters intended for publication
should be written on one side of the paper only and must be
authenticated with the name and address of the writer, not
necessary for publication but as evidence of identity.

Dr. A. D.—The newspaper paragraph to which you draw attention
is an advertisement in the worst possible taste, and for this reason
cannot have been connived at by the physlolan mentioned therein. In
all probability it Is one of those unfortunate instances of journalistic
Irresponsibility, to which members of our profession are peculiarly
subject.

G. W. M.—Your communication came to hand as we were at
press "; it will be duly considered before our next Issue.

Docks. —It is a common mistake to attribute to Manson the
original theory that the organism of malaria passed
through the mosquito as its intermediate hoet. As a matter of
fact, Laveran, who discovered the organism in 1880, formulated
the theory of mosquito transference in 1884. But 8ir Patrick
ManBon did more than anyone to keep the theory in being till
ite truth was demonstrated by Ross.

STATISTICS OF INDUSTRIAL POISONING.

Alien.— Regular returns are made monthly by the Home Offloe
as to Industrial poisoning and anthrax; they can be obtained
from the Government printer. The returns for June last show that
there were 48 cases of lead-poisoning and 4 of anthrax. Four
deaths from lead-poisoning were also reported. Moreover there
were 17 oasee—with five deaths—from lead-poisoning in house
painters. The figures for the first six months of the year are
slightly better than those for the corresponding period of 1906,
viz.: —1906.—348 oases of poisoning and anthrax, with 28 deaths,
nnd 82 oases of lead-poisoning in painters, with 21 deaths. 1907.—
261 cases, with 20 deaths, and 74 cases, with 22 deaths respec-
tively.

Dubious. —The condition you describe has been called “ Salaam
Convulsion.” It is not pathognomonic of any condition, for it
occurs (besides in Spasmus Nutans) in epilepsy and Menl&res’
disease, and is also seen in teething disturbances In riekety
children.

DOCTOR 8 HARD TO PLEA 8 E.
“Valetudinarian” writes:— _ _ , ,,

“ Having been under the care of dootors lately, I am told
that if I wish to keep in good health I must follow these
instructions:— , . „ , . , , .

“‘Eat only a light breakfast’; also, ’Breakfast should be
the best meal of the day.' .... , _- T _

“ ’ Run or walk two mi lee before breakfast ; also, "TJ^er
attempt to do anything on an empty stomach.’ '

“ ’ Take a oold bath the first thing In the morning ; also,

’ Remember the shook to the system of suddenly entering heat
or oold is very injurious.’ ......

“’Never use a pillow’; also, ’The most refreshing sleep is
obtained when the head is elevated.’ ,

“ • Do not get into the habit of sleeping in the daytime ;
also, ’ Always take a nap in the afternoon.’

“’Eat only at meal-times’; also, ‘Eat whenever you feel

hn "*Get up at 5 o’olock every morning’; also, ' 81eep until
thoroughly rested, no matter how late it is.’”— Neva.

Pater. _The average composition fee tor the complete five

years’ oourse at a London hospital is about 130 to 140 guineas.
This includes practically everything; but in event of failure to
pass exams it does not always include second courses in
practical classes. The fees may be paid in one sum, or in
instalments, but the latter plan is rather more expensive. As a
rule the fees for the London University classes run a little
higher than those merely for the conjoint diploma. The differ¬
ence averages about 10 or 12 guineas. Atbletio subscriptions,
instruments, books, dissecting parts are, of oourse, extras.

A Chemical Student.— In writing analytical reports, some¬
times the volume percentage is' desired, sometimes the weight
percentage, nnd sometimes the percentage of alcohol expressed
ns proof spirit. As the great majority of alcohol determinations
nre returned as " by volume,” except in the case of figures for
the Inland Revenue, our reports are usually put in this form.

$arana*fi.

Cl if den Union.—Medical Officer. Salary. £140 a year, and £20 a yaar
as Med>oal Officer of Health, together with Vaccination Fees.
Applications to the Presiding Chairman, T. King, Clerk of Union.
(Bee Advert.)

Royal Victoria Eye and Ear Hospital, Dublin.—House Surgeon
Salary. £40 per annum, with rations. Applications to
E. Parker, Registrar. (See advert.)

Glasgow District Asylum.—Assistant Medical Officer required at
Woodilee, Lenzie. 8 alary, £135 per annum, with board,
lodging, washing, etc. Applications to the Medical Superin¬
tendent.

Bridgnorth and South Shropshire Infirmary.—House 8 urgeon.
Salary, £110 per annum, with board and lodgings in the
Infirmary. Applications to the Hon. Secretary, the Inflrmsrr,
Bridgnorth.

Birmingham General Hospital.—Receiving Room Officers. 8 alarv,
£150 per annum. Applications to Howard J. Collins, House
Governor.

Egyptian Government.—Kasr El Ainv Hospital.—Resident Medical
Officer. Salary £250 a year, with quarters, servants, wash¬
ing, coal, and light Applications to the Director-General,
Public Health Department. Cairo

Egyptian Government.—Ministry of Education.—School of Medi¬
cine, Cairo. Assistant to the Professor of Pathology. Salary,
£E.320 per annum. Anpllcations to be addressed The
Direotor, Government School of Medicine, Cairo, Egypt.

Worcester County and City Asylum.—Third Assistant Medical
Officer. Salary, £140 per anpum, all found. Applications to
Superintendent Powick, Worcester.

Devon County Asylum.—Assistant Medical Officer. Salary, £140
per annum, with board, apartments, and laundry. Applica¬
tions to the Medical Superintendent, Exminster.

Prestwich, Manchester, County Asylum.—Junior Assistant
Medical Officer. 8 alary, £160 per annum, with board, fur¬
nished apartments, and washing. Applications to the Medical
Superintendent.

Loughborough and District General Hospital and Dispensary.—
Resident House Surgeon. Salary £100 a year, with ’fur¬
nished rooms, attendance, board, and washing. Applications
to Thos. J. Webb, Secretary.

Aberdeen Provincial Committee for the Training of Teachers —
Lecturer on Hygiene. Salary £400 per annum. Applications
to George Smith, Director of Studies, Training College.
Aberdeen.

Manchester Township.—Assistant Medical Officer. Salary £110
per annum, with furnished apartments, fire, light, washing,
and attendance. Applications to James Macdonald, Clerk to
the Guardians, Poor Law Offices, New Bridge 8 treet,
Manchester.

London County Asylum, Long Grove, Epsom, Surrey.—Fourth
Assistant Medical Officer. Salary £180 a rear, with board,
furnished apartments, and washing. Applications to H. F.
Keene, Clerk of the Asylums Committee, London Asylums
Committee Office, 6 Waterloo Place, S.W.

County Asylum, Miokleover. Derby.—Junior Assistant Medical
Offloer. Salary £120 per annum, with furnished apartments,
board, washing, and attendance. Applications to Dr. Legge.

JLppoiittmeniB.

Battebsbt, James, F.R.C.S.Eng., Lecturer on Anatomy in St.
Mungo’s College, Glasgow.

Danvers, H., M.D. Parma, L.R C.P. and S. Edin., L.F.P.S.
Gias., Assistant Physician to the Italian Hospital, Queen's
Square, W.O.

ElliSon, Francis Charles, M.D. Dub., Resident Medical Super¬
intendent at the Mayo County Asylum, Castlebar.

Knox, Robert, M.D. Edin., M.R.C.S. Eng., L.R.C.P. Lond..
Medioal Offloer in charge of the Electrical Department at the
Great Northern Central Hospital
Muir, Gavin D., M.B., Oh.B. Glasg., Resident Medical Officer at
the Royal Albert Hospital, Devonport.

Pennt, Sidney Greenwood, L.R.C.P. Lond., M.R.C.S.. Medical
Offloer for the Fourth District by the Penzance Board of
Guardians.

firths.

Fraser. —On August 14th, at 36 Moray Place, Edinburgh, the
wife of John S. Fraser, M B., of a son.

Hat.—O n August 15th, at Ancaster Drive, Anniesland, Glasgow,
the wife of A. G. Hay, M.D., of a son.

Key.—O n August 18th, at Valetta, Clarendon Road, Southses,
the wife of Aston Key, M.B., B.C., of a daughter.

Martin.— On August 16th, at 1 Marlborough Avenue, Hull, the *if*
of Edward Lister Martin, M.D., M.B., Ac., Ac., of a daughter.

JHarriagw.

Forrester—Hartnoll. —On August 14th, at S. John’s, Potters
Bar, Charles Carmichael Forrester, M.D., Public Health
Department, Ministry of the Interior, Cairo, son of the late
William Forrester, of Arngibbon, Stirlingshire, to Adeline
Braund, youngest daughter of the late James Hartnoll, of
Ganwic, Barnet. ... .

Grayson—Walker. —On August 17th, at 8 t John ■ Churcn.
Burgess Hill, Lionel Dorrell, son of Francis Dorrell Grayson.
M.R.C.S., of Rayleigh, Essex, to Gertrude Bardsley, daughter
of the late Herbert John Walker, M.D., of Sheffield.

$Krth0.

Adams.-Ou Aug. 15th, at The Lawn. Martock, Ernest Beadou
Adams. M.R.C.S., L.R.C.P., Lond.. lateH.M/s Colomsl
Medical Service, second son of J. Dixon Adams M.D.
COLTART.— On August 17th, at Granville House, 714 Fulham Road,
London, Joan Mary, Infant daughter of Dr. and Mra. Guy B.
Coltart, aged 13 daya.

zed by G00gle

The Medical Press and Circular.

-SALUS POPUU SUPREMA LEX.*

Vol. CXXXV. WEDNESDAY, AUG. 28, 1907. No. 9

Notes and Comments.

The almost phenomenal amount
Abaadaat of cold and wet which have
PrecipHatioa. characterised this summer may
have ruined the temper and
holidays of a great many, but
they have at least effected a vart saving of infant
life. The experience of last quarter, when, to
quote the picturesque terminology of the Regis¬
trar-General, “ Precipitation was abundant,”
was very favourable as regards diarrhoea, the
rate being 0.05 below the decennial average.
But just as every Juliet is judged by her balcony
scene, so every diarrhoea season stands or falls
by its July and August performances, and
as the returns come in these are seen to have
been unusually benign. In some districts, in¬
deed, the diarrhoea deaths have fallen almost
to vanishing point; in Marylebone, for instance,
there were only two for the whole of July, and
in Leicester for the middle week of August only one.
On the other hand, in spite of the weather, cholera
appears to be rolling up in considerable force.
It is taking its usual overland route, and having
reached Southern Russia is spreading with con¬
siderable alacrity across the steppes. The usual
sanitary cordons have been placed round the
infected centres, but without avail, and the
disease is making great progress. It is hardly
possible that cholera will gain sufficient foothold
in Central Europe to cause great devastation
this year, as the season is too late, but had the
temperature been at all propitious it might have
reached Europe earlier and caused great havoc.
So that there may be greater blessings than we
are aware of disguised in the " abundant precipita¬
tion ” we have so abundantly abused.

We had occasion a few weeks ago
Pittsbirf sad to comment on the atrocious want
Appendices- of good form which distinguishes
tpay. what passes for " society ” in
Pittsburg, as instanced by the
giving of " whooping-cough parties,” in which
prizes were given to those who had the most
severe paroxysms or made the loudest noise.
They seemed to u? far more vulgar than the
game that gutter-urchins indulge in, of seeing who
can spit the furthest. The great ladies of Pitts¬
burg are nouvelles riches in the most odious form,
aamely, that of trying to outdo the extravagances
of the most ouirie of their kind. The last report
is that these gentle creatures, being tired of the
usual excesses, decided by way of deriving a
new sensation to have the appendix vermiformis

removed. Last month eighty-four of the “ leading
society women ” of that town accordingly had
the operation carried out, although there was|no
surgical need for it, and their medical advisers
were strongly opposed. • The astonishing thing is
that surgeons were found to perform a
merely mutilating operation of the kind, but
presumably a demand creates a supply,Tand
money seems to be able to buy anything
in Pittsburg, except good taste. It seems
almost a pity that ail the unavoidable fatalities
of appendicectomy over a suitable period
were not crowded into these eighty-four opera¬
tions.

Dr. Rentoul, among reformers,
A Royal Order possesses the invaluable quality
•f of imagination, and he now comes

Motherhood. forward with the suggestion that

in order to encourage the rearing
of children the Queen should institute a Royal
Order of Motherhood, to be awarded to those
women who have the largest and healthiest
families. It certainly seems reasonable that as
decorations and knighthoods galore are given
for the destruction of human fife, a little reward
should occasionally reach those who devote them¬
selves to its creation and nurture. True, there is
the King’s Bounty for triplets, but after all the
‘bearing of triplets reflects but little glory on the
mother, and for State purposes these pleonastic
births are of little use, as the infants almost in¬
variably are puny and not infrequently die within
a few hours. In these piping times of peace and
International Congresses, the slaying of men is
happily a less popular and lucrative trade than
of yore, and, contemporaneously, but perhaps not
etiologically related to this decline, i3 the fall in
propagation of mankind, so that it might be
well to make the begetting of children as honour¬
able a business as the slaughter of adults.
Both are ancient and popular pursuits, and
the former has the additional recommendation
of economic utility.

The death of triplets caused an
' Triplets sad interesting point to arise at Barnes
Trouble. last week. A medical man, Dr. H. P.

Daniell, attended a woman who
was confined of triplets. One of the children was
bom dead, and the other two died shortly
after birth. Not being satisfied as to the cause of
their sudden deaths, Dr. Daniell declined to give a
certificate, but he wrote on a piece of paper the
fact that the children died shortly after birth.

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20 8 The Medical Press.

LEADING ARTICLES.

Aug. 28. 1907.

This document not being a valid certificate, as
indeed it was not intended to be, the children
could not be buried and, as the result of the
pother that ensued, Dr. Daniell was summoned on
no less than six charges by the Registrar-General
for unlawfully refusing, without reasonable excuse,
to give a certificate. Counsel for the prosecution,
after giving his version of the affair went so far as
to state that Dr. Daniell was trying to get money
out of the affair by making post-mortems on the
three children and giving evidence at three inquests.
What evidence there may have been on which to
rest this charge the prosecuting counsel did not
call, and as it was shown that when interviewed by
the coroner’s officer and told there was to be no
inquest, Dr. Daniell still refused to give a certificate
it may be taken that there was pretty cogent
evidence against the suggestion. The evidence
that the prosecution called, namely, that of the
coroner and the police surgeon who had viewed
the bodies was to the effect that there was no
reason from what they knew of the circum¬
stances to suspect foul play, and Dr. Daniell,
simply stated that he did not know why
the children died and therefore proceeded
to throw the onus on the coroner.

Now, as a medical man is required
Oplaloi sad to state on a certificate what in
Practice. his opinion is the cause of death,

it is obvious that if he has no
opinion he cannot certify. In practice when a
medical man has no reason to suspect foul play he
usually fills in a certificate to save his patients the
pain of an inquest, but this position is a compro¬
mise with the very bad law regarding certification.
Not only is the law bad, but it is also both
mean and harsh, for besides providing no
payment for the medical man’s opinion, it
penalises him if he does not certify. And it
is still more illogical in not precribing any
procedure in the case of a medical man being
unable to certify. Again, what happens practically
is that a medical man usually writes an unofficial
note to the coroner, but this he is by no means
bound to do, and certainly the State has no right
to expect it of him. It is such distasteful work to
quarrel with forms and ceremonies in connection
with death that medical men have long suffered
under this unjust law, when all that is necessary to
correct it is a general refusal to give information.

Dr. Daniel has stood on his
Law and strict rights, and his action has
Logic. given the authorities some trouble ;

he has, therefore, been subjected
to the ignominy of police-court proceedings in
order, as they would probably say, “ to bring
him to his senses.” As a matter of fact
the people who need bringing to their senses
are those who frame unjust laws and administer
them by inquisitorial methods. In the case in
question there were two magistrates on the
bench and they disagreed in opinion, so that the
case is one which obviously presents complex
issues, and when one reflects that hundreds of
persons, principally children, are buried every year
without certificate and without inquest, the
farcical nature of the whole administration of the
law is at once revealed. Attempts are made to
bully and cajole medical men, after giving the
State free information, to make them give it in
certain words most convenient to the Registrar-

General. In fact registrars often make great
difficulty about accepting certificates except
according to the nomenclature of the College of
Physicians, and to save patients annoyance
medical men have to submit to this slight As
the Registrar-General is paid a handsome salary
and given a large staff to assist him, any
difficulty in the classification of a death should
certainly fall on him, and not on a private
practitioner, who has already given more informa¬
tion than can reasonably be expected from
him.

LEADING ARTICLES.

THE RATIONAL ECONOMY OF SANATORIA
FOR CONSUMPTIVES.

The slow and gradual evolution of public health
matters is apt to discourage scientific enthusiasts
who devote their energies to that particular field
of work. The old proverb which reminds us that
“ Rome was not built in a day ” applies with em¬
phatic point, mutatis mutandis, to the practical
adoption of fresh truths into our national system
of sanitary administration. Take the case of con¬
sumption, the study of which was first placed on
a sound scientific basis by the demonstration of
its specific pathogenic organism by Koch in 1882.
Twenty-five years have elapsed since the an¬
nouncement of his great discovery, and the whole
question raised thereby has been the subject of
universal interest. It may safely be said that
no matter in the whole range of medical affairs
has received a greater amount of serious discus¬
sion, both inside ond outside the profession. It
has taken more than a quarter of a century to
decide authoritatively that bovine and human bacil¬
lus tuberculosis are identical. As a corollary it has
taken an equal period of time to arrive at the
conclusion that infected milk must henceforth be
regarded as the probable source of much of the
terrible incidence of tuberculosis upon our infantile
population. That result, it must be acknowledged,
has been arrived at short of actual practical demon¬
stration of such transmissibility. The slow in¬
cubation of the disease and the difficulty of esta¬
blishing adequate and absolute proof of infection
in individual cases render the application of any
direct logical processes well nigh hopeless. There
are sufficient data, nevertheless, to enable us to
form a reasonable inference as to which direction
will be taken by the balance of probabilities. Given
a specific bacillus shown to exist in man and to be
extremely prevalent in cows, the milk of which is
infected thereby; given the use of cow’s milk as
the staple food of infants and children; and given
the existence of a terrible mortality from tubercu¬
losis amongst the infantile population; then it is
not altogether unreasonable to assume that the
bacillus in the cow is more or less answerable for
the disease among children. That assumption, at
any rate, appears to afford the best explanation
that can be framed in our present state of know¬
ledge. It is open to those stern logicians who
demand more stringent logical proof of the rela¬
tion of cause and effect in this particular case to
advance a more probable and a more convincing
working theory, that will be more in consonance
with the facts so far as they are known to us.
Meanwhile, the recognition of the infectivity of

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Aug. 28. 1907.

CURRENT

phthisis has led to a great diminution in the
disease; whatever doubts may surround etiology,
there emerges the distinct and gratifying fact that
modern science is gradually ousting the malady.
At best, however, the campaign is slow and
protracted, resembling the ancient wars that
lasted for many years rather than the sharp con¬
tests of modern warfare. It may be said that one
great and sweeping strategic movement will con¬
sist in the eradication of tuberculous meat and
tuberculous milk from our food supplies. In any
case, it is tolerably safe to assume that the actual
cure of consumptives will play a comparatively
small part in the ultimate eradication of the disease,
which is the only permissible goal of the scientific
sanitarian. Nevertheless, on humane and other
grounds, it is clearly the duty of society to neglect
no means whereby the disease may be held in
check, especially amongst our working-class popu¬
lation. Among the practical achievements of which
the past quarter of a century has reason to be
proud is that of the open-air treatment of consump¬
tives. In the attempt to render that method
available, huge sums have been spent on special
sanatoria. After the lapse of a few years it seems
likely that the erection of costly buildings for the
purpose is already obsolete as a practical scheme.
In one notorious instance the prime cost has
reached as much as ^1,000 per bed, and even
then only a minimum of gratuitous relief is
available. A correspondent to a London news¬
paper recently showed that a serviceable garden
bedroom, constructed on three sides by matchwood
boarding covered with tarpaulin, and on the fourth
by a blind, could be constructed at a cost of £2.
Instead of a bed costing ;£i,ooo it would be simpler
to erect 500 beds at jQ2 each, and to devote the
interest on the vast capital sunk in founding the
remaining £ 1,000 beds in providing a medical,
nursing and commissariat staff and the necessary
maintenance of patients. Even now the mistake
of the big sanatoria might be to some extent
remedied by selling them for other purposes, and
then devoting the purchase-money to sanatoria on
more economical and rational lines. The main
curative problem is to get at the working-man
consumptive in the early stages of the disease, and
to restore him as an effective worker in the indus¬
trial army.

MR. JOHN BURNS ON THE NOBILITY
OF THE MEDICAL PROFESSION.

The notification of the Births Bill passed its
third reading in the House of Commons on Friday
last. As many of our readers know, the measure
is in the charge of Mr. John Burns, President of
the Local Government Board. The intention
of the Bill is sound enough, inasmuch as it aims
at securing an important administrative return.
Incidentally, however, it throws upon the medical
profession a new duty, as recently insisted upon
in our columns, without providing for the pay¬
ment of any fee. More than that the Government
has now actually made it penal for medical
men to refuse to discharge gratuitously the
responsible service thus thrust upon them by
the State. The legislature has in this way
marred the statute book with a monstrous
violation of the rights of an honourable pro-

- *• _ The Medical Pkess. 209

fession. In refusing the amendment which would
have freed medical men from the obligation to sign
such a certificate Mr. John Burns made some
remarks that are worthy of attention as showing
the characteristic attitude of legislators with
regard to our profession. He said in effect
that it was a matter of extreme regret to him that
a great, honourable and charitable profession
should have practically dissociated themselves
from what he believed to be one of the most
beneficient movements of recent years. Let
Mr. Burns compare a parallel case. Criminal
law reform may be described equally, if not far
more so, as one of the most beneficient move¬
ments for the proper administration of justice
in this country that has been witnessed for cen¬
turies. Would Mr. Bums on that account ask
the lawyers to undertake important professional
duties imposed by a new Criminal Law Reform
Act without fee or reward ? We trow not.
The lawyers in and out of the House would
treat the suggestion as a farcical joke. Why then
should Mr. Burns seek to exact the rendering
of responsible legal documents gratuitously from
another learned profession ? Medical men cannot
live on honour and charity alone, and it is pre¬
cisely in ratio to the loftiness of their principles
and of their lives that the Government should
consider the question of their remuneration
for services rendered to the State. At present
the Government exacts much money and many
stringent conditions in return for a legal medical
qualification. It then abandons the duly quali¬
fied practitioner to the unrestricted competition
of every quack and charlatan who chooses to
batten on the community. Of all men we should
have thought Mr. John Burns the first to concede
the principle that the labourer is worthy of his
hire. Possibly he has grown so accustomed
to the generous prodigality of medical science
that he regards it as fair play to any Minister
wishing to carry out his measures economically.
However, as the Bill now stands, medical men
will be subject to prosecution for refusing to
sign a gratuitous birth certificate. The thanks
of the profession are due to Dr. Cooper, M.P.,
who fought their cause in the House, and we only
regret he was compelled to withdraw from the
position of demanding fees for the signature
of the certificates in question. If lawyers had
such a duty thrust upon them they would prob¬
ably resist, to a man, and it is a question how
far the doctrine of passive resistance might be
accepted by the medical profession with advantage
in this and other matters.when their corporate
rights are threatened and invaded. The Govern¬
ment could hardly complain if medical men
throughout the kingdom refused to sign certifi¬
cates forced on them under such conditions.

CURRENT TOPICS.

Typhoid Epidemiol at Peterhead.

Peterhead has been for some time past in the
throes of an epidemic of enteric fever. Fortunately
it appears to be on the decrease, as the last weekly

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210 The Medical Press.

CURRENT TOPICS.

Aug. 28, 1907.

report shows eleven cases as against twenty-four
for the preceding week. The total number of
cases at that time was 341, which is a somewhat
serious percentage of a population returned
as 13,674. An investigation has been made
by Dr. Matthew Hay, of Aberdeen. From his
interim report it appeared that the origin of the
epidemic lies in the water supply. It seems
that the sources were subject to considerable
pollution at the time when the outbreak begun
and from the report it is clear that a great
deal remains to be done before the supply can
be regarded as safe. The incident emphasises
the need of unrelaxing vigilance in the control
of a water supply from its sources and all
along the line. Neglect of this supervision
is apt to be followed by a terrible nemesis
in the shape of sickness, death and com¬
mercial disaster to a whole community. One
of the clearest lessons of modern sanitary science
is the absolute need of the provision and main¬
tenance of a pure water supply.

Mr. Gladstone and Alcohol.

The perennial problem of “ doctors and drink ”
—as the lay journals tersely dub the topic—
receives day by day fresh and amusing com¬
ments from newspaper correspondents. Recently
one writer said that Mr. Gladstone was often a
great deal at his father’s house, and one day, then
a boy, leant over the dinner table and said to him,

“ There are few things better in this world than
the pint glass of champagne on a hot summer’s
evening.” He gently hints that the great
man’s first was not his last, and was eked out
later with two or three glasses of port, not light
port from the wood, but heavy vintage wine of
1863. This interesting bit of biography will be
held by many moderate drinkers to afford pretty
strong testimony to their view of the case, namely,
that alcohol in reasonable quantities is con¬
sonant with the highest sustained intellectual
and bodily fitness. Not so with the narrator of
this incident, who remarks that ‘‘it is positively
appalling to try to conceive what Mr. Gladstone
One of the giant intellects of his own or any other
age, and one of the strongest men physically,
might not have done had he not poisoned both
his mind and body consistently during his long
and active life.” This attitude reminds one of
the gentleman who informed a teetotal audience
that he had smoked and drunk all his life and was
still hale and hearty at ninety-six years of age,
when the lecturer retorted there was no knowing
what age he would have reached had he not
“ tasted the poison at all—at all.”

Death from Easton’s Syrup.

A recent prosecution, instigated by the
Pharmaceutical Society under the Sale of Poisons
Act, deserves the attention of medical men,
inasmuch aS it calls attention to a risk that
would otherwise hardly receive attention. The
defendants were “ Boot’s, described as Cash
Chemists,” who sold a bottle of tablets of
“ Easton’s Syrup ” to a customer without making j

any entry in the poison book, although each tablet
i contained i-64th of a grain of strychnine.
By some inadvertance the bottle got into the
hands of a baby, who swallowed about seventeen
tablets and died in half an hour. The manager
of Boot’s admitted that two such bottles would
contain enough strychnine to kill a man. A
fine of /5, with 25s. costs, was inflicted. Now
that the danger has been pointed out it is probable
that chemists will take care to impress their
customers with the nature of such a preparation.
It seems still more likely that the manufacturers
of the tablets will cease to put up the drug in
tablet form, especially as there seems to be no
particular advantage over the fluid form in which
it is usually prescribed.

Urticaria and Military Service.

The subject of urticaria, owing to the recent
prominence in a London police court, is likely
to leap into considerable prominence in the
medical world. Without in any way discussing
the legal issues involved it may be interesting
to call to mind some of the chief facts of the
malady in relation to the physical disability 01
otherwise of the sufferer. The origin of the
affair was the prosecution of a Birmingham
Yeomanry trooper for absenting himself from
the annual training. He was arrested and
brought to London under military escort, and
when brought into Court presented the magis¬
trate with three medical certificates, stating
he was unfit to attend the training on account
of urticaria. The medical officer of the Yeomanry
suggested that the malady in question was not
serious enough to warrant defendant’s absence.
Owing to the cost of jbringing the medical wit¬
nesses from Birmingham the defendant’s side of
the question was not supported medically at the
first hearing, but the magistrate adjourned the
case so that the evidence of the signatories could
be obtained. When the case was heard again the
defendant’s case was supported by three medical
men, one of them being a well-known Birmingham
dermatologist, and the magistrate, in view of their
evidence, could only find that the trooper’s
absence was justified. There is, of course,
urticaria and urticaria, but few who have seen
a really severe case with its attendant fever,
prostration, vomiting and general misery 7 , would
wish to see the patient on horseback playing the
part of one of the Empire’s defenders.

Infection from Old Bottles.

A point of some importance was raised by a
deputation from the National Glass Bottle Haw¬
kers’ Trade Union, which recently waited on the
President of the Local Government Board, with
the object of directing the attention to the danger
to public health involved in the indiscriminate use
of old bottles. There is little doubt that bottles
collected from ash-pits and other unsavoury
surroundings, are, with no more than a perfunc¬
tory cleansing, again put to use. It is not im¬
probable too that bottles from the 6ick-room of
an infective patient are occasionally returned to

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Aug. 28, 1907.

PERSONAL.

The Medical Press. 211

the druggist for re-filling without sufficient dis¬
infection of the exterior. In this way infection is
liable to be carried from the sick to the healthy.
It is doubtful whether the interference of the Local
Government Board in the matter would be likely
to result in any good, but the deputation has done
useful work in drawing public attention to a pos¬
sible danger. The cleansing of a glass bottle is,
in most cases, a sufficiently simple matter, and
when any difficulty presents itself, it is better that
the bottle should be destroyed than that any risk
should be run.

The Cardigan Cancer- 1 ' Carers.”

An interesting but rather odd article on the
Welsh Cancer-' 1 Curers ” appears in the current
number of The Crown, the Court and Country
Family Newspaper. It is from the pen of Dr. W.
R. Hadwen, and its curious nature consists in this
that while it contains mainly facts and opinions
which form a ruthless expost of these persons, at the
same time they themselves are throughout spoken
of in terms of toleration, if not of indulgence.
The brothers are no doubt enthusiasts, especially
the elder, Daniel, but if men are so blinded with
enthusiasm for their own gain as to cause intense
unnecessary suffering to people, it becomes the
duty of the Public Prosecutor to proceed against
them. There are certain kinds of barbarous
enthusiasm with which the State becomes intimate¬
ly concerned, and even in India and Africa cruel
native customs which are part of their very religion
are suppressed. The tale told by Dr. Hadwen is a
ghastly one. These brothers, glutted with semi-
religicus fervour, but jealously guarding their
precious “ secret ” ; crowds of wretched sufferers
tortured with the pangs of cancer enhanced by the
“ remedy ” ; dead and dying and suffering from
every country of the globe, in every quarter of the
little town; sufferers with awful wounds sent home as
“ cures ” when their patience, money, or credulity
has given out; cancer diagnosed in every case
and whole organs charred in the caustic appli¬
cation ; and an analysis of the “Secret Oil,”
which was obtained from part of an eschar, and
found to be composed of zinc chloride with traces
of arsenic and antimony. There are some
hundreds of these wretched patients, and appli¬
cations are pouring in every day from fresh ones,
while money seems to be rolling in on every side.
We ask, in the name of good government and
common humanity, if this state of affairs does not
form a prima facie case for the attention of the
Public Prosecutor.

Roof Gardens.

One of the penalties paid by mankind for the
privilege of living the corporate life of great cities
is the excessive value attached to the necessarily
limited land area. All sorts of shifts are adopted
in order to make the most of an available area.
The most obvious is to build skywards, on the plan
adopted in ancient walled cities. Another is to
burrow beneath the earth's surface, as in the case
of the tube railways. One of the most recent move¬
ments is to utilise the roof tops, after the manner

of some Eastern countries. There is no particular
reason why a hanging garden should not exist on
most of our modern roofs, provided always that the
jerry-builder has not been concerned in providing
walls unequal to any additional strain. Where
gardens are not adopted it would be feasible to erect
glazed conservatories for recreation purposes. Sir
Lauder Brunton, who advocated this departure at
the recent Housing Congress, put the matter in a
nutshell when he said that our roofs should be flat
instead of sloping, “terraced, with covered parts to
shelter from rain and sun, and with walls high
enough to prevent accidents.” As a matter of
scientific fact, the air at the level of roofs is purer
than that of the roadway in direct proportion to the
altitude.

PERSONAL.

The Prince of Wales, as Grand Prior of the Order
of St. John of Jerusalem, bas awarded the gold medal
of the Order to Dr. Albert von Lecoq, of Berlin,
for marked heroism during attendance on an English
officer in Turkestan.

We are asked to announce that H.H. Prince Henry
zu Schonaich-Carolath has consented to act as presi¬
dent of the fourteenth International Congress of
Hygiene and Demography. Dr. Rubner, Privy
Councillor of Medicine, Professor of Hygiene at the
Royal University of Berlin, and Professor Dr. von
Mayr, Under-Secretary of State, Munich, will be
vice-presidents.

Surgeon-Lieut.-Colonel C. R. Kilkenny, C.B.,
Medical Superintendent to Officers’ Convalescent
Home, Osborne, Isle of Wight, has been appointed
a Member of the Fourth Class of the Royal Victorian
Order.

Lieut.-C-olonel James Wise, R.A.M.C., Principal
Medical Officer, has been appointed an Official Member
of the Legislative Council of the East African Pro¬
tectorate.

Dr. Oliver C. Maurice, Consulting Surgeon, to
the Royal Berks Hospital, Surgeon to H.M. Prison,
Reading, whose death was recently recorded in these
columns, has left estate valued at about ^26,000.

A testimonial is to be presented to Mr. John
Carswell as a mark of sympathy with him in the
recent attack made by a lunatic whom he had recently
certified. The honorary treasurer is Mr. Nicoll, City
Chamberlain of Glasgow.

Any friends of the late Major D. M. Moir, professor
of anatomy at Calcutta, wishing to subscribe to a fund
now being raised for a memorial are requested to
communicate to Captain F. R. Connor, I.M.S.. or to
Rai Bahadur Dr. Hira Lai Basu, the honorary secre¬
taries.

We regret to learn that Dr. D. Nicholson, C.B.,
a Lord Chancellor’s Visitor in Lunacy, has sustained
considerable injuries in a cab accident. Dr. Nichol¬
son is progressing favourably."

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212 The Medical Press.

CLINICAL LECTURE.

Aug. 28, 1907-

A Clinical Lecture

INFANTILE DIARRHOEA.

By G. F. STILL. M.A* M.D„ F.R.GP*
Prolessor ol Diseases ol Children. King's College. London.
[specially reported for this journal.]

I have chosen rather a hackneyed subject for
my lecture this afternoon, but it, at any rate,
possesses the interest which belongs to the
commonplace, for I suppose all of us are concerned
at some time or other in dealing with the dangers
and difficulties of infantile diarrhoea.

In the first place, let me show you some statistics
which emphasise certain points of practical im¬
portance.

Deaths from All
Causes in London.

Deaths from Diar*
rhcea in London.

Total

3 month*

Total

1 months

under

Under

to

under

Under

I year old.

3 month*.

6 month*

1 year.

3 month*

6 months

1891

20,776

9 662

4,286

2,272

608

742

1892

20,441

9.614

4,162

2,340

745

845

J893

21,814

10,282

4,752

3.265

953

1,144

1894

18,812

9.083

3,680

1,866

5 i 8

620

1895

22,252

10,091

4,755

3.803

1,024

1,282

1901

19,678

9.565

4.”3

4.029

1,071

1.383

1902

18.307

8,927

3,545

2.542

590

859

*903

17.223

8,594

3.463

2,818

729

981

1904

19,012

9.050

3.948

4,408

1,076

1.474

1905

16,603

8,253

3.224

3.347

869

1,092

Notice that there are between 2,000 and 4,000
deaths annually in London under the age of one
year from infantile diarrhoea, and that the number,
so far from diminishing during the past ten years,
has rather increased. The series of years I have
taken at random. It may be objected that there
is a possible fallacy, namely, that a larger area
may be included under the term London in one
period than in another ; but this fallacy is avoided
by regarding the proportion of deaths due to diar¬
rhoea relatively to those due to all causes. In
1891, nearly one-tenth of the deaths under one
year of age were due to diarrhoea. In 1901, the
fraction rises to one-fifth, or twice the relative
number. This fact has a practical bearing. We
hear a great deal about the advances which have
been made in regard to sanitation, about muni¬
cipal milk depots, and so on ; but it is clear, in
spite of all boasting to the contrary, that the cause
of infantile diarrhoea remains, the mortality from
that disease has increased instead of decreased ;
the reduction of the infantile diarrhoea mortality
calls for some other remedy besides improvement
of the milk supply and of the methods of artificial
feeding. This table shows a striking difference
in the proportion dying under three months
compared with those between three and six months,
the latter being always the more numerous.
In 1891, 9,662 died from all causes under three
months of age, and out of that number 608, or one-
sixteenth, died from diarrhoea. In the same year
there were 4,286 deaths between three and six
months from all causes, and 742 in the same age
period from diarrhoea—or about one-sixth. At

(a) Dsilvered at the Medical Graduate*’ College and Polyclinic,
July 9 tb, 1907 .

first sight this appears contrary to all we know
as to the liability to diarrhoea and its danger at
those ages. We know from clinical experience
that the infant under three months old who
has diarrhoea is in much greater danger than is a
baby between three and six months old ; yet the
number of deaths is much less at that age. The
explanation is obvious : that the infants under
three months old are breast-fed for the most part;
but breast-feeding is progressively less frequent
as the infant becomes older. There, I take it,
lies the key to the reduction of infant mortality
in this country, the encouragement of breast¬
feeding and the instruction of mothers as to the
importance of suckling their infants as long as
possible. This is being realised more and more
by the people, and among the hospital class the
advice which has been steadily tendered at
children’s hospitals is bearing fruit The para¬
mount importance of breast-feeding comes out
very strikingly from statistics of the fatal cases.
I investigated cases at the Children’s Hospital,
and found that 96 per cent of the infants who
died of infantile diarrhoea were hand-fed ; 92 per
cent out of the 96 per cent were hand-fed entirely,
the remaining 4 per cent had had both kinds of
feeding. Only 4 per cent of the deaths from this
disease were in children who had been entirely
breast-fed. So breast-feeding, or even partial
breast-feeding, is the great safeguard against
diarrhoea.

Now let me draw your attention to a very prac¬
tical point which is not generally realised, namely,
the part played by condensed milk in the causa¬
tion of infantile diarrhoea. I have been told by
practitioners that they order condensed milk
because it is sterile, and therefore so much safer.
But so far from this being. true, condensed milk
seems to be particularly dangerous, and the child
who is taking it runs a special risk of having
summer diarrhoea. I have kept a note of the feed¬
ing of a large number of babies, and I find that
12 per cent, of infants brought to hospital had
been fed upon condensed milk, whereas of the
fatal cases of diarrhoea, 25.8 per cent, had been
fed upon condensed milk.

The mode of feeding is not the only factor in
the production of this disease ; temperature is
also important And if this is so, we may expect
a reduction in the mortality this year. I show
you a chart, based upon the Registrar-General’s
returns of deaths, and the Greenwich Observatory
records of temperature, t.e., the mean weekly
temperature. At first glance, the curves do not
seem to agree, but on closer inspection they do so
fairly closely. The rise in the temperature curve
naturally precedes by three or four weeks the rise
in the death curve, because the disease takes some
time to kill—usually three or four weeks.

What is the connection between high tempera¬
ture and infantile diarrhoea ? Clearly it is not the
heat alone which increases the death-rate, or

ed by Google

Diqitizi

Aug. 28. 1907-

CLINICAL LECTURE.

The Medical Pre ss. 213

breast-fed children would suffer equally with the
others, but they do not. It has been supposed
to be due to the growth of some bacterium which
is present in the soil, and Ballard published some
observations in support of this view ; but there
has been no proof of it in bacteriological research
since. There is the obvious suggestion that it is
something carried by milk, but we have no proof 1
even of that. Several bacteria have been de- I
scribed, within recent years, as the cause of
infantile diarrhoea, but none of them have been
shown to exist particularly in the food which
the infant takes. Another possibility is that the
bacteria which cause the disease are normal in¬
habitants of the intestine and only become
pathological under certain conditions—that when
an irritating food is given repeatedly to a child
the intestines become much more liable to in¬
vasion, and permit of a rapid growth of bacteria.
As an American writer puts it: repeated insults to
the intestine make it particularly susceptible to
bacterial invasions.

Some reference I must make to the classification
of diarrhoea, because it has some bearing on treat¬
ment, and it is of treatment I wish particularly
to speak. All sorts of elaborate classifications
have been suggested, some based upon bacterio¬
logical grounds, some upon clinical observation,
and some upon morbid anatomy. Many of those
given in text-books are of but little value for
clinical purposes; they assume more than we
know. I think the simplest way is to divide
them into two, or possibly three, groups:—

(1) Simple gastro-intestinal catarrh, which
some people call “ intestinal dyspepsia,” that
is, simple diarrhoea due to some faulty food.

(2) The more severe form known as gastro-enteritis
with ileo-colitis, in which there is a rise of tem¬
perature possibly due to some infection. It in¬
cludes “ summer diarrhoea ” and “ febrile diar¬
rhea.” (3) The most severe form, known as
cholera infantum, in which the child, in twenty-
four hours, is almost moribund. I doubt very
much whether even such a classification has any
really solid ground to rest upon. It amounts,
after all, to little more than a distinction of degrees
of severity. It is often impossible to distinguish
between gastro-intestinal catarrh and gastro¬
enteritis. I have no doubt there is a difference
between the simple diarrhoea in the child whose
food is indigestible, and the severe diarrhoea
which comes on in the middle of summer. But
there are cases in which it is difficult to draw the
line ; they seem to merge the one into the other.

I do not know of any proof that cholera infantum
differs from severe gastro-enteritis, except in the
“ rice-water ” stools, and the fulminating course.
Until we know a difference in aetiology, our dis¬
tinctions are somewhat premature. However, the
treatment of some of these conditions differs from
the treatment of others. You may be able to
say that in one child the lower part of the intestine
is affected more than the upper, although you
may not be able to say what the change is. You
know that the child’s colon is distended and that
it is passing much mucus and streaks of bright
blood in the stools, and that it suffers from
tepesmus, and gets prolapse, and you are justified
in supposing that there is some colitis or ileo-colitis.
Another child may not be passing either blood or
mucus, but vomits and has loose watery stools.
We say such a child has gastro-enteritis, and the
treatment will differ correspondingly.

I have not time to say much about the com¬
plications of infantile diarrhoea, but one which is
very apt to be overlooked is otitis media. In all
acute diseases of infancy and early childhood, this
is a very common complication, and the symp¬
toms are often wrongly interpreted. The infant
suffering from diarrhoea begins to scream and the
screaming is supposed to be due to pain in the
abdomen, but it is not, and in a few days the
child is found to have a discharge from the ear.
Such a child may have head retraction, and
other symptoms reminding one of meningitis.
These have been verified at autopsies as due to
ear mischief; there is not necessarily any dis¬
charge from the external ear.

Now with regard to treatment, for that is my
main point: I suppose there is scarcely any
disease for which more methods of treatment have
been suggested, yet in very few diseases is it so
difficult to decide what method of treatment is
likely to suit in a given case. Let me first venture
to find fault with what has sometimes appeared
to me to be a shortcoming in the treatment of
these cases. The practitioner, when called in,
finds the child very bad ; he orders some medicine,
and says he will call again to-morrow. But in¬
fantile diarrhoea acts so quickly that the case may
have slipped through his fingers before the next
day ; such a child should be seen, if at all possible,
three or four times a day. In the simple gastro¬
intestinal catarrh, little is necessary beyond an
aperient to clear the bowels, and I know of nothing
so good for this as the old-fashioned castor oil,
which has the advantage that its subsequent effect
is to constipate. The food may require to be
made a little weaker, and it may be advisable to
give opium.

It is the severe forms which are difficult to
treat, and, as the feeding is of prime importance,
I shall consider that first. It is poor economy to
attempt to feed these cases with milk diluted or
modified first this way and then that. It is better
to stop milk altogether at the outset; no ground
is lost by so doing, for the infant does better by
retaining even plain water than by having its
vomiting and diarrhoea prolonged, or possibly
aggravated, by some form of milk feeding. What,
then, is to be substituted for milk ? I put them
down in the order of strength. First, veal or
chicken broth (I believe these are preferable to
mutton broth); next I put various cereal decoc¬
tions. Rice-water is more likely to suit than
barley water. Let an ounce of rice soak for three
hours in a quart of tepid water, then boil for an
hour, then strain. Next I put albumen water—
ordinary white of egg water. Next, something
which is much used on the Continent for infantile
diarrhoea, though only rarely here—extremely
weak tea. At a hospital in Germany I was told
it was given because the tannin had an astringent
effect on the intestine ; in another, that it had a
stimulating effect At any rate, it has been found
useful. Lastly, there is plain water, on which a
child will live for many hours, and if difficulty
is found with albumen water, this is the wisest
thing to give.

When the vomiting begins to subside, you can
reverse the order, until finally you get back to the
broth. Next to broth, on the return journey,
the best thing is whey. I did not mention in this
connection with the treatment of the diarrhoea,
because it often prolongs the diarrhoea and vomit¬
ing if given in the early stage. In making the

214 The Medical Press.

CLINICAL LECTURE.

Aug. 28, 1907*

whey, the curd should not be broken up at first,
but as the infant improves the curd may be more
and more thoroughly broken up before straining
off the whey, so that the infant may get a food
containing more fat. The next step is to use
peptonised milk, to which lime-water should be
added to prevent any laxative effect It is well
to give alternate feeds of peptonised milk and
whey at first Sherry whey is another useful food
as a stage in the return to milk.

A very important point is to give only small
feeds. One sometimes finds the strength of the
food has been reduced, but the child is having
4 oz. or 5 oz. feeds when £ oz. would be much
better. It is better to give a teaspoonful and
have it kept down than an ounce and have it
vomited. I believe it is often wise to reduce the
feed even where there is only diarrhoea and no
vomiting. An error often made is to continue too
long the frequent small feeds. It is bad to con¬
tinue giving food every hour if the child can take
more every one-and-a-half-hours; the longer
interval allows the stomach more time to rest
In many cases of cholera infantum, the child
cannot keep anything down at all. There is
nothing, then, like a saline infusion under the
skin. It will save lives which cannot be saved in
any other way. After the infusion, the infant
goes to sleep, and wakes up a different child.
But in many cases this has to be a last
resource, because parents are naturally averse to
anything that savours of operation. Absorp¬
tion of the fluid will be very slow, so it is better,
if the child is apparently in extremis , to give some
stimulant first, such as strychnine, or a mustard
bath, or alcohol, until the infusion can take effect.
But remember that strychnine in infants, even in
very small doses, is apt to cause convulsions. I
have seen this result from i«i. of the liq. strych.
B.P. If it is tolerated you can repeat a dose of
half a minim after a couple of hours. As to the
value of brandy, one is almost afraid, nowadays,
to say anything about it. I have even been told
that it is useless in any disease ; my experience
leads me to think that in infantile diarrhoea, as
in many other serious diseases, brandy is ex¬
tremely useful. But it is possible to do much harm
by giving too large doses of it. I see infants who
are having, as it seems to me, an altogether
excessive amount of brandy, with the result that
vomiting is actually excited, and kept up by this
overdosing. For a child under six months,
10 to 15m. is enough, and you can repeat this in a
couple of hours, if necessary. 30 m. I regard as an
outside dose for a child under a year, and I should
not give that quantity unless I was hard pressed.
I am satisfied that five drops of brandy put into
a feed of whey or milk causes a feed to be kept
down in some cases when otherwise it would be
rejected. There is a carminative as well as a
stimulant effect in brandy. The doctor should
specify how long the brandy is to be continued ;
one has found brandy being given quite unneces¬
sarily for weeks because the doctor had omitted
to say when it should be stopped. Sherry whey
must only be given under conditions in which you
would use a stimulant. It has a remarkable
carminative effect, and is sometimes kept down
well when other preparations of milk are vomited.

As to drugs, my own experience is that there is
not a great range of drugs which are of use in this
disease. I know some people believe that opium
is bad in infantile diarrhoea, but I should put it at

the top of the list. There are, however, cases in
which it does harm ; and I think it is difficult in
any given case to know whether it will do harm
or not until you have tried. If you constipate
an infant by giving opium, it sometimes happens
that cerebral symptoms develop which make the
case look like one of “ spurious hydrocephalus.”
This is supposed to be due to the retention of the
foul diarrhosal stools in the intestines and absorp¬
tion taking place, so that there is auto-intoxica-
tion. Such a result, however, is very rare in my
experience. How should the opium be given ?
The solid forms of opium are, I think, more
useful than the liquid in infantile diarrhoea.
Dover’s powder is most useful; under three months
old, | grain; six months, or under to three
months, £ grain ; and over six months, £ grain.
This may be repeated three or four times a day.
If you have the child under close observation you
can give more. If the stools are very offensive,
it is good to combine it with £ grain of hyd. cum
creta. If giving liquid opium during the first
six weeks of life, I use tinct camph. co. You
may take it as a safe rule to give a quarter-minim
dose of tinc+ure of opium for every quarter year
of age. But this, as I have said, can be increased
f the child is under constant supervision.

Two other valuable drugs for this condition are
castor oil and bismuth. I am not speaking of
castor oil now as an aperient. There is much
misapprehension about castor oil in the diar¬
rhoea of infants. For clearing out the bowel, you
use \ drachm or a drachm. Its other use is as an
astringent, and that is the use most commonly
made in children’s hospitals. We have there a
mixture of 5 "l. castor oil, 15 m. mucilage of acacia
and dill water to 1 drachm. This mixture is
almost as constipating as opium; it has no
aperient effect whatever. If you give a baby six
weeks old 5 m. of castor oil, you will occasionally
get an aperient action, and xom. will usually cause
such action. So for a baby six weeks old I order
4m. It must not, however, be ordered every
three hours, as one orders bismuth, else its effect
will be aperient.

Bismuth is best given, I think, in a mixture,
for the reason that the baby with bad diarrhoea
is of course craving for drink, and will take the
medicine in a drink ; whereas if you give it a dry
powder it will vomit on that account. In other
conditions also you will find some children will
never take powders. You need to give 5 to 10 grs.
of bismuth carbonate, and you can give it every
two or three hours. Some people think a great
deal of disinfectants for infantile diarrhoea. They
should, theoretically, do good ; but my experience
with them in the acute diarrhoea of infants has
been most disappointing. They are useful in
chronic conditions where the bowels are opened
four or five times a day and the stools are offensive
and the child is wasting.

There is a difference between the treatment of
a case where the colon seems to be chiefly affected,
and one in which the stomach is chiefly at fault.
Put tersely, I should say give bismuth where there
is gastro-enteritis ; castor oil where there is ileo¬
colitis. Castor oil seems to have a very soothing
effect on colon conditions : also in children with
big abdomens, who are passing a great deal of
mucus, and perhaps wasting like a case of tubercle.
The acuter cases of ileo-colitis often do much better
with castor oil than with bismuth ; whereas, the

Aug. 28, 1007.

ORIGINAL PAPERS.

The Medical Press. 215

child with much vomiting and loose watery stools
will do better with bismuth.

Rectal irrigations are useful where there is ileo¬
colitis, and the child passing much slime. Some
use antiseptics, others astringents, and others
plain saline for the irrigations. Plain saline is, I
think, as good as any. You can use 2 per cent,
resorcine and tannic acid, but I do not think they
do more good than plain saline; it is largely a
question of washing out the intestine.

A valuable drug in cases of diarrhoea arising
from affection of the colon, particularly in acute
diarrhoea running on to a sub-acute condition, is
silver nitrate, given in ^-grain doses in distilled
water, perhaps sweetened with saccharine. I have
tried ordinary astringents, and given an extensive
trial to haematoxyline and catechu, and prepara¬
tions of tannic acid brought out recently, and I
think they are of very little use in acute cases.
They are more useful in sub-acute cases.

In treating cases of acute infantile diarrhoea
you must watch your patient almost from hour to
hour. It is no use going on day after day with a
particular drug or a particular mode of feeding if
the child is not obviously improving under it.
The medical man must needs exercise a close and
almost constant supervision, and must be prompt
to appreciate the slightest change in the infant’s
condition and to adapt his treatment thereto, if
he would save life in these severe cases of infantile
diarrhoea.

Note. —A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture
for next week will be by Professor F. Raymond, M.D.,
of the Faculty of Medicine of Paris ; Physician to the
Salpitri&re Hospital, Paris. Subject “ Abortive Forms
of Tabes.”

ORIGINAL PAPERS.

A CASE OF

THORACIC LYMPHOSARCOMA, (a)

By JOBSON HORNE, M.D., B.C., Cantab.,

Surgeon, Metropolitan Ear, Nose and Throat Hospital, London, etc.

Clinical history. —The patient, a man, aet. 49,
was quite well up to two months previous to his
death, his weight being fifteen stone. He first
noticed an increasing inability to eat meat, and
within a month of the onset of this difficulty
he was unable to take solid food, the attempt
causing vomiting. He was able to take liquids
by drinking fast, only about a teaspoonful return¬
ing from three quarters of a pint. Five weeks
after the onset of the dysphagia—that is, three
weeks previous to his death—there developed
difficulty in breathing, which became worse, and
was attended with “ occasional spasm of the
windpipe,” so that he had to sit up. Latterly
the attacks became more frequent, recurring
twice a day, and lasting half an hour; they were
worse at night, so that he was afraid to lie
down in bed.

Condition on admission to hospital. —He had
an anxious look. There had evidently been
considerable wasting. The breathing was rapid,
and associated with inspiratory and expiratory
stridor, and much “ wheezing,” as if bronchial.
He experienced a feeling as though a weight
were on the chest along the sternum.

The examination of the thorax revealed no

' 1 °) f*per read before the Laryngologlcal Society of London, April,

physical signs of aneurysm. Both sides of the
i chest moved equally; there was no area of
dulness. The area of cardiac dulness was dimin¬
ished ; the cardiac sounds were normal. The
larynx was observed to be congested, but the
vocal cords moved well, and there was no sign
of obstruction. A radiograph of the chest was
not obtainable.

The oesophagus permitted the passing of a
bougie of the largest size.

; A photograph of the larynx opened from behind to
show: (1) The localised oedema over the right
artysenoid. The oedema has somewhat subsided
in the process of preserving the specimen. (2)
The puckered scar in the fold of mucous mem¬
brane passing down between the cartilages of
Santorini and Wrisberg, and referred to by the
author as the vulnerable spot of the lamyx as a
source of systemic infection.

The patient rapidly became much worse, very
cyanosed, and distressed, and on the second day
after admission death occurred from asphyxia.

The post-mortem examination revealed in the
posterior mediastinum a lobulated mass of new
growth, the size of a large peai, apparently
springing from the bifurcation of the trachea,
and extending forwards into the pericardium,
and downwards and backwards for the most
part to the right of the middle line. The growth
had bulged into the lumen of the oesophagus so
considerably that the mucous membrane covering
it was extremely thinned and atrophied, the
oesophagus itself being obstructed by the new
growth to the extent of 115 mm. in the vertical
direction, the growth within its walls measuring
40 mm. across, whilst the entile width of the

litized by

Google

21 6 The Medical Press.

ORIGINAL PAPERS.

Aug. 28. 1907.

growth in the posterior mediastinum was 70 mm.
There was some dilatation of the oesophagus
above at the level of the bifurcation of the trachea.
Both pulmonary veins were surrounded by the
growth, the right bronchus, although not invaded,
was considerably narrowed. There was a direct
extension of the growth into the lower lobe of the
right lung. There was much surgical emphy-

size of a raisin. On the inner aspect of the
right arytenoid there was the puckered scar of
an abrasion, situated in the fold of mucous
membrane passing down between the cartilages
of Santorini and Wrisberg, a site which I have
described elsewhere as one lending itself to
systemic infection, and which I have termed
the vulnerable spot in the larynx (a). It is
indicated in the accompanying
diagram by a dotted line, and
must be distinguished from the
common site of a tuberculous
ulcer, which is immediately
behind and a little below the
vocal process (the posterior
sesamoid cartilage) of the vocal
cord. There was no marked

A diagram of the interior of the
left half of a larynx to show
the site referred to as the
vulnerable spot, which is indi¬
cated by a dotted line.

1 23 45

A photograph taken from behind to show the invasion of the posterior
mediastinum by the new growth. The structures entering into the
photograph from left to right are :—(1) The inner portion of the
left luDg. (2) The descending aorta. (3) The oesophagus laid open
to display that portion of the growth which bulges into, and almost
obliterates, the lumen to the extent of 115 mm. The walls of the
oesophagus are separated by a glass rod inserted in the upper part
at a level corresponding to that of the bifurcation of the trachea.
The oesophagus above this level is dilated. (4) The main portion of
the growth outside the oesophagus, and to the right of the middle
line. (5) The inner portion of the right lung showing the direct
extension of the growth irto the lower lobe.

sema round the root of the right lung, and also
between the chest and the pleura; the lungs
were somewhat collapsed, but presented no
further evidence of disease.

Microscopic examination of the growth showed
it to be a round-celled sarcoma.

enlargement of the cervical
lymphatic glands.

The case presents some un¬
usual features of clinical and
pathological importance :

(1) The extent of the occlusion
of the lumen of the oesophagus
by an extrinsic new growth.

(2) The possibility of passing
a bougie of the largest size, in
spite of such marked oesophageal
obstruction, illustrates both a
clinical fallacy, which may attend
the use of soft rubber instru¬
ments, and also the value of
oesophagoscopy in the diagnosis
of such cases; it being im¬
probable that a rigid tube would have passed
the growth.

(3) The localised oedema of the larynx might
be accounted for by the conditions within the
thorax. At the same time it is as well to consider
the possibility of such oedema being occasioned

The larynx presented, over the right arytenoid
region, a circumscribed area of oedema, about the

(a) Introductory irapcr to a discussion on “The Upper ltespiraiorjr
Tract aa a Source of Systemic Infection,” British Medical Association.
Annual Meeting, Swansea, 1803 .

Aug. 28. 1907.

ORIGINAL PAPERS.

The Medical Press. 217

by a local infection at the site indicated.
The presence of the scar in the larynx raises the
interesting question whether the thoracic growth
were not the result of an infection, and whether
lympho-sarcoma may not eventually have to
be numbered, together with the lesions met with
in Hodgkin’s disease, amongst the infective
granulomata. The question is not necessarily
negatived by the absence of enlarged cervical
glands, for I have shown experimentally that
after an inoculation the proximal group of glands
may not be permanently affected, whilst post¬
mortem a distal group may be found markedly
enlarged.

THE TREATMENT OF URINARY
DISORDERS BY THE MINERAL
WATER OF EVIAN.

By J. GRISEL, M.D.

Consulting Physician at Evian-les-Bains, France.

From ancient records it would seem that from
the earliest times the mineral waters of Evian
were used for gout, nephritic colic, gravel, and
other urinary disorders. In fact the first ac¬
count of a recovery due to the drinking of this
water concerns a certain Baron de la Rochette,
who was thus cured of gout in the fifteenth
century. It is not until the end of the eighteenth
and at the beginning of the nineteenth centuries
that treatment of the Evian Spa was regularly
applied, after the testimony of Tingry, a pro¬
fessor of chemistry at the University of Geneva (a).
There were then sent to the Spa people suffering
from “ irritative diseases.” For a long time
gout and other unhealthy conditions of the
urinary tract mostly brought sufferers to this
spa: among them many patients affected with
catarrh of the bladder, urethritis or gravel were
to be seen. Even now the physicians who have
been practising at Evian for a tolerably long
while, can recall more than one stricture of the
urethra treated there. The use of this pure
water, with its accompanying mineral qualities,
in such a state of dilution is, that its passage
through the kidneys and urinary organs effects a
regular flushing and sedative action, and proves
highly beneficial to many patients of this class.

Of course the peculiar property of the water,
resulting from its quick passage and rapid elimina¬
tion, would make it unavailing and even in¬
jurious for people in whose urinary tract there
is an obstacle to the free discharge of the urine—
e.g., big renal calculi, excessive hypertrophy of
the prostate—especially of the median lobe—or
a tight stricture of the urethra. Such patients
should entirely abstain from the water, or be sent
to Evian only when the obstacle is removed by
means of an operation designed either to destroy
the calculi or to remove the stricture, &c.(b)
Then not only will they be able to make use
of the water without inconvenience, but it will
be a duty for the medical men, under whose
care they are, to prescribe it, when they become
aware of the benefit that their patients will
derive therefrom. Under its influence the
inflammatory symptoms disappear, the general
nutrition is improved, and in most cases relief
speedily ensues.

(a) An analysis of the mineral soapy (alkaline) waters of Evian,
Geneva, 1808.

<M Should they be sent here, however, suffering from acute con¬
ditions, they require the greatest care during the treatment in order
to obviate, as far as possible any untoward effect.

Is it possible to discriminate, d priori, between the
patients who can be sent directly to this spa
and those who need preparatory treatment or
operation ? This question finds its solution in
the statement of a precise diagnosis, the elements
of which we have not here to deal with. It
ought, however, to be pointed out, among the
latest processes of investigation, that cystoscopy,
and the examination of the urine of each kidney,
obtained separately with the help of Cathelin’s
or other “ diviseur,” would generally reveal the
true state of affairs. Above ail, in order to make
out, as far as possible, the position and size of
the calculi, it may prove useful to resort to the
X-ray examination and to radiography, especi¬
ally in the case of very obese persons, with the
use of a compression cylinder (a).

Dr. O. Kraus, of Carlsbad, asserts that the
biggest calculi he ever saw eliminated in an
attack of nephritic colics were about the size
of an almond ( b ). From another point of view
the shape of the calculi is of considerable im¬
portance as to the ease or difficulty of their going
out of the pelvis and down the ureter. I have
before me an opuscule written by Dr. Rafin, of
Lyons, relating to “ renal calculi and radio¬
graphy,” in which some samples of stones were
radiographed—first, when still in the kidneys,
and then after their removal by nephrotomy ;
it is easy to understand that some of these con¬
cretions, in spite of their small size, would have
produced severe pain when passing through
the ureter, on account of the sharp points and
edges that are spread all over their surface (c).

It will, therefore, be well to remember that
the largest stones do not, in every instance, give
rise in situ to the most obvious symptoms, and
that, not uncommonly, gravel, and even tolerably
big calculi can be passed through the ureter
without acute pain. In such cases stones are
often only noticed when, having reached the
bladder, they cause evident disorder. How often
does the renal lithiasis remain concealed, some
pain or even a mere weight in the loins being
noticeable, until pyelitis, or renewed haematuria,
awake the practitioner’s perspicacity !

Perhaps, by resorting more frequently to
Rontgen rays, it will be possible, in many a case (d),
to trace back to their real cause some symptoms
of which the interpretation is puzzling, and
therefore to infer more speedily the right mode
of dealing with the disease.

But here, as everywhere in medicine, we shall
probably prevent rather than cure, and attempt
to stop the production and the increase of calculi
by prescribing the use of the mineral water of
Evian, the efficacy of which is testified by many
years, not to say centuries, of experience. It
is indeed the results of the latter, supported by
the investigations and work of the medical
profession on the spot, that Professor Landouzy
summed up, when he observed (e) that the
ingestion of the water of Evian, opportunely

(a) Dr. Arclin, from Lyons, uses, instead of a cylinder, a rubber
balloon applied to the abdomen by means of a strap, at each end of
which is hanging a bag filled witn sand (or any other material), as
much as is necessary to exert a compression sufficient to keep the wall
and the kidney motionless.

(b) The Lancd No. 4366, May 4th, 1907, p. naa.

{() Dr. M. Rafin, communication b la dixiAme session de l'association
Francaise d’urologie.—Evreux HArisy et fils, 1906.

(a) As far as we can imagine from what we know of X-rays, it is pos¬
sible to suppose that, in the actual state of their application, not all
kinds of calculi can be revealed, those composed, partly or wholly, of
lime salts will be most readily made out.

(e) Lecture delivered at Evian, September lath, 1901.

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218 The Medical Press.

ORIGINAL PAPERS.

Aug. 23 , 1907.

prescribed, is the best plan we can conceive
to modify the cellular and visceral nutritions,
and to flush the urinary tract of patients affected
with a catarrh of the bladder, ureters or kidneys.

SOME POINTS IN THE PROBLEM OF

ILL-HEALTH AND SCHOOL
ATTENDANCE, (*)

By F. J. POYNTON, M.D., F.R.C.P.Lond.

Physician to Out-Patients at the Hospital for Sick Children, Great
Ormond Street, and Assistant Physician to University College
Hospital, London.

With regard to infectious diseases, I shall be content
to echo a sentence in Dr. Kerr’s report for 1905-1906,
p. 30, to this effect :—“ The time has come to press
on the Board of Education the necessity for allowing
the Epidemic Grant as a natural insurance against
the school diffusion of disease, and as a means of allow¬
ing sufficient prolongation of the convalescent period
when children have been suffering from infectious
diseases.”

This mention of infectious diseases leads to the
question of sore throat. We know that the first
symptom of such important diseases as diphtheria,
scarlet fever, measles, mumps, and rheumatic fever
may be a sore throat. How alive the London County
Council have become to this danger in the case of
diphtheria is clearly shown in their resolution to the
effect that during the presence of diphtheria in any
district readmission is refused to children who have
been excluded on account of sore throat or diphtheria,
until they have obtained a medical certificate of
freedom from infection based on a bacteriological
examination. But what is to be done with a child
who comes to a doctor with a sore throat when there
is not an outbreak of diphtheria ? The bacteriological
examination cannot by any means always tell us the
meaning of that sore throat, and inspection is also often
not sufficient. It may be a passing tonsillitis or a
commencing scarlet fever. The child may be practi¬
cally harmless ora virulent focus of infection, and yet
the decision at first may be impossible. I am of opinion
that all cases of sore throat which come to the know¬
ledge of medical men should be excluded by a certificate
from school attendance until they are well, and that
school teachers should be particularly watchful for
complaints of sore throat and not hesitate to bring
such cases at once for inspection. I admit the danger
of the abuse of this precaution by unprincipled parents,
but it is a lesser of the two evils, and medical men will
not, I think, be often outwitted by sore throats. Epi¬
demics will be more easily dealt with, and more
rapidly stamped out if the danger of a sore throat in
childhood is clearly recognised.

A sore throat may be the first symptom of acute
rheumatism or rheumatic fever, and leads me to
consider next this important disease. So far as my
own contribution to the discussion is concerned,
it is upon this subject that I most hope to be of some
assistance.

The general public are but little aware of the fre¬
quency and severity of this disease in childhood. They
associate acute rheumatism with painful and swollen
joints in adult life, and speaking vaguely of acidity
in the blood do not realise that the disease is the
result of an infection by a micro-organism and that
many important organs other than the joints are
frequently damaged. Should any here be in doubt
as to my meaning, I would ask them to compare
rheumatism to tuberculosis. Tuberculosis may attack
many organs. The most familiar condition is tuber¬
culosis of the lungs, but there may be tuberculosis
of the joints, or brain, or alimentary canal. So, too,
with rheumatism, there may be rheumatism of the
joints, rheumatism of the heart, rheumatism of the
brain, and so on.

In childhood this disease often attacks many organs.

(a' Paper read at the International Congreu on School Hygiene,
Lon Ion, July, 1907 .

and two may be mentioned as of first importance—
the heart and brain. Rheumatism is the great cause
of heart disease in childhood, and it is also the great
cause of chorea or St. Vitus’s dance.

Dr. Newsholme some years ago pointed out that
acute rheumatism was essentially an urban disease,
and in London it is particularly frequent, and it is
common in all large towns. This disease is strongly
hereditary, and one believes this to mean that the
children of rheumatic parentage have transmitted
to them a delicacy of tissues which makes them
especially susceptible to the rheumatic infection.
The problem of rheumatism and school attendance
presents several aspects. The first of these is con¬
cerned with the children of rheumatic parentage.
It is an observation of general acceptance among
medical men that such children are often highly
nervous and subject to night terrors and headaches,
and that they easily get over-excited and over-tired.
They derive much good from school discipline, but
when they begin to dream about their school-work
at night and worry over their lessons, no children
more certainly need rest and relief from mental
exertion.

The next consideration is a much more urgent one,
for it is concerned with the proper treatment of those
children, whether of rheumatic parentage or not,
who develop an attack of acute rheumatism. If the
joints are affected then the pain and incapacity for
movement at once renders school attendance im¬
possible. When, on the other hand, the heart or the
brain is affected—structures of incomparably greater
importance—strange though it may seem. I con¬
tinually meet with the fact that these children have
been attending school until there is a complete break¬
down. Yet no rule in medicine is probably more
assured than that which lays down rest in bed
as an essential treatment for acute rheumatism.
How is it then that active heart and brain rheumatism
are so easily overlooked ? The reasons are two,
the first is that their early warnings are often very
indefinite, the other is that there is not a general
knowledge of the fact that the conditions are rheu¬
matic. Early heart disease is singularly free from
pain, and on this account pallor, lassitude and short¬
ness of breath are not given their due importance;
vague pains are, peharps, called growing pains, and
the absence of swelling of the joints tends to dispel
all suspicion of rheumatism. The headaches, irri¬
tability, and irregular movements of early chorea
are put down to naughtiness or carelessness, and
the impossibility of fixing attention is attributed to
wilful disobedience. Then those attendance medals
which, from my pomt of view, appear to be so in¬
jurious, stimulate the child himself to hold on until
compelled by illness to give up. Valuable time—
invaluable time, in fact—is thus lost, for it may be
asserted that though the majority of children recover
from an attack of heart rheumatism, few escape without
some permanent damage to the valves of the heart.
Again, as I have remarked, rheumatism in childhood
often affects many organs at the same time, and so
it comes about that many cases of brain rheumatism
or chorea, are also suffering at the same time from
heart rheumatism. How can these difficulties be
dealt with ? No sudden or sweeping measures will
Succeed, I think, but there must be a gradual education
of the general public to the recognition of the frequency
and meaning of active rheumatism in children, and I
hold it of great importance that school teachers,
especially, should be acquainted with its chief dangers.
They have the power of doing both children and
doctors a great service by thus helping to solve what
is one of the greatest problems of disease in this
country—the arrest of the vast amount of organic
heart disease of rheumatic origin. Much of the
heart disease of adult life, let me add, dates from
rheumatism in childhood.

The third difficulty in this problem of rheumatism
and school attendance is the great tendency there is
for rheumatism to relapse. It is a common experience
in London for a child of six years of age to be attacked

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Aug. 28, 1907 .

ORIGINAL PAPERS.

The Medical Press. 219

with rheumatism, and from that time forward to
suffer repeatedly from relapses now it is brain
rheumatism, now cardiac rheumatism, now joint
rheumatism. The recoveries, especially from cardiac
and brain rheumatism are very slow, and the cases
of chorea are so numerous that hospitals cannot cope
with them, and yet when they are in the convalescent
stage their home-life is often unsuitable, and school
attendance is quite out of the question. We need in
this country some of our great philanthropists to
found convalescent homes where the rheumatic
children might thoroughly rest and if they only knew
the sadness of children’s rheumatism I am positive
those homes would soon be founded.

The last point for consideration in rheumatism
is the child with heart disease. By this I mean
the child who has recovered from the acute rheumatic
lesion but is left with a heart more or less damaged.
These children must be educated, but they are delicate
and need careful management. The disturbance of the
circulation of the brain by the heart disease often
makes them nervous, and cold bitter weather and long
flights of stairs are most obnoxious. It is evident
that no routine school attendance is permissible,
and so far as possible these cases should be singled
out and special arrangements made for them.

To summarise these remarks upon rheumatism
and school attendance, there are four main con¬
siderations:—(1) The excitable nature of the child
of rheumatic parentage ; (2) The danger of active
rheumatism when untreated by rest; (3) The stub¬
born and relapsing character of the disease ; (4) The
delicacy of children left with chronic heart disease.

Should there be any here who think that I exaggerate
the great importance of rheumatism, I need only
add that if they spent one week in making the round
of our large London hospitals and infirmaries they
would be astounded at the answers they would receive
as to the frequency and severity of this scourge.
In seven years as an out-patient physician, attending
twice a week at only one of the children’s hospitals,
I have made notes of over 500 cases in children under
twelve years and have seen quite as many more.

In passing I would mention a small group of children
who are bom with malformed hearts and who live
to grow up to adult life. These need also most careful
supervision during school life and must be grouped
with the victims of acquired heart disease.

Leaving heart disease I would next direct your atten¬
tion to a considerable group of cases of chronic lung
disease which are not tubercular. Such, for example,
as asthmatics, who are often most intelligent children.
Those again who have suffered from severe pneumonia
and bronchitis. Many of these among the well-to-do
should not be permitted to winter in England. They
are delicate, and during inclement weather want
supervision, but a considerable number would recover
completely, I think, with more care as to their school
attendance.

Kidney disease again, often a heritage of scarlet
fever, is a very important condition. It is certain
that if a child who has suffered from the acute disease
is—from insufficient care—allowed to drift into a
state of chronic kidney disease, there can be only one
end—viz., persistent ill-health and early death.
School attendance must then often be very imperfect
until the danger of a relapse has been thoroughly
warded off, and yet the ordinary observer could
detect nothing amiss during this time of convales¬
cence. Only a medical man can accurately judge the
stage of convalescence. There are seasons, too.
which are most dangerous to those who have had
kidney disease, and I have never seen a better ex¬
ample of this than in last April, when there was an
extraordinary increase of acute kidney disease. Dur¬
ing such times much judgment is required as to school
attendance of a child who has suffered from renal
disease.

A well-organised system of medical certificates and
a greater development of schools for the physically
defective are two precautions of first importance

in dealing with these victims of rheumatic, cardiac,
pulmonary and renal disease.

I would venture to suggest (paradoxically) it may
seem that in these days of specialism medical men
are not sufficiently aware of these special schools,
and I think something might be done by the school
authorities to make them more known. We ought,
I admit, to be well acquainted with them, but we are
so engrossed in our own heavy duties that we need to
have their existence impressed upon us. They have
been a revelation to me, and I am full of admiration
for the splendid work they are doing. Yet I realise
that they are very expensive, and that their multi¬
plication must mean time and money. At present,
too, I think, that though a recommendation from the
medical man or hospital physician should be en¬
couraged and welcomed, the ultimate decision of
admission of a child to such a school should rest
with the medical officers of the school board, because,
in my opinion, they alone at the present time can
decide the essential point as to whether the particular
case is the most suitable among the many claimants
for the limited accommodation now available.

Medical certificates will need to be as brief as possible.
I can assure the Education Department that they can
hardly realise the labour of a modern hospital out¬
patient department, with its enormous numbers,
its school and vaccination certificates, its letter to
be signed for convalescent homes (some of which are
cruelly exacting), and its teaching duties. When I
say that in a morning between seventy-five and one
hundred medical cases may have to be dealt with
in one department at a large children’s hospital,
some here may understand how worrying it is to have
to turn even for a moment from the actual medical
work.

EPILEPTIC CHILDREN.

The next class of cases to be touched upon is a
most difficult one, and this is the epileptic. It is
particularly difficult because there are two separate
problems. One is, that of the actual fit, the other
the mental condition between whiles. The severe
fits are most distressing, and are most alarming to other
children. Their occurrence during a class must of
necessity upset everyone. Clearly a child who is
suffering from repeated severe fits should not be
attending an ordinary school. Experience, how¬
ever, shows that we have all grades and varieties of
attacks. In a collection of about 200 cases kindly
made for me by my assistants, Drs. Moon, Brincker,
Sweet and Crampton, this fact is well illustrated.
Among them there are a number of children who only
exceptionally have attacks—once in two months,
for example. Many of these are quite intelligent,
and if it were not for the alarming character of an
epileptic attack they would be to all intents normal
children. Then there are others who have infrequent
attacks, too, occurring only at night, and then for
some mysterious reason suffer from storms in which
forty or fifty fits may occur in a week. Others,
again, steadily improve under treatment. It is
then evident that even if we consider the fits alone that
no single rule can be laid down for the education of
these children.

The other problem concerned with epilepsy is the
mental state. This also varies greatly. As a general
rule, it may be said, that the occurrence of many fits,
whether of the severe or mild type, will in the course
of time greatly damage the mind. It is, however,
equally true, that some cases degenerate much more
rapidly than others, and that mental failure may some¬
times follow rapidly upon the occurrence of one or
two attacks. The mental degeneration associated
with epilepsy is a very serious one, and the imbecility
of a dangerous type ; and with regard to the mental
question I should be much interested to hear from some
of those who take part in this discussion the general
experience of school authorities in dealing with the
education of epileptic children.

In addition to the damaging effect of repeated
epileptic attacks on the brain, there are the strange
mental states that sometimes follow immediately upon

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220 The Medical Pkess.

OUT-PATIENTS’ ROOM.

Aug. 28, 1907.

the fit and which are transient. The most dangerous
of these is mania, a condition which, in adults, has
been the cause of the most horrible murders some¬
times of a wholesale description. Children, though
they generally sleep heavily or remain quiet after a
severe fit, may also sometimes do extraordinary things
and be, for a while, quite dangerous to those near
them. One boy under my observation ran away
from home time after time immediately after a fit.

Persona! experience of epileptic children leads me
to think that, from the educational point of view,
we cannot group them into two great classes. From
the standpoint of convenience this would be a simple
measure, for the slight cases would attend school
and the severe would go to an epileptic colony, but I
feel convinced we should not have done our best,
for there would be a large number left not able to
attend school with regularity, and not suited for a
colony. These would run a great risk of becoming
uneducated, a deplorable event, when we bear in
mind that even bad cases may get quite well under
steady treatment and with others the fits be greatly
curtailed. In dealing with this problem, I see the
brightest light in an intelligent co-operation between
parents, school teachers and medical men, coupled
with the cautious trial of special schools for the large
class of epileptics that lie between the very mild
and very severe types. Deficient children form a
very large class in big towns, and with many types
of these I cannot attempt to deal.

I would most briefly allude to certain common con¬
ditions among the poor, which may at first sight seem
somewhat trivial, but which through the ignorance
and, I might even say, the degenerate carelessness
of many parents are productive of great harm. These
are neglected teeth, chronic ear discharges and ade¬
noids. The teeth of poor children are horribly neg¬
lected, and the tender and offensive conditions of
their mouths and gums produce dyspepsia from food
bolting and anaemia from continual poisoning. Some
homely instruction upon this point and some practical
illustrations of the use of the tooth-brush would be
as useful as any physical drill.

Chronic ear discharges are a danger to the child
and an offence to its associates, and it is deplorable
how callous parents are upon this point. Adenoids,
by blocking the nasal passages, are the cause of much
stupidity among children. It is, in fact, impossible
for a child to keep his attention when the condition
is severe. Few people, I think, who are fixing their
attention do so with their mouths open, but these
children cannot breathe if their mouths are closed.
Respiration is impaired, and the blood not thoroughly
cleansed, the chest becomes deformed, and middle
ear disease and deafness are constant occurrences in
the victims of adenoids. These cases should be pro¬
perly treated and responsibilities of the parents
aroused.

The last group I mention is a very large one, and
it can, I think, only be dealt with by skilful and
gradual organisation. Many children, naturally robust,
become, particularly in the summer, pale, languid,
irritable, and highly nervous. No actual disease
is discovered, though some enlarged glands in the neck
may raise a suspicion of early tuberculosis. Among
the more well-to-do such children are promptly sent
to a bracing seaside or inland resort, and lessons
stopped or reduced to a minimum. Poor children
cannot be got away like this and are often in a worse
plight at home than they are at school. Yet we
cannot escape from the fact that many severe
illnesses result from the neglect of this early sign
of failure of health, and that it would be a great
step forward if some scheme could be gradually
evolved by which these cases could be drafted to
country or seaside convalescent homes in touch
with country schools. An organisation of a system
of convalescent homes would be required, and the
whole undertaking would need the greatest caution
and watchfulness in order to prevent the immediate
abuse that would spring up as surely as it has in our

hospitals. The present splendid effort of the Lord
Mayor of London on behalf of the cripple children
is an encouragement to hope for some further steps
in the direction of that true education which strives
to preserve the mens sang in corpora sgno, _

THE OUT-PATIENTS’ ROOM.

FRENCH HOSPITAL, LONDON.

Columnar Carcinoma.

White Swelling at the Wrist.

By A. D. Kennard, F.R.C.S. (Ed.)

Amongst Dr. Vintra’s out - patients was a
man, a?t. 52, who came up with a history of
five weeks’ slight pain in the lower part of the
abdomen, and constipation, alternating with diar¬
rhoea, and the passage of blood and mucus.
He had been getting thinner for the last four or five
months. No history of vomiting, though he suffered
from nausea. On examination, patient had a cachetic
appearance; he was not at all emaciated. The heart
and lungs were normal, and liver was not enlarged.
Urine, Sp.gr. 1015, contained a little albumen, but no
other abnormal constituents. On rectal examination
a hard ulcerating tumour could be felt about 2$ inches
above the anal aperture, it admitted the passage
of a finger with difficulty, and completely surrounded
the bowel, and was firmly fixed to the surrounding
tissues. It was, in fact, an advanced case of columnar
carcinoma.

Treatment. —Patient was given a weak perman¬
ganate lotion to use as an enema every morning, aod
a laxative to keep the bowels open.

Remarks. —This case was in a very advanced con¬
dition, and was quite inoperable, and showed how
very few symptoms accompany carcinoma of the
rectum in the majority of cases. If the patient had
been seen earlier it would have been quite easy to
remove the tumour, as the growth was quite low down.
The only question that remained was that of a colo-
tomy, and I am in favour of delaying this operation
to the very last, in fact until the symptoms of
oncoming obstruction present themselves.

Awoman.ast. 30, single, came up with a history ol
pain and swelling in the right wrist, of two months
duration, caused, she thought, by lifting a pail of water.
She said she had been quite healthy, except for an
occasional cough. On examination, the wrist presented
the familiar appearance called by the name of “ white
swelling.” Anteriorly there is thickening along the
tendon sheath, and behind a certain amount of ill-
defined fluctuation could be felt. There is a loss of
mobility in the wrist and there was some pain on
manipulation.

On examination of the chest there was found to
be diminished expansion and a certain amount^ of
dulness at the left apex with prolonged expiratior, but
no r&ies were present.

Treatment. —The forearm was put upon a splint,
and the wrist dressed wiith Scott’s ointment. She
was given an emulsion of cod liver oil, to take three
times a day.

Koch’s New Tuberculin 1-5000 of a milligramme was
injected into the gluteal region, and the patient told
to remain in bed for twenty-four hours.

Remarks .— This case was one of tuberculous disease
of the wrist joint, with a patch of old phthisis at the
left apex. These cases nearly all do well with small
injections of tuberculin once a fortnight; it is advis¬
able to take the opsonic index, but if very small doses
are given, and the duration between the injections
kept at about fifteen days, this was not absolutely
necessary. I believe that keeping the patient in bed
for twenty-four hours after the injection is of great
benefit in the treatment of these cases.

The will of Dr. Alfred Square Cooke, M.R.C.S.Eng.
L.S.A.Lond., of Stroud, Gloucestershire, for thirty-
seven years medical officer at the Stroud Workhouse,
who died June 1st, has been proved by the widow
and sole executrix, Mrs. Margaret Cooke, at
^I.7QC i8« rd

Digitized by GOOglC

Aug. 28, 1907 -

CORRESPONDENCE.

The Medical Press. 221

OPERATING THEATRES.

GREAT NORTHERN HOSPITAL.

Fracture of the Lower End of the Humerus :
Wiring. —Mr. Arthur Edmunds operated on a
child, aet. 5, who had been admitted suffering from
a fracture in the lower end of the humerus in the
neighbourhood of the epiphysial line, the result of a
fall. An X-iay demonstrated the fact that the
shaft of the humerus was displaced anteriorly to the
lower fragment, so that when the limb was flexed
with the deformity unreduced, the bones of the
forearm came into contact with the lower end of the
upper fragment, preventing effectually a permanent
flexion of the arm beyond a right angle. An attempt
was made to manipulate the fragments into position,
but this was found to be impossible, and accordingly
an incision was made through the lower third of the
triceps right down to the bone. The fascial attach¬
ments of the lower end of this muscle were stripped
slightly to each side, so as to give access to the seat
of the fracture. A periosteum detacher was then
thrust forwards and downwards between the two
fragments, and in this way they were lowered into
position. When once in position they showed little
tendency to displacement, but, in order further to
steady them, a wire was passed through the outer
condyle, and then carried up to a point above,
and internal to it on the shaft, just clearing the
olecranon and the coronoid fossae. When the ends
of the wire had been twisted up it seemed to
steady the bone quite effectively, therefore no further
wire was put in. All bleeding points were carefully
arrested, and the muscular layer was just drawn
together with a few catgut sutures. The skin wound
was closed without drainage. Mr. Edmunds said
that cases of fracture of the lower end of the humerus,
especially in children, were amongst the most difficult
fractures to deal with. They frequently involved
through part of their extent to epiphysial line, but
the line of fracture was pretty certain to extend
into the shaft of the bone or the epiphysis. It was
very difficult, he pointed out, to be perfectly certain
by digital examination that accurate apposition of
the fragments had been obtained, and these fractures
should always be most carefully examined by stereo¬
scopic skiagrams to see how far the attempts at
manipulation had been successful. It the fragments
can be manipulated into position by traction upon
the flexed forearm, it was usually possible, he re¬
marked, to maintain the reduction, the arm being
put up at an acute angle, about 6o°, but when, as in
the present case, this cannot be done, an operation
should be undertaken as soon after the injury as
possible, for any imperfections of the joint surfaces
lead to the greatest impairment of the joint. After
wiring. Mr. Edmunds said, it was frequently found
when the wound had healed that movement was not
as perfect as it was at the actual moment of operation,
but this difficulty was often unavoidable, as it was
produced by the callus which formed about the line
of fracture ; this callus, however, rapidly disappears,
and the movements of the joint become perfectly
normal. It was rare, he asserted, that the surgeon
has to operate on children under four, as in these
cases reduction can nearly always be obtained.
Above this age operation was very frequently neces¬
sary. Whatever method of reduction was adopted,
the after-treatment, he remarked, was about the
same : the arm should be put up at an acute angle ;
the object of this was, that at the time of the re¬
duction it was usually possible to place the arm in

any position the surgeon may desire, but a certain
amount of limitation of movement always occurred,
at any rate temporarily. A limb which can only
move through an angle of 6o°, starting at the fully
extended position, was practically useless, and the
patient had no inducement to use the arm, and so
by the ordinary movements of every-day life increase
this range. A range of movement, however, of
exactly the same extent, but extending from 30°
on one side of the right angle to a position of 30° on
the other side of the right angle left the arm tor all
practical purposes perfect; the patient can use the
limb freely, and by so doing would inevitably increase
this range until the full flexion and extension could
be obtained ; for this reason the acute position should
always be employed, affording, as it does, not only
a more satisfactory maintenance of the fragments in
position, but also an earlier utility of the limb.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Paris, A off. 2 Sth, 1907.

The Method of Bier.

Bier’s method on passive hyperaemic stagnation
tends more and more to take an important place in
therapeutics. Passive hyperaemia is obtained in
two ways—either by provoking the sanguine stagnation
in the whole of the limb or by localising it to the affected
region.

In the first case, an indiarubber band is wound round
the root of the limb; in the second, an apparatus is
used from which the air is exhausted by means of an
aspirator or an elastic syphon. The bandages em¬
ployed by Dr. Delagenidre (a French authority on the
subject) are made of soft indiarubber, varying in width
according to the region treated—three inches for the
thigh, two for the arm, and half an inch for the fingers.

The application of the band is the delicate point in
the treatment and requires a certain experience to
produce the desired constriction.

The arterial circulation must in no way be impeded,
while the venous circulation should, on the contrary,
be arrested in order to produce hyperamia. This
rule, being always kept in mind, the bandage is applied
to the root of the limb, each turn covering the previous
one and the caoutchouc slightly stretched so as to
obtain the desired constriction by ‘the elasticity of
the band and the ends tied in a knot or, as Klapp
recommends, simply welted and applied exactly, at
the point of termination.

Immediately after application, the skin becomes
congested, the veins turgescent, and the limb takes on
a violet colour. If the patient complains of a feeling
of numbness in the limb, the constriction is too tight,
the band must be removed, and applied again, for in
no case should it cause suffering.

When the band is well tolerated, it can be left on
an hour, and the stance repeated several times a day.
In case of acute inflammation, M. Delagentere leaves
it on twenty or twenty-two hours a day; in such cases
the constriction is not so tight, but the patient must be
watched for fear of accidents.

When the stance is ended, the band is removed,
when the violet colour of the skin disappears and gives
place to a bright red coloration. The numbness
caused by the constriction also disappears, and the
patient experiences a bien ttre which lasts to the next
application.

In certain regions (axilla, neck, trunk, abdomen,
inguinal regions) the band cannot be employed. It
is in such cases that recourse is had to the apparatus
already alluded to, of which the simplest kind is the
ordinary instrument for dry cupping, composed of a
glass dome surmounted with an elastic tall by which

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222 The Medical Press.

CORRESPONDENCE.

Aug. 28, 1907.

the air is expelled; others are more complicated and
require aspirators. With these apparatus, the stance
should not last more than five minutes at a time, but
should be frequently repeated.

The applications of Bier’s method are very numer¬
ous. They render great service in cases of boils and
anthrax, where the dry cup can arrest the non-suppurat¬
ing boils in four or five days, while where suppuration
has set in, a small incision is made with the bistoury
and the dry cup applied, it withdraws the pus and
produces a rapid cure.

Inflammatory abscesses and frequently cold abscesses
after incision, whitlow, phlegmon, should be treated
by long stances, but the band must be attended to as
certain patients present a special susceptibility of the
skin, recognised by phlyctenas indicating that the
constriction should cease.

Bier’s method gives also excellent results in the
treatment of abscess of the breast, acute or chronic.
The same may be said of suppurating or non-suppurat¬
ing ganglions. Each stance should last one hour.

In cases of crushed limbs, the band applied for one
hour, twice a day, is very beneficial and frequently a
whole limb or a part of it is preserved, which otherwise
would have to be sacrificed.

Id fractures, the consolidation is more rapid if the
band is applied to the root of the limb for one hour
every morning.

Osteitis osteo-myelitis, tuberculous osteitis, spina
ventosa are very favourably influenced by this treat¬
ment.

The hyperxmic stagnation favours the absorption
of articular effusions. In chronic hydrarthrosis, and in
haemorrhagic arthritis, it gives splendid results.

In acute tuberculous arthritis, the application of
the band has a remarkable effect by diminishing rapidly
the redness, the pain and the inflammatory phenomena.

Orchitis, treated by an indiarubber tube rolled
around the scrotum, yields readily.

Such are the principal cases in which the Bier method
is indicated. The mechanism of its action seems as
yet somewhat mysterious, and the different theories
proposed are not fully satisfactory. But there is one
point on which it is necessary to insist—the application
of the method requires training and a good deal of
patience in order to arrive at good results.

Intertrigo in the Adult.

The inguinal region is the favourite seat of inter¬
trigo in the adult, and the cause is generally to be found
in obesity.

Eau de Cologne, 6 ozs.

Tincture of iodine, 2 ozs.

Or.

Liquid saponified tar, 4 dr.

Eau de Cologne, 6 ozs.

Or,

Ichthyol, 2 dr.

Water, 4 ozs.

Applied as lotions.

Where the lesions are more aggravated, a solution
of nitrate of silver (1—15) or permanganate of potash
(1—2,000) might be employed, followed by an appli¬
cation of—

aa 4 dr.

Oxide of zinc, 4 ozs.

Carbonate of bismuth, | dr.

Lanoline ^

Vaseline j

In women, the intestrigo is complicated with in¬
tolerable itching of the vulva, with cedema. The
following ointment renders service :—

Codol,

Oxide of zinc

Ichthyol,

Resorcine

Vaseline

Lanoline

aa 1 dr..

a a xv gr.
a a 4 dr.

The report of the medical officer for Leicester
shows that the week produced only a single death
from diarrhoea. In 1902 the corresponding week
yielded but two.

GERMANY.

BmUel Aar 25 th, 1907.

The Treatment of Backward Displacements of
the Uterus.

At the Hufeland Society Hr. Strassmann brought
forward the subject • “ When and in What Way are
Backward Displacements of the Uterus to be Treated ? ”
There were in Berlin, he said, 80.000 women with
retroversio uteri. This displacement did not occur
amongst the lower animals. The uterus in them was
longer and reached to the kidney region ; moreover
the manner of walking on all-fours prevented its falling
back. Without a doubt the upright position was the
principal cause of the abnormality ; there was also the
width of the pelvis necessary for the passage of the
head of the child. The human uterus developed in a
certain position. The flexed anteversion was main¬
tained bythe abdominal walls and increased by abdomi¬
nal pressure. No flexion of the organ backwards
occurred even after severe injuries, as the uterus was,
considering its importance, the least protected organ in
the body.

It might have a wrong position to begin with;
retroversion was either congenital or acquired. The
latter was the most frequent. 1 he sixth part of back¬
ward displacements was congenital (in virgins and
nulliparx). A mechanical action was not excluded :
1. by the conventional over-distention of the bladder ;
this caused a softening and backward pressure of the
part; 2. by the habitual overloading of the rectum.
Both factors were in action in childbed. The liga¬
ments of the uterus acted as a kind of stay. If the uterus
once became displaced backwards further changes took
place. The anterior vaginal wall became free and the
bladder became more easily distended. Cystocele
occurred and the anterior vaginal wall became depressed.
The rectum also became distended, a rectocele formed
and prolapse easily took place. The utero-sacral
ligaments played but a small part. The cervix as a
firm tube had also an importance as regarded position,
as had also cicatricial changes of the portio vaginalis.

Consequences of the displacement. The broad liga¬
ments embraced the uterus and these were responsible
for many troubles. Twisting of the vessels tcok place,
venous stasis followed, with the formation of varices.
The posterior lip became thick and pale and not
infrequently there was erosion ; the anterior vaginal
wall became thin. The uterus as a whole thickened
and disturbances of menstruation showed themselves ;
it became more profuse with excretion of mucu-, in
consequence of endometritis. Pains occurred when the
mucus was expelled in virgins and nulliparae. The
displacement of the ovaries was also of importance.
The follicular haematomata became larger from venous
stagnation. An anticipating menstruation might take
place, occasionally the formation of hxmatomata of the
ovary might take place and, by transudation, small
cysted degeneration of it. Fertility was often disturbed
It might not cease as the flexed organ might become
pregnant. In many cases, however, bleeding took
place in the membranes, followed by abortion. The
impeded gravidity was a result of the change of direction
of the portio vaginalis.

Patients complained of a feeling of continuous
pressure downwards. The vessels of the rectum were
full and compressed, and the patients suffered from
ha-morrhoids and reflex gastric troubles, although the
tongue was clean ; hysterical symptoms; in severe
cases there may even be amaurosis and paralysis.

A large part of the troubles might undergo com¬
pensation by the body itself. The uterus could only
become erect during pregnancy. Adhesiors were
formed by small extravasations of blood from the ova¬
ries, etc.' In secondar y displacements no operative
measures should be undertaken during the first year.
In nine months most of the excitors of inflammation
were dead. Later than that sterile pus was found.
Here tamponnade and sitz baths were useful.

1 7 reatuievt. —Not every c.ise of retroflexion required
operation. Where the symptoms were slight and the
patient beyond the climacteric, operation might be

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Aug. 28. 1907.

CORRESPONDENCE.

The Medical Press. 223

dispensed with. There were a number of cases in
which treatment by pessaries was sufficient (t6 jo%)
these were cases without complications of laceration
of the cervix or perineum.

Operation was reserved for those cases in which the
uterus couid not be brought into position otherwise.
Ihe speaker then discussed the various operations and
expressed hi.- preference lor vagina! fixation.

Prophylaxis .—Nothing need be said alxnit the
congenital form. Every lying-in woman should be
examined about the end of the third or beginning of
the fourth week, if displaced the uterus should be put
right and a pessary inserted. Too early getting up as
some patients desired favoured the displacement.

AUSTRIA-

Vienna. Ang. 25th, 1907.

Collum Anatomic m Humeri.

Eiselberg presented a patient at the Gesellschaft
suffering from a fracture of the anatomical neck of
the humerus in the left arm from a fall. Immediately
after a very large haematoma formed on the inner
side of the arm below the fracture. The pulse in the
radial and cubital regions was imperceptible. He
thought this a very good example for demonstrating
the danger of gangrene from bandaging in fractures.
He admonished careful vigilance of the pulse in the
fractured extremity when applying a bandage for
fracture.

Phosphorus Necrosis.

Teleky followed with a statistical account of the
past and present incidence of this disease. In
the Vienna hospitals at the present time this disease
was very rare owing to the decadence of the match¬
making industry. During the last decennium the
factory inspector had only 75 cases to report, while
in the preceding period for the same time 400 were
reported. Whatever the philosophy of the nature
of the poisoning, one thing is agreed upon, that some
ill-defined change takes place in.the osseous system
that leads to destruction.

The nature of the disease seems to be a contra¬
diction of our therapeutic dogmas, that bones require
phosphorus for their building and repair, for in the
match works it is the bane of the industry whose
operatives suffer from a friable state of the long bones,
particularly of the arms, that spontaneous fracture
often occurs amongst them.

This altered state of the bone leads to a low resist¬
ing power in purulent attacks that occur in the jaws
where the bones are more exposed to the fumes.
It seems that the purulent cell is first stimulated
in the periosteum that succeeds the altered state of
the bone by some metamorphoses in the nutrition
which, when produced, allows the purulent cell to
commence its destruction of the periosteum, and
finally of the bone which depends on it for its support.
Having once obtained a lodgment, its ravages extend
to more remote portions of the body, more particu¬
larly to the brain, from which 20 per cent, of these
patients die. The pus cell seems to be carried to the
brain or some of its coverings, where a new centre
of inflammation is produced, generally resulting in
death.

The membrane of the eye is another portion of
the body that the purulent cell attacks with violence,
doing irreparable damage.

The therapy of this disease has not been a success,
as we are as yet undecided on the primary cause.
Conservative treatment is therefore the safest course
in improving the hygienic condition of the operation.

Different countries have adopted different methods
of manufacture for the same reason—one preferring
yellow phosphorus, others white.

Extirpation of Carcinomatous Uterus.

This is an operation that one surgeon praises in
youth, but as age advances can see very little benefit
derived.

Veit records twenty of these operations without a
death. Eighteen of these had uterus, ovaries, tubes and
glands removed, the other two had the vagina re¬
moved as well after Freund’s advice, but he thinks

Wertheim’s technique better. With the, use of spinal
anaesthesia he has no scruples about heart failure,
which is always a grave concern when chloroform is
used. The results are much better when no chloro¬
form is used. Veit tells us that too much is made
of the surroundings containing the carcinomatous
germs, but there is no such virulence to be dreaded
if the parts be kept clean of the cancerous surface,
and the abdomen kept dry afterwards.

Pancreatic Reaction in Urine.

Eichler has been experimenting with Cammidge’s
test for the pancreatic reaction in the urine as a
diagnostic test for the disease. Cammidge found
that when Phenyl hydrazin was added to the urine
of a patient suffering from pancreatic disease, a white
or bright yellow precipitate was formed. This was
supposed to be the result of some fatty necrosis.
Eichler fermented the pancreatic secretion, and split
up the fluid into a fatty acid and glycerine. The
glycerine was separated from the urine by boiling
with HC 1 ., and converting it into glycerose, which
afterwards admitted of the Phenyl hydrazin test.
Three dogs were next affected with the pancreatic
disease, the urine tested with a positive result, while
the control of healthy dogs’ urine was negative.

CONTINENTAL HEALTH RESORTS

[from our special correspondent.]

CHATEL-GUY ON.

Chatel-Guyon is justly entitled to a high position
amongst Continental Health Stations, because of its
readiness of access from our shores, its pleasant sur¬
roundings (interesting alike to artist, scientist, and
antiquarian), its good Bath and hotel accommodation,
its talented medical staff, granitic dry soil, pure and
light atmosphere, and. above all, the excellence of its
mineral springs. Particularly, its waters are most
important for treatment of intestinal, stomachic, and
liver diseases.

Situated in the Department of Puy-de-Dome (part
of the historic Province of Auvergne), its location is
the very centre of France.

Southerly and Easterly it overlooks the vast plain
of Limagne ; Northerly and Westerly, it is shielded
by the Auvergne mountain-chain. September is its
desirable month for British visitors; “the Season’’
prolonging itself pleasantly through October.

As at the neighbouring Spas of Bourboule, Mont.
Dore, and Royat, remains here attest the knowledge
and use of Chatel-Guyon mineral-waters by the
Romans. The present Bath-Establishments (the
“Grands Thermes" and “ /’ ttablissement Henry’’)
contain: —

Baths with running mineral-water at the natural
temperature of 28 3 and 34 0 Centigrade;

Baths with standing mineral-water at any tempera¬
ture required;

Baths with more or less concentrated mineral-water
at any prescribed strength and heat;

Baths of medicated waters, vapour, hot-air, douches,
massages, local lavages, &c.

The electro-therapic installation is up-to-date and
complete for electro-intestinal lavages, hydro-electric
baths, carbonic-acid baths, vibratory massages, and
continuous-current baths.

The Twenty-seven Mineral Springs emerge at the
junction of the primary rock (extraordinarily hard
red porphyric quartz) with the tertiary Limagne soil.
They yield over five million litres every twenty-four
hours; the whole enormous flow being absolutely
protected from the slightest possibility of contamina¬
tion or admixture in the passage from the primitive
rock to the concrete-lined cast-iron reservoirs.

The analyses of the different Springs are almost
identical, and are thus given by three distinguished
chemists :—

Chlorides: Magnesium, 1.563; sodium, 1.633.

Bicarbonates: Lime, 2.17,6; soda, 0.955; iron,
0.685 > bthia, 0.0194 ; potash, 0.2538.

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224 The Medical Press.

CORRESPONDENCE.

Aug. 28, 1907.

Free Carbonic Acid, 1.112.

Sulphate of Lime. 0.5.

Only traces of Silica, Arsenic, Alumnia, &c.

Total per litre of water, 8.3986 gr.

At Chatel-Guyon these waters are employed in
medicinal treatment both internally and externally.
For internal purposes, five burettes are in the two Parks.
Three, from the springs Yvonne, Deval, and Germaine,
showing 33 0 to 36® Centigrade ; and two, from Springs
Gubler IV. and Marguerite, 26°. They are usually
drank three times daily (one hour at least before each
principal meal), and at intervals of several minutes.
Their action, immediate, is tonic and stimulating to
the nervous system ; secondary, stimulative to the
digestive functions ; and later they affect the intes¬
tines. Digestion becomes more active and regular ;
urine passes more rapidly, plentifully, and thoroughly ;
gravel frequently occurs ; uric acid (in gouty cases)
first increases, then gradually disappears ; phosphoric
acid diminishes ; urea and chlorides increase; albumi¬
nuria, if due to liver or digestive troubles, rapidly
improves.

In the running-water baths, the temperature at
les grands Thermes is 34°, and at the Henry Baths
about 28° Centigrade; these temperatures being the
natural ones.

The special feature of the external treatment at
Chatel-Guyon is a Bath Carbogaseous, with freely-
flowing Mineral-Water at its natural temperature, so
conserving without any modification its richness in
gas and in salts. Owing to the great copiousness of
the Springs, 1,000 litres is frequently used in each daily
bath; thus representing a dose of about 8 kilos of
mineral-salts and 2,000 litres of carbonic-acid. Dr.
Angelbv therefore justly claims Chatel-Guyon un¬
rivalled, in this respect, on the Continent.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

THE NEW HOSPITAL AT AYR ASYLUM.

There are several special features of the hospital
which has recently been added to Ayr Asylum, to
which attention may be usefully drawn. It is a sub¬
stantial one-storeyed building, after the cottage hos¬
pital type, specially designed for the accommodation
of those insane patients who are more appropriately
treated in a building of hospital character, and the
design gives effect to certain principles which, in the
opinion of the medical superintendent, Dr. Easter-
brook, should underlie the construction of a mental,
as distinguished from an ordinary hospital, specially
the principle of the treatment of active insanity by
rest in bed in the open air, isolation, and other special
measures for the alleviation of mental and nervous
disorders. The design, it may be added, facilitates the
work of the staff, which may in consequence be rela¬
tively smaller than usual; and so, while an efficient
instrument for its purpose, is distinctly economical
to administrate. Another important point is that
owing mainly to the elimination from the design of
everything which was considered superfluous, and
notwithstanding the fact that the cottage-hospital
type of structure is relatively expensive to build,
the hospital at Ayr Asylum has cost, for total con¬
struction and fittings, £100 per bed, which is con¬
siderably less than the cost per bed of asylum hospitals
hitherto. Efficiency for its purpose, low cost of original
construction, and permanent saving in future expend
ditnre on upkeep and administration, are cogent reasons
at this time, when the public press is constantly harp¬
ing on the cost of modern asylums and the ever-in¬
creasing burden of the lunacy of the country, for this
descriptive note of the latest addition to our institu¬
tions for ..the treatment of the insane. Although the
cost of this new hospital per bed is so much less than
has before been considered reasonable, no detail
appears to have been overlooked, the explanation being

that while securing the means of efficient treatment,
the medical superintendent was permitted to eliminate
from the design everything that could be considered
superfluous.

A Colossal Enterprise. —Notwithstanding the
strenuous efforts of certain legislators and well-dis¬
posed temperance reformers in the direction of what
is euphemistically styled, “ the drink problem,” more
elaborate machinery and distilleries of greater capacity
are still found to be needed, at least in the whisky trade.
Last week there were opened in Glasgow the largest
bonded stores of their kind in the world, which have
been erected in Washington Street, by Messrs. James
Buchanan and Co., the well-known whiskey distillers
and blenders. Some idea of the extent of the buildings
will be conveyed when it is mentioned that the site
is as extensive as a large cricket field, and the ware¬
housing capacity is 20,000 butts, representing a
Government Revenue duty of £1, 500,000. There are
two blending vats of 20,000 gallons each, and nine
others from 10,000 gallons downwards. In the blend¬
ing department the contents of the vats reach the
total of 70,000 gallons; whilst the contents of the
vats for the bottling department are 30,000 gallons.
In describing this colossal undertaking, the Daily
Telegraph remarks that one week’s work is equivalent
to a pile of cases four deep, reaching to the height
of Ben Nevis; and eight days would yield a stock
of single cases as high as Mount Everest. A week’s
bottles laid end to end would be over fifty-three miles
long. The employes engaged in the enterprise number
over 650, and the Inland Revenue department is
represented by two supervisors, each with a separate
office, assisted by a staff of twenty officers.

BELFAST.

The Notification of Deaths from Infectious
Diseases. —During the sittings of the Health Com¬
mission, the questioq of the notification of deaths from
infectious diseases, including tuberculosis, was under
discussion several times, and as a result the Corpora¬
tion applied to the Local Government Board to know
the limits of their powers to expend money- in obtaining
such notification. The Board informed the Corpora¬
tion that they had no statutory power to authorize
such payments, and referred them to the Registrar-
General as the official who could and should furnish
the returns regarding such cases. The Public Health
Committee applied to him. and hoped for a favourable
reply, but have just had an answer regretting that he
cannot give the returns to Belfast which in the case
of Dublin he supplies to the local authorities each week.
It appears that in the case of Belfast the material
with which the Registrar-General deals is quite differ¬
ent from that which he receives from Dublin. In
the latter city he receives full particulars, which are
tabulated in his office, but from Belfast he receives
only numerical returns, the tabulation being done by
the local registrars. He could not, therefore, give full
returns unless he had the full information to deal with,
and even if the information were sent to him, with his
present staff, he could not deal with it. He concludes
with a sentence of interest to Dublin : ‘‘I beg to add
that, as it appears from a letter from the Town Clerk
of Dublin, printed on page 239 of the evidence given
before the Belfast Health Commission, that of the lists
of persons dying of infectious diseases furnished weekly
to the Dublin Corporation from this department, the
list of persons who have died from pulmonary tuber¬
culosis ‘ is the only one which is really of advantage
to the Corporation,’ the question must now be con¬
sidered whether the department should be put to the
trouble and expense of furnishing information which
is declared not to be of practica l value.” _

In Committee of the House of Commons on the
Expiring Laws Continuance Bill, Mr. Lupton moved
the omission of the Vaccination Act of 1098, because
since the Act came into force cancer cases had in¬
creased by over 5,000 a year, which was due to the
substitution of calf lymph for humanised lymph!

^ooQle

o

Aug. 28, 1907.

CORRESPONDENCE.

The Medical Peem. 225

LETTERS to the editor.

"THE USE OF COCAINE IN THE MORPHIA
HABIT : A WARNING.”

To the Editor of The Medical Press and Circular.

Sir, —During the past six months, I have had
several morphia habituis under my care, who, on the
advice of medical men, have taken cocaine with a
view to curing themselves of the morphia habit. It
cannot be too widely recognised that it is not only
useless but in the highest degree dangerous to pre¬
scribe cocaine in these cases; it is true that cocaine
does to a certain extent neutralize the effect of morphia,
but this, in point of fact, is a disadvantage rather than
a gain, as it merely tempts the patient to take larger
doses of morphia and then balance the excess with a
heavy dose of cocaine.

But the principal danger lies in the fact that such
treatment inevitably produces the cocaine habit, by
the side of which the morphia habit is comparatively
insignificant; uncomplicated chronic morphinism is
usually curable, but, when patients begin to take
cocaine also, the difficulties of the situation are in¬
creased a hundredfold; not only is their immediate
condition rendered worse by the advent of delusions
and hallucinations, but their chance of ultimate cure
is very much lessened, and relapses are much more
common than in cases of simple morphinism.

The sudden withdrawal of cocaine leads to no actual
distress or reflex disturbances such as occur in the
case of morphia, and, when once patients know this,
they are very apt to return to the cocaine, reassuring
themselves meanwhile that they can break it off at
any time without acute suffering.

In a fairly large experience of morphia cases, I have
never seen a single cure expedited by the use of cocaine,
and its dangers are so great as to make its recom¬
mendation quite unjustifiable.

I am, Sir, yours faithfully.

J. Henry Chaldecott.

Harley Street, W., August, 1907.

THE MEDICAL ASPECT OF DENTAL CARIES
IN CHILDHOOD.

To the Editor of The Medical Press and Circular.

Sir, —It is very satisfactory to find that the medical
profession at length has been brought to recognise the
relation of dental disease to general pathology, and
to note also that leading physicians, like Dr. G. F.
Still, of King’s College (whose paper appears in The
Medical Press and Circular of August 14th) take
occasion to bring forward and emphasise all the facts
of practical importance bearing upon the question.
One cannot help, further, feeling satisfaction at the
knowledge that even in smaller country towns there
is now usually to be found a properly qualified dental
surgeon fully competent to co-operate with medical
men in cases where special skill is needed. It is
perhaps enough that the physician should recognise
and act upon the fact that the teeth need taking into
consideration as possibly the sole or contributory causes
of systemic disease. It perhaps matters little if he
has not a complete and correct acquaintance with
the etiology and pathology of dental diseases. It
would, however, save some mistakes, such as, I think.
Dr. Still falls into, if some fundamental facts of dental
physiology were fully understood and kept in view.
One such fact is that enamel and dentine, when fully
calcified, or when the process of their development
has ended, are incapable of physiological activity.
They are not the seat of malnutrition or of processes
of atrophy or wasting, and any changes these tissues
undergo after completion can be due to external
agents alone. The exteriors of the crowns of aH
the temporary teeth are fully formed at birth;
and these teeth can be influenced therefore only
through the mother. By this time—at birth—the
first permanent molars, incisors, and canines
are so far advanced in development that it is more
than doubtful whether treatment could have any
effect_upon their enamel. Rickets and all infantile

diseases of malnutrition no doubt are associated with
ill-made dental tissues, and, if the mothers could be
taught and made able to maintain their own
health during pregnancy, could be taught and made
able to suckle their babies during the proper period,
and if they could be taught and made able to feed them
properly during childhood, much degeneration of
developing dental tissue might be stopped, and much
subsequent dental disease prevented. Imperfect for¬
mation and calcification of the tissues—especially
enamel—constitute the chief predisposing cause of
caries. Perfect enamel will endure almost any
amount of neglect or ill-usage, but no amount of care
will save teeth the tissues of which are easily damaged
mechanically and easily dissolved by the weak acids,
the product of fermenting particles of food, against
the action of which it is impossible fully to guard them.
In rickets and other such diseases there exist inherently
defective tissues, whilst the constantly foul and
vitiated secretions of the mouth which are always
observable provide the agents by which the enamel
and dentine are gradually penetrated at their weakest
spots and more or less rapidly broken down.

I am. Sir, yours truly,

M.R.C.S., L.D.S.

London, W., August 25th, 1907.

MILK AND TUBERCULOSIS.

To the Editor of The Medical Press and Circular.

Sir, —Permit me to thank Dr. Granville Bantock
for his reply to my query. That gentleman, after
reading Dr. Armstrong’s able summary of current know¬
ledge on the above subject (The Medical Press and
Circular, August 7th) nevertheless retains his attitude.
It is, as I before remarked, Bantock contra mundum.
He apparently denies all the demonstrated and easily-
demonstrable facts leading up to the conclusion of
the argument on the mere ground that it is impossible
to trace out the origin of tuberculous infection, and
to place one’s finger on the exact source of contagion
in particular instances. The possible sources of in¬
fection in the case of the cow asked for by Dr. Bantock.
are named by Dr. Armstrong, and he states the fact
which I also mentioned, that the long period of incu¬
bation in the human subject prevents, at present,
determination of the source of the poison and the time
of its reception. Dr. Bantock says I “ accept state¬
ments not supported by any evidence.” I reject his
statements on precisely that ground. On the other
hand, I accept the statements of bacteriological science
with regard to tuberculosis, because I am satisfied
that if 1 investigated the matter for myself I should
arrive at the conclusions accepted by Dr. Armstrong
and the vast majority of practical sanitarians. Dr.
Armstrong accepts them, no doubt, like I, because
he knows that the chain of facts has been proved by
scores of independent workers in scores of pathological
laboratories throughout the civilised world. Dr.
Bantock has detached passages from Dr. Armstrong’s
paper which give a distorted view ot the argument
and conclusions. It is, of course, a demonstrated fact
that malnutrition, and insanitary surroundings pre¬
dispose to tuberculosis, as they do to many other
diseases. These predisposing causes are being di¬
minished, but it will be many years before they are
eliminated. In the meantime, everyone—except, I
suppose, Dr. Bantock—will take part in the endeavour
to discover and destroy the sources of tubercular in¬
fection in every situation in which they are known to
appear or suspected to exist.

I am, Sir, yours truly,

A Family Doctor.

August 22nd, 1907.

IS CANCER CURABLE ?

To the Editor of the Medical Press and Circular.

Sir,—H aving read the interesting report of the
discussion on Cancer, I am tempted to ask the follow¬
ing questions: (1) Is cancer curable by operation ?
(2) Wnat time must elapse from date of operation till
patient is certified as cured? (3) Can the diagnosis
of nterine cancer be made to a certainty by any means

feed by Google

226 The Medical Pees*

REVIEWS OF BOOKS.

Aug. 28. 1907.

at our disposal, including the microscope ? (4) Cancer

being a constitutional disease (somewhat like tubercle)
how can the removal of its various manifestations
arrest the disease for good, or prevent its showing
itself again by metastasis ?—I am. Sir, yours truly,

Alexander Duke.

London, W., August 24th, 1907.

OBITUARY.

MAJOR HARRY FREDERICK WHITCHURCH.
V.C., M.R.C.S., L.R.C.P.

We regret to announce the death, on August 17th,
at Dharmsala, Punjab, of Major H. F. Whitchurch,
V.C., of the Indian Medical Service. Bora in 1866
in the Isle of Wight, he entered the Indian Army at
the age of twenty-two, and took part in the Lushai
Expedition, including the relief of Changsil and Aigal,
for which he had the medal with clasp, and in the
operations in Chitral in 1895, including the defence of
the fort during its investment in March and April.
For these operations he obtained mention in despatches,
and was awarded the medal with clasp and the Victorian
Cross for an act of conspicuous bravery in rescuing
Captain Baird, who was wounded during a sortie from
Chitral Fort. Major Whitchurch was also engaged
in the campaign on the North-West Frontier of India
in 1897-8, taking part in the defence of Malakand,
the relief of Chakdara, the action of Landakai, and the
operations in Bajaur and in the Mamund country,
being again mentioned in despatches and receiving
two clasps He also participated in the operations
in China in 1900, when he was a third time mentioned,
and was awarded the medal with clasp.

LABORATORY REPORTS.

ALLSOPP’S LAGER.

The reading of a paper at the recent meeting of
the British Medical Association at Exeter on the
subject of “ alcohol ” produced a somewhat heated dis¬
cussion cm the relative values and uses of this agent
in the practice of medicine, light beers, such as are
in common use in Germany, receiving commendation
by several speakers.

In 1899, w ben Messrs. Allsopp first commenced the
manufacture of lager beer in this country, we published
an analysis and report on the same by Sir Charles
Cameron, which plainly showed the excellence and
purity of this lager. We have recently submitted
samples of the beer to a fresh analysis, and have
obtained results practically identical with those ol
Sir Charles. We find the beer to contain—

4.38 per cent, of extractives,

0.26 per cent, of mineral matter, and
4.06 per cent, of alcohol (by weight).

It is absolutely free from arsenic, while the flavour and
aeration leave nothing to be desired. To produce
beer of this purity, the materials used must necessarily
be of the highest quality, which, together with the
method and conditions of manufacture, allows the
production of a beverage, which, in our opinion, is
much to be preferred to the ordinary lager of German
manufacture. We would commend this beer to the
dyspeptic and debilitated, as a routine beverage on
account of its low content of alcohol, and its tonic
and stimulating properties. This lager can with
confidence be recommended to patients where it is
undesirable to prescribe other forms of alcohol, and
its substitution for ordinary beer and whisky would,
in the great majority of cases, be productive of nothing
but good. The brewers claim many virtues for
their beer, and so far as oar experience goes, these
claims are well justified.

LEMONADE.

The present summer weather has not so far been of
such character as to necessitate frequent resort by
" the thirsty soul ” to the many tempting forms of

lemonade put forward by manufacturers of this
favourite yet harmless beverage. We have just had
sent us for laboratory examination a granulated

S owder made by Messrs. Foster, Clark and Co., of
[aidstone, called “ Eiffel Tower Lemonade," which
we have tested both chemically and practically, and
find it to be what the manufacturers claim for it—a
concentrated essence of the juice of lemons solidified
and granulated. A strong recommendation to this
form of manufacture, especially in large establish¬
ments such as hospitals, convalescent institutions, and
the like, is its extreme simplicity. One has but to
empty the powder into water with the necessary quan¬
tity of sugar, and the lemonade is ready to drink.

REVIEWS OF BOOKS.

COOPER’S RONTGEN RAYS, (a)

This is a well-written little book, intended to inform
the general practitioner of the help he may get in
practice from the Rontgen rays. The section upon
renal calculus is especially clever, and gives the exact
information that is wanted by those who are not ex¬
perts in the art of radiography. The most popular
part of the book will probably be that which deals
with treatment. We are glad to see that Mr. Cooper
recommends the practitioner who has only an occa¬
sional case of ringworm to treat to use the fractional
method as against that of the single maximum dose,
which is dangerous in any but Rkilled hands. The
use of the rays as a depilatory in ordinary hvper-
trachosis is very properly condemned. The' brilliant
results often obtainable in eczema of the anus com¬
bined with pruritus should be borne in mind by every
practitioner of medicine. The treatment of rodent
ulcer by the X-ray tube is much lauded by some autho¬
rities. The author, however, testifies that the scar is
almost certain to break down again sooner or later.
This fact is not always estimated at the proper value
in considering the therapeutics of the Rontgen ray in
relation to lupus. In our own opinion, for the majority
of cases early surgical measures are incomparably the
best means of attack. This excellent little volume
may be commended to all who need a condensed and
trustworthy guide book to this branch of medical
science.

THE ANALYSIS OF WATER. (6).

The scheme of analysis prescribed in this book
is said to offer two advantages—the analysis is quickly
done without involving the use of cumbersome appara¬
tus and by persons having only a small knowledge
of water.

Although there are parts of the world where expert
analysts are non-existent, and where the collection
of apparatus and chemicals supplied by Messrs.
Burroughs Wellcome and Co. would be useful, it is
probable that in very many cases where a proper
chemical analysis could be performed, Dr. Thresh’s
less satisfactory scheme is followed, and Dr. Thresh
would be the first to deplore this. Further, although
a man may in a short time master the technique
of water analysis, it requires years of continuous
study before he can place a correct interpretation
on the results of his analysis. Hence the scheme
propounded in this book may, in the hands of a novice,
be a source of great danger. Could the analysis of
water be simplified, medical officers and analysts
would be glad to accept the innovation, but as it is
they are justified in declining to place lives in jeopardy
, by adopting the well meant but dangerous idea of
Dr. Thresh.

(a) " The Rdntgen Ray* in General Practice.” By R. Highara
Cooper, L.S.A., in charge of the Radiographic Department at Univer¬
sity College Hospital. London: Bailliere, Tindall and Cox. 1907.
as. 6d. net.

(b) “ Une Methode Simple pour 1’Analyse de l'Eau.” By John C.

Thresh, MJ5.(Vic.), D.8c., D.P.H. Translated from the Fifth English
Edition by Dr*. Magnier and Thtry. Pp. 6a. London J. and A.
Churchill. 1907. To be obtained from Messrs. Burroughs Wellcome
and Co., London. .

Digitized by G00gle

Apg. 28, 1907.

WEEKLY SUMMARY.

The Medical Press. 227

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled foe Thb Medical Press and Circular.

RECENT GYNECOLOGICAL AND OBSTETRICAL LITERATURE.

Hyoacine Anesthesia in Obstetrics. —Butler (Amer.
Joum. Obstet., August, 1907). Despite the discourag¬
ing reports of early observers, the new method of
securing anesthesia in obstetrics is being widely tested
and rapidly coming into favour. The most important
report on the subject is that of Gauss, of Freiberg,
who gives his experience of 1,000 cases anaesthetised
with hyoacine. He insists on the use of pure alkaloids,
and he states scopalamine is apt to be contaminated
with bodies which seriously modify its action. This
seems not to be the case with hyoscine derived from
hyoscyamus. The object sought is the production of
a peculiar state of half narcosis, known as “ twilight-
sleep." From this the patient may be awakened at
any moment if desired, but does not retain recollection
afterwards. The first injection is given when the pains
become really severe, and consists of three to four deci-
milligrammes of hyoscine with one centigramme of
morphine. Half an hour later the patien t is shown some
test object, and in thirty minutes more is asked if she
remembers what was shown her. On this Gauss lays
stress, since the capacity to remember regulates the
dosage, rather than the cries of the patient, which are
less sig nifican t. When the patient remembers the
test object, a second injection is given of hyoscine
alone, unless the pain is excessive, and only then is
the morphine repeated. Usually four injections
suffice, at intervals of not less than one hour, generally
two to four hours. The ears are stopped to exclude
noises. The secrets of success lie in the choice of
good, fresh preparations beginning with small doses,
and careful testing of the memory power as a means
of regulating the doses. The causes of failure are—
forcing the effects by large doses too often repeated,
beginning the process too early in the labour, or leaving
it until there is not sufficient time for the effect to
develop, or, finally, regulation of the dosage by the
patients cries. In regard to the effects on the mother.
Gauss found the women complain of thirst, as hyoscine
lessens mucous secretions; hallucinations and delu¬
sions of transitory character were occasionally noted.
No effect on the secretion of milk could be detected,
and Gauss declares that hyoscine does the child in
utero no injury whatever. F.

Care ef Nipples and Breasts daring Pregnancy and
Lactation. —Lagusua (Amer. Jottrn. Obstet ., August,
1907. The author of this paper says that during
pregnancy, if the nipples are well formed and not
painful, no treatment except absolute cleanliness is
necessary. If the nipples are small, it is best to use
massage in the shape of traction for fifteen minutes
daily during the last two months, using boracic acid
vaseline as a lubricant. During lactation, the breasts
and everything that touch them should be kept as
aseptic as possible, and enveloped in sterilised gauze.
If there are cracks in the nipples the application re¬
commended is nitrate of silver, 1-10, applied with
cotton on a stick. When the patient does not nurse
her infant, the breasts and axillae should be enveloped
in cotton pads and a firm bandage applied, which re¬
mains on till the milk disappears from the breast.
If they become painful and full, Rochelle salts should
be given. When a patient is nursing, a bandage is
used to support the breasts, and should they become
painful, massage is used every four hours to distribute'
the milk evenly in the breasts. If there is not enough
milk the patient should take milk, eggs, butter, and
cream. If the breast becomes infected, massage is
useful to remove the pus from the milk ducts; it
should be given first lightly, then with more pressure,
every four hours, with the use of the icebag between.

When the skin becomes red and inflammation sets in
the abscess must be opened and treated like an abscess
in any other place. F.

A Contribution to the Etiology of Cborio-epithe-
Horna without a Primary Tumour In the lUterns.—

Walthard (Zei f schrift fur Geb und Gyn., Bd. LIX.
Hft. 3) reports a case of chorio-epithelioma malig-
num occurring in the second half of a normal pregnancy
of a woman, set 27, who had previously been quite
healthy. It was her fifth pregnancy, and from the
middle of the seventh month she had suffered from
haemorrhage and a sanious discharge. The cause of
this was found to be two polypoid growths about
the size of hazel nuts with ulcerated surfaces which
sprang from the anterior and posterior walls of the
vagina. These were removed and examined micro¬
scopically. The diagnosis was chorio-epithelioma
metastases. A Caesarean section was consequently
performed in the interest of the child, and was followed
immediately by abdominal total extirpation of the
uterus. The patient died seven months alter the
operation. The post-mortem examination revealed
metastases, especially in both kidneys, in the lung and
in the liver. Microscopical examination of the fresh
uterus with the placenta in situ showed neither in
the placenta nor in the uterus any appearance of a
primary chono-epithelioma of the placenta or of
nydatidiform alteration in the villi. The micro¬
scopical examination, which was most thorough,
haa the same result. One may, therefore, conclude
with certainty that even fatal chorio-epithelioma
may extend to the different organs of a patient from
the epithelium of the chorion or from the syncytium
of the placenta without it being possible to find a
primary tumour in the placenta either as a chorio-
epithelioma, a hydatidiform or any other alteration
of the placental cells. G.

The Recurrence of Carcinoma after Hysterectomy
anf the Treatment of Inoperable Uterine Cancer.—

In a paper on this subject Hankel (Zeitschrift fur
Geb und Gyn, Bd. LIX., Hft. 3) points out many
unclear points which exist in the teaching regarding
carcinoma uteri. He particularly wishes that one
may be able to recognise from future reports on what
grounds the different operators decide that operation
is indicated, in other words, what cases are operable;
and also in the different cases whether the carcinoma
was primary in the portio or in the cervix. As regards
recurrence the very rich material of the Berlin Klinik
teaches the important fact, that, during hysterectomy
for carcinoma, the glands need not be so very com¬
pletely removed. If infiltrated glands are felt they
are to be removed but unopened, because rupture
of the gland capsule produces a greater danger to the
patient than the retention of the carcinomatous
glands in the abdomen. Ii the carcinoma is limited
to the uterus, or is not extensively spread into the
parametrium, the igni-extirpation of the uterus with,
if it is necessary, Schuchardt’s incision, is the best
operation. The whole vagina or the greater part of
it is to be removed at the same time. Every extensive
infiltration of the pelvic connective tissue indicates
laparotomy, as one can thus operate more radically.
Every recurrence must be operated on if it is at all
possible, and the earlier the better. In order to
recognise recurrence at an early date the patients
must report themselves regularly every ten to fourteen
days. In cases of inoperable cancer the Paquelin
and after that one of the usual caustics are to be em¬
ployed. A single curetting and cauterisation of the

228 The Medical Press.

MEDICAL NEWS IN BRIEF.

Aug. 28, 1907.

carcinomatous tissue is not sufficient. The patients
must remain under observation, and whenever neces¬
sary, the cauterisation is to be repeated. G.

Disappearance of Pregnancy: A Contribution to
the Study of Hydatldiform Mole.—Polano (Zeit-
schrtft fur Geb. und Gyn., Bd, LIX. Hft. 3) records
the following interesting case. The patient, aet. 28,
had missed three periods. She had suffered from a
bloody discharge for some days, and fever up to
39 0 C. To the left of the uterus, which was enlarged
to the size of about four months’ pregnancy, a soft
turnout the size of half a fist was to be felt, so that a
diagnosis of pregnancy of from three to four months,
together with a left-sided pyosalpinx was made, at
the same time the possibility of a tubal gestation
was considered. The laparotomy revealed a distinctly
pregnant uterus of from three to four months, the
Jeft ovary which contained many cysts enlarged
to the size of half a fist, the right ovary smaller, but
also cystic. Both tumours were removed, recovery
was undisturbed, and there was no haemorrhage from
the uterus. When the patient was dismissed nineteen
days after the operation the uterus was soft, but was
certainly smaller than before the operation. The
diminution in size continued without any appearance
of haemorrhage, so that nine months later a normal
uterus 7 cm. in length by the Sound was to be palpated.
As one cannot assume that a normal pregnancy
at the third or fourth month thus completely dis¬
appeared, there only remains for this case the possi¬
bility that an abnormal product of conception had
been present. This view is strengthened by the
result of the microscopical examination of the ovaries
which revealed the usual changes connected with
hydatldiform mole formation. This case was therefore
one of absorption of a hydatidiform mole which the
author is inclined to believe was due to autolytic
processes within the mole. G.

Hysterotomia Vaginalis Anterior.—Liepmann (Med.
Klinik, 1906. Nr. 14) describes the technique of this
operation, the vaginal Caesarean section. Its chief
indication is eclampsia. Since for this the author
considers rapid and immediate delivery the best
treatment, and as eclampsia usually sets in before
or shortly after the onset of pains and usually that
in primiparae with rigid cervices, he considers that
there is a wide field for this operation. In aiddition
to this a series of placenta praevia patients were
delivered by this method in Bumin’s Klinik. It is
also indicated in nephritis gravidarum, heart disease,
lung diseatse, cicatricial stenosis of the cervix, car¬
cinoma, premature detachment of the placenta, and
even prolapse of the cord when the cervix is undilated.
Dulussen’s method of splitting the anterior and posterior
walls of the cervix need not be performed, since it is
possible to deliver large fully-developed infants by the
one incision through the anterior walls of the vagina
and uterus. The author’s paper is the result of
sixty-six cases, nineteen of which he had operated
on himself. G.

Medical News in Brief.

Tuberculosis la Ireland.

The Women’s National Health Association of
Ireland, as already announced has organised a Tuber¬
culosis Exhibition, on the lines of several held in
America and on the Continent. The Exhibition
will be open in the Home Industries Section at Balls-
bridge during the last weeks of October, after which
it is proposed to send it on tour to different parts
of the country, beginning at Belfast, where a public
meeting to inaugurate a branch of the Women’s
National Health Association is to be held about the
beginning of November. The work of organisation
has been in progress for some weeks, in the hands of a
small Committee, under the presidency of Her Ex¬
cellency the CouDtess of Aberdeen. A Consultative

Committee is being formed, to which the leading
medical societies and several public bodies have already
appointed delegates. The meetings of the Committee
are held at 76 Grafton Street, to which address any
communications can be send to the Hon. Secretaries,
Tuberculosis Exhibition.

THE QUESTION OF REPRESENTATION.

At the last meeting of the Public Health Committee
of the Borough, a letter was read from the Women’s
National Health Association, asking the Public Health
Committee to lay the matter before the Council, and
to let them know if the latter would appoint two repre¬
sentatives on the Consultative Committee, to whom
the scheme of the exhibition will be submitted for
criticism and advice. The committee resolved : “ That
a copy of the foregoing communication be forwarded
to the Local Government Board, with an intimation
that the committee approve of the proposed exhibition,
&c., and would be glad to appoint representatives to
the Consultative Committee as requested ; but, in
view of their auditor’s recent surcharges of the ex¬
penses of members attending meetings of associations
not coming under the definition of ‘ conferences of
local authorities,’ they cannot see their way to autho¬
rise members to incur any expenditure in this instance,
and they regret they must, therefore, abstain from
being represented, unless the Local Government Board
will authorise the outlay beforehand.”

At yesterday’s meeting the following reply from
the Local Government Board was read :—“ Local
Government Board, Dublin, August 20th, 1907.—
Sir,—I am directed by the Local Government Board
or Ireland to acknowledge the receipt of your letter
of the 15th inst., in connection with tne attendance of
delegates from the Corporation of Belfast, at the
Tuberculosis Exhibition which is being promoted by
the Women’s Health Association ; and I am to state
that the Board are not in a position to give the Cor¬
poration the undertaking referred to in the conclusion
of your letter. I am to point out that the auditor is
bound under section 47 *2) of the Local Government
Act of 1898 to surcharge payments made for any pur¬
pose not expressly authorised by statute.—I am, sir,
your obedient servant, H. Courtenay, assistant secre¬
tary.”

The Committee expressed their regret that under
the circumstances they could not see their way to
appoint representatives to act on the Consultative
Committee of the proposed exhibition as requested,
but intimated that if any of the members desired to
attend at their own expense, the committee would
facilitate them by giving them formal nominations
to represent the Council.

Oyster Merchant Fined.

At Colchester, cm Saturday, William Bartlett, for
47 years an oyster merchant at Wivenhoe, was fined
£20 and costs for selling Portuguese oysters which,
according to the evidence of Dr. Klein, of St. Bar¬
tholomew’s Hospital, were grossly polluted with sewage
and contained an abundance of microbes. The prose¬
cutors were the Wivenhoe Urban District Council,
and Mr. Muskett, solicitor, watched the case for the
Worshipful Company of Fishmongers. The Company’s
Chief Inspector stated that the defendant sold him
the oysters from a bag, which was in such a position
in defendant’s yard that water from an adjacent
sewer could flow over it. On receiving Dr. Klein’s
report, the district authority ordered the destruction
of the defendant’s remaining oysters and claimed a
penalty against him for each unsound oyster, the
total penalties claimed amounting to £160. The
defendant had sent a sample of the oysters to D.
Thresh, Medical Officer of Health for Essex, whose
certificate stated that although not of a high standard
of purity, the oysters were not grossly contaminated.
The defendant stated that the oysters came from his
its at Tollesbury, and die and his family ate twentv-
ve for supper the night before th e ins pector called
without harm resulting.

Digitized by GoOgle

MEDICAL NEWS IN BRIEF.

The Medical Press. 229

Aug. 28. 19° 7 -

Mr. Mortoy and the Indian Government.

Following upon the King’s letter comes an im¬
portant blue-book despatch to the Governor-Genera'
written on July 26th. Mr^Morley says:—

“ Your policy, in brief, is to rely for the present
upon improved sanitation in towns, the co-operation
oi the people in the evacuation of villages, the destruc-
tion of rats, and such other measures as further in-
vestigations may suggest. You again consulted the
I ocal Governments as to the expediency of constitut¬
ing a special organisation for dealing with plague ;
but the reports of the Governments consulted are
practically unanimous in condemning it as unsuited
to Indian needs. Their reports are to the effect that
suitable organisations for coping with the epidemic
already exist, and that, although the executive may
need strengthening in many cases, it is not desirable
to strengthen it by importing medical men from Eng¬
land, who, being unfamiliar with the language and
customs of the people, would not be qualified to direct
measures which might involve interference with re¬
ligious usage, and provoke a popular outbreak. The
reports frankly recognise that the general sanitary
service requires development, and that in this respect
the needs of the times can be met by the employment
of natives of the country. You state that proposals
to this end are at present under your consideration.
The fact that plague has been fatallv active in India
over eleven years, that the number of victims exceeds
5t millions, that its virulence is unabated and its
progress uncontrolled, necessarily give rise to doubt
as to whether everything that can be done has been
done by the responsible authorities, and whether the
last word of medical science and administrative skill
has really been said. I wish with you that your efforts
were attended with a greater measure of success. The
conclusion expressed in the resolution of January,
1906, that ‘ in the last resort all preventive measures
depend for their success upon the hearty co-operation
of the people themselves,’ while it defines the con¬
ditions of success, does not affect the obligation resting
upon the governing powers of the country to endeavour
to improve the quality of these measures, and win
acceptance for them by skilled and considerate ad¬
ministration. I desire that no effort should be spared
to arrest the spread of the disease by means acceptable
to the people, and to give aid to the sufferers. I shall
be glad to receive at an early date the proposals which
are under your consideration for extending the
general sanitary service by the increased employment
of qualified natives of the country as medical officers
of health and sanitary inspectors. Within reasonable
limits of cost any proposals of the kind which you
may submit will have my cordial support.

Medical Inspection of School*.

Sir William Collins, on the 25th instant, asked
the President of the Board of Education whether
under the Education (Administrative Provisions) Bill
there was any obligation on parents to submit children
attending public elementary schools to medical in¬
spection, as well as an obligation upon local education
authorities to provide for such medical inspection.

Mr. M’Kenna: In the view of the Board the obligation
placed by the Bill upon the authority to provide for
inspection does not of itself compel a parent to submit
his child to inspection.

Death of a Medical Man by Morphia Poisoning.

Mr. Walter Schroder conducted an inquest at
St. Pancras, on August 24th, on Cyril Waldron Shaw,
aged 42, bachelor, a doctor of medicine, found dead
in bed at King’s Cross, from the effects of morphia.
The Rev. Seymour Shaw, Vicar of Warcop, stated that
the deceased was his brother. He had been a good
deal abroad in South Africa. He complained to witness
of an abscess in the ear, which pained him acutely.
Other evidence showed that Dr. Shaw complained to
his landlord of a “ maddening pain, ' and wrote a
prescription which he took to a neighbouring chemjst,

where he was supplied with twenty grains of morphia
in a sealed packet Mr. Platt left him in bed on Wed¬
nesday night, and the next morning discovered him
there lying dead. The bed-room door was unlocked.
Dr. A. W. Dingley, Argyle Square; who had made an
autopsy, said that no doubt Dr. Shaw had a severe
pain in his ear, although there was no abscess. He
suffered from bronchitis and alcoholism, and in his
condition two or three grains of morphia would suffice
to cause death. Death was due to morphia. A verdict
of death by misadventure was returned.

St. Thomas’* Hospital—House Appointment*.

The following gentlemen have been selected as
House Officers for the ensuing term. ;—

Casualty Officers.— (Senior) W. O. Sankey, M B.,
B.S.Lond., M.R.C.S., L.R.C.P. ; (Junior), C. M. Page,
M JB. , B.S.Lond., M.R.C.S., L.R.C.P.

Resident House Physicians. —G. G. Butler, B.A.
Cantab., M.R.C.S. L.R.C.P. ; S. L. Walker, B.A.,
B.C.Cantab., M.R.C.S., L.R.C.P. ; C. E. Whitehead.
P..A.Can tab., M.R.C.S., L.R.C.P. (extension); H. G.
Bennett, M.B., B.S.Lord., M.R.C.S., L.R.C.P. ( exten¬
sion ); A. L. Loughborough, M.R.C.S., L.R.C.P.

House Physicians to Out-Patients.— W. H. P. Sutton,
B.A., M.B., B.C.Cantab.. M.R.C.S., L.R.C.P. (exten.
sion) ; S. Churchill, B.A.Cantab., M.R.C.S., L.R.C.P.
(extension) ; B. T. Parsons-Smith, M.R.C.S., L.R.C.P.;

A. J. S. Pinchin, M.B., B.S.Lond., M.R.C.S., L.R.C.P.

Resident House Surgeons.— H. J. Nightingale, M.B.,

B. S.Lord., M.R.C.S., L.R.C.P. ; H. R. Unwin, M.A.,
M.B., B.C.Cantab., M.R.C.S., L.R.C.P.; G. M. Huggins,
M.R.C.S., L.R.C.P.; F. M. Neild, M.B., B.S.Lond.,
M.R.C.S., L.R.C.P.;

House-Surgeons to Out-Patients. —H. H. Carleton,
B.A., M.B., BCh. Oxor ; R. E. Todd, M.B., B.S.Lond.
M.R.C.S., L.R.C.P.; W. R. Bristow, M.R. C.S.,
L.R.C.P.; H. E. T. Dawes, B.A.Cantab., M.R.CS.

L. R.C.P.

Obstetric House Physicians. —(Senior) F. S. Hewett,
B.A., M.B., B.C.Cantab., M.R.C.S., L.R.C.P. ; (Junior)
H. B. Whitehouse, M.B., B.S.Lond., M.R.C.S., L.R.C.P
Ophthalmic House Surgeons.— (Senior) A. S. Burgess,

M. A.Cantab., M.R.C.S., L.R.C.P. ; (Junior) A. 1 .
Cooke, B.A., B.C.Cantab.

Throat. —R. G. Bingham, M.R.C.S., L.R.C.P. >
A. W. C. Drake, B.A.Cantab., M.R.C.S., L.R.CjP.

Sktn. —E. C. Sparrow, B.A.Cantab., M.R.C.S.,

L. R.C.P. (extension); J. F. Windsor, B.A. Cantab.,

M, R.C.S., L.R.C.P.

Ear.— W. H. G. Verdon, M.R.C.S., L.R.C.P.; W.
Patey, M.R.C.S., L.R.C.P.

Children’s Surgical. —W. A. Morton Jack, M.R.C.S.
L.R.C.P. •

Society oi Apothecaries of London.

The following candidates passed the necessary
examinations, and have been granted the L.S.A.
Diploma of the Society, entitling them to practise
medicine, surgery, and midwifery :—C. L. Driscoll and
E. E. Wilbe.

A sixth edition of “ The Pharmacopoeia for Diseases
of the Skin,” by Dr. James Startin. has just been,
published by Messrs. John Wright and Co., of Bristol.
This little work contains in condensed form much useful-
information about diseases of the skin, and many
valuable formulas for their treatment, The author
has also drawn up a few rules of diet and some general
directions on the management of skin lesions, and the
work is completed bv a dermatological classification-
and a therapeutic index. Practitioners who have
not yet met with the book in its previous editions will
find the present one a pleasing addition to their thera¬
peutic resources.

Aug. ;8, 1907.

230 The Medical Press. NOTICES TO CORRESPONDENTS.

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8mall announcements of Practices, Assistances, Vacancies, Books,
Ac.—Seven lines or under (70 words), 4 s. 6d. per insertion;
6d. per line beyond.

D. B. H. — We are In accordance with the general opinion
of the public on the subject, namely, that chicory is not in¬
jurious. If it had been, the fact must have been widely known
long ere this. Occasional bad results have been reported, but
these may be due to idiosyncrasy, or, what is more likely, to
some other root having been accidentally substituted for
chicory. The ohemistry of chioory has not been muoh studied,
ws believe, but it is obvious that there can be no directly
injurious substanoe present. It has little or no dietetio value.

R. P.—Tour question is rather an odd one, but we are suffi¬
ciently versed in comparative anatomy to be able to assure
you that dogs do suffer from sea sickness. Nor are they the
only animals which do, for horses and cattle are subject to the
malady too. The question was treated of in the spring by M.
Landrieux, who read a paper before the Hocietd de Pathologic
Compares in Paris, in which he gave some striking instances.
One fox-terrier puppy, eleven months old, fell an easy prey to
the malady. The symptoms were practically the same, as in
man. Lack of interest in surroundings, dejection, salivation,
and vomiting with rapid recovery on reaching terra flrma.

L. K. Q. C. P. I.—The prises (£ 25 , £ 10 , and £ 5 ) offered by
Mr. George Sturge for authors of the best essays on “ The
Causes of Financial Depression in the Hospitals of London, with
Suggestions for Improving their Administration in Finances,”
were proposed in August, 1886 .

Podaora-Marlioz is a suburb of Aix-les-Bains, and connected
therewith by a good omnibus servioe. It is only fifteen minutes’
very pleasant shaded walk from centre of Aix. The three Marlioz
springs are cold, alkaline, sulphurous, and bromo-iodinated. Their
waters are specially efficacious for bronchitis (ohronio, catarrhal,
asthmatic), chronic diseases of the larynx, phnrnynx, nose, ears,
and uterus. The Marlioz Bath Establishment contains large
inhalation-rooms, fine spray apparatus, and local douches for
nose, throat, etc. Dr. Mace (of Aix-les-Bains) has published
excellent articles and pamphlets on Marlioz waters and treat¬
ment. For further particulars write to the Director, Marlioz
Baths, Aix-les-Bains.

A SUCCESSFUL FAT CURE.

We are not prepared to confirm or deny the last of the following
statements from our contemporary, the Pelican, but if
it be true we certainly agree that it is not ..." un¬
funny”:—“That the various medicines for reducing, the
ultra-plump and making them sylph-like still oontinue to be
very freely advertised and commented upon in singularly
favourable fashion by the papers in whose columns the ad¬
vertisements appear. That many of these preparations are
dangerous things to take. That anyhow it is not an unfunny
thing to reflect on the fact that the chief proprietor of a cer¬
tain greatly advertised fat-reducer weighs over treenty-two stone
himself— or did so last week 1 ”

D. R. A.—The tumour may be malignant, but such growths
generally occur in old-standing goitres. Carcinoma and sarcoma
both occur; it is practically impossible to distinguish the two
by merely clinical examination. Removal by operation can be
undertaken, but the prognosis is not very rosy.

Toxus.—The question of pressing for payment must, we
think, be left to your own judgment. If taken to oourt, we
have no doubt twenty guineas would not be considered out of
the way. That the patient expected that you would do the
operation gratuitously would be no defence in law, unless there
was a very clear understanding to that effect, as it is obvious
that a man does not expect a surgeon in the ordinary way to
do operations for charity. If yon showed that he had reason¬
able means, we think you would be qnite safe to reoover.

Meus.—W e do not know anything of the institution in ques¬
tion, and cannot therefore advise. It professes to be run on
ethical lines, and may be genuine. There is a “ fishy ” look
about it, we agree, and while there are other excellent institu¬
tions of the kind elsewhere, you would be well advised to go
where you can repose confidence.

Pater. —Of oourse, the adding of a fifth year to the medical
curriculum has made a difference in the fees oharged by London
hospital schools. Moreover, the larger number of practical
classes has necessarily made study more expensive. In the
old days the composition fee was roughly a hundred guineas., if
paid'in one snm, and about £120 if paid by instalments. As we
said last week, the average composition fee is now about £130
or £ 140 .

Baranctes.

MIo « 2 >Ter ( Derb T) County Asylum.—Junior Assistant Medioal
Officer. Salry £120 per annum, with furnished apartments,
board, washing, and attendance. Applications to Dr. Legge.

West Herts Inflramry, Hemel Hempstead, Herts.—House Surgeon
Salary £100 per annum; rooms, board, and washing found
Application* to the Rav. W. T. T. Drake. Boro' Gate, 8t.
Albans.

Bedford County Hospital.—House Surgeon. Salary £100 per
annum, with apartments, board, and laundry. Applications
to W. F. Morley, Secretary.

Edmonton Union.—Assistant Medical Officer. Salary £180 per
annum, and £40 per annum in lieu of residential allowance.
Applications to F. Shelton, Clerk, White Hart Lane,
Tottenham.

Toxteth Park Township.—Assistant Resident Medical Officer.
Salary £100 per annum, with board, washing, and apart¬
ments. Applications to R. Albert James, Clerk to the
Guardians, 15 High Park Street, Liverpool.

Bridgnorth and South Shropshire Infirmary.—House Surgeon.
Salary £100 per annum, with board and lodgings in the
Infirmary. Applications to the Hon. Secretary, the Infirmary,
Bridgnorth.

Egyptian Government.—Kasr El Ainy Hospital.—Resident
Medical Offioer. Salary £250 a year, with quarters, servants,
washing, ooal, and light. Applications to the Direotor-
General, Public Health Department, Cairo.

Egyptian Government.—Ministry of Education.—School of

Medicine, Cairo.—Assistant to the Professor of Pathology.
Salary £E .390 per annum. Applications to the Director,
Government School of Medioine, Cairo, Egypt.

Loughborough and District General Hospital and Dispensary.—
Resident House Surgeon. Salary £100 a year, with fur¬
nished rooms, attendance, board, and washing. Applications
to Thos. J. Webb, Secretary, Loughborough.

Scarborough Hospital and Dispensary.—Senior House Surgeon.
Salary £100 per annum, with residence, board, and allow¬
ance for laundress. Applications to the Hon. Secretary.

Wallasey Urban District Counoil.—Medical Officer of Health.
Salary £500 per annum. Applications to H. W. Cook,
Publio Offloes, Egremont, Cheshire.

Barnsley.—House Surgeon. Salary £100 per annum, with board
and lodging. Applications to R F. Pawsey, Honorary
Secretary, Barnsley.

Leicester Corporation.—Isolation Hospital.—Resident Medical
Officer. Salary £120 per annum, with board, lodging, and
washing. Applications to O. Killick Mallard, M.D., Town
Hall, Leicester.

Leicester Parish.—Resident Assistant Medical Offioer. Salary
£120 per annum, with rations, furnished apartments, and
washing. Applications to Herbert Mansfield, Clerk to the
Guardians, Poor-Law Offloes, Leicester.

London County Asylum, Long Grove, Epsom, Surrey.—Fourth
Assistant Medical Officer. 8alary £180 a jear, with board,
furnished apartments, and washing. Applications to H. F.
Keene, Clerk to the Asylums Committee, Asylums Committee
Office, 6 Waterloo Place, 8.W.

5ppomttttcm».

Ball, W. Girlixo, F.R.C.S.Eng., Assistant Surgeon to the City
of London Truss Sooiety.

Gasx, G. E., F.R.C.S.Eng., Surgeon to the City of London
Truss 8ociety.

Gorham, P. C., L.R.O.P. and S.Edin., Certifying Surgeon under
the Factory and Workshop Act for the Clifden District of
the County of Galway.

Harvet, Frank, M.R.C.S., L.8.A., Publio Vaocinator for the
St. Issey and 8t. Breock Districts by the St. Oolumb (Corn¬
wall) Board of Guardians.

Hustler, G. H-, M.B., Ch.B.Leeds, Government Medical Officer
for Fiji.

Niven, A. M., M.B., Ch.B., on the Resident Medioal Staff of
the Royal Infirmary, Aberdeen.

Stewart, Alex., M.B., Ch.B., on the Resident Medical Staff of
the Royal Infirmary, Aberdeen.

Walfohd, Harold R. 8., M.R.C.S., L.R.C.P.Lond., Assistant
House Surgeon at the Coventry and Warwickshire Hospital,
Coventry.

Carriage.

Dowden—Oswald. —On August 21 st, at St. Mary's Cathedral,
Edinburgh, John Wheeler Dowden, F.R.C.8.E., to Edith
Georgians, younger daughter of the late Surgeon-General
H. R. Oswald, I.M.S.

9tath0.

Anthobus.— On August 22 nd, at The Chase, Great Malvern,
Edmund Antrobus, M.D., aged 45 .

Margrave.— On August 10 th, at Moffat, N.B., Malcolm Llewelyn
Margrave, M.R.C.8., L.R.C.P.Lond., late of Llanelly and
Newton Abbott, aged 42 years.

Maurice. —On August 20 th, at the Vicarage, Isleworth, Benjamin
Maurice, M.R.O.8., L.8.A., of 12 Osborne Road, Clifton.

Bristol, son of the late William Maurice, of Clifton,
formerly Surgeon to the 7 th Hussars.

Digitized by G00gle

The Medical Press and Circular.

"SALUS POPUU SUPREMA LEX."

Vol. CXXXV. WEDNESDAY, SEPT. 4, 1907. No. 10

Notes and Comments.

After a full and eventful session,
Saali Parliament rose last week, leaving
Holdings. behind it an amount of completed
legislation of considerable and
varied importance. The session 1
is notable among many other things for the j
number of measures dealing, directly or indirectly, j
with public health and medical polity. Foremost
among these stands the Small Holdings and
Allotments Bill, which in principle was uncontro-
versial, though in practice its details came in for
a good deal of criticism. If the anticipations of
the promoters and supporters of this measure are
realised, it may have exceedingly far-reaching
results on the physique of the nation, for it will
bring into existence a large class of peasant tillers
of the soil, than whom no hardier and more virile
men can be found. The nation which consists
principally of town-dwellers is obviously a nation
living under conditions not conducive to the best
physical development, and the population of large
towns such as are growing with apparently irre¬
sistible force in England, is bound sooner or later
to lose the sturdy qualities that the wrestle with
the land under sun and hail bring out and keep
alive. We are hardly sufficiently optimistic to
expect that this new Act, or even a series of similar
ones will greatly change the current economic
factors, but it is just possible that it may establish
in this country a class of public tenants who will
be available as a source of recruiting for townsfolk,
and that thus a good backbone of physical
resource will be created. At any rate, the Act
is beneficent and praiseworthy in intent and it
is only a pity that a technical detail of adminis¬
trative arrangement should have prevented Scot¬
land enjoying similar opportunities.

The next most important achieve-
Edncatloa ment of the session has been the
{Administrative passing into law of the Education
Previsions). (Administrative Provisions) Bill,*
and it has shown Mr. McKenna to
be possessed of a quality rare in
politicians, namely, that of fulfilling in fact more
than he would promise in prospect. This bill
again was practically non-controversial, especially
as the details had been pretty well thrashed out
last year in Mr. Birrell’s ill-starred and more com¬
prehensive measure. By this Act the Board of
Education are authorised to Organise the work
of medical inspection of elementary school children
throughout the country, and the birth of school
hygiene may now be looked upon as an imminent
event. If we may be allowed to offer advice on

this subject we would of all things implore the
President of the Board of Education to beware
of the faddists in making his arrangements for
this duty. There is a large class of unmarried ladies
of unimpeachable motives and of elderly bachelors
read in the schools of Tubingen who, by reason
of their interest in the subject of the education of
children, are looked upon as “ experts.” May Mr.
McKenna eschew such “ experts ” 1 The science of
school hygiene is yet in its infancy and has little of
technical lore of its own. It is yet, and is likely
for many a day to be, but the sanctified common-
sense of a wise physician who is acquainted with
hygiene and acquainted with children. The head¬
quarters medical staff will be effective or ineffective
in creating an effective administration of the provi¬
sions of the new Act in so far as they are not
committed to any scheme of Scandinavian gym¬
nastics, exotic anthropometry, or other doctrinaire
panaceas. The British child is a person who likes
play, dislikes book-work, and is subject to certain
ailments. His salvation may be worked out largely
by attention to his limitations.

Another beneficent measure is
Pabllc Health the Public Health (Regulation of
Acta. Food) Act, which has safely found

its way to the Statute Book.

As we have often pointed out in
these columns the outburst of indignation against
Chicago was largely an outburst of ignorance, the
people of this favoured land fondly imagining
that all their food was of the best in the best of
all possible countries. On the contrary, the
amount of bad and diseased food openly and
covertly trafficked in is enormous, and the safe¬
guards provided by law, the seizure of unsound
food intended for the food of man by the health
officials, and its destruction by magistrate’s order,
largely illusory. The respect of the Constitution for
the sacred rights of property is no less exhibited in
practice than in legislation, and not only is it
difficult to prove the food is intended for the food
of man, but magistrates are often extremely
lenient to owners of such food. Now, however,
the local authorities have far larger powers of in¬
spection and control over food supplies and places
where food is kept, and it may confidently be
anticipated that, if properly used, there will be
far less ill-health and death from the consumption
of offal of various kinds which has been refused by
the stricter regulations of foreign countries and
dumped on these shores. Mr. Burns also got
through another Public Health Bill, and his Vacci¬
nation Bill for tempering the wind of magisterial

Digitized by boogie

232 The Medical Press.

LEADING ARTICLES.

Sept. 4 , 1907.

criticism to the shorn conscientious objector, and
the Secretary for Scotland, besides performing
the latter service also for his country, obtained a
smali butj needful change in its own Public
Health Act.

Of the Notification of Births Act
Notification it is difficult to write temperately,
of Births— In object it is praiseworthy enough,
for it aims merely at giving the
medical officer of health early in¬
formation of births in his district, so that he
may be in a position to take steps to see that the
children are properly cared for by their mothers
in the first few days of their lives. Whether the
steps taken will conduce to that desirable end
naturally remains to be seen, but the point which
affects medical men, and which we dealt with at
length in our leading columns last week, is that
it places a new and definite obligation on private
medical men pursuing their profession, without
fee and yet with penalty in default of the father
notifying. The time really seems to be ripe for
some definite movement among members of the
profession for letting the public know that while
they are willing and anxious to promote the public
weal in every reasonable way, they do object to
be constituted informal spies on their patients,
and they do object to be laden with responsibilities
which may land them in the police-court, and
for which they receive no compensation. The
habit of regarding the medical man as a beast to
bear the communal burden is growing alarmingly.
The Midwives’ Act made him responsible, of course
without payment, to hold himself in readiness to
obey the summons of every midwife who found
herself in difficulties, without giving him any con¬
trol over the midwife’s practice. The indignity
thrust on him by this new Act is scarcely less,
and to prate in high-falutin’ style about doctors’
benevolence is only to take an unconscionably
mean advantage of the present private charit¬
ableness of medical men. Were the appeal made
to medical benevolence and to that alone, a re¬
sponse, we believe, would be forthcoming, but a
police-court penalty is an abominable outrage.

As to other Acts, we, as members
Aid other of a working profession, have to
New Acts. thank the Chancellor of the Ex¬
chequer for the relief granted in
the income-tax. It has always
been a patent anomaly that the worker should
be taxed at the same rate as the drone, and though,
as in all enactments, there will be certain hard
cases, the broad principle of preference for the
earner as against the beneficed is now established.
Medical men will wish all possible success to
Mr. Asquith’s cleek and gun during the next few
months. They will perhaps not care much one
way or the other as to the measure which enables
women to sit on local bodies. Theoretically the
gentle influence of the sex should have play in the
sphere of minor government, but it is a rather
common experience to those who have served on
and under such boards that though many excellent
ladies have done good work on them in the past,
there is an unfortunate tendency for the Martha
rather than the Mary variety to seek municipal
honours. With the growing interest in local
government, let it be hoped the electors will learn
to discriminate between their respective qualifi¬
cations.

The fresh series of cattle outrages
Great Wyrley at Great Wyrley lends confirm-
Oatrafes. atory evidence, if any were needed,
to the innocence of George Edalji
of the crime with which he was
originally charged, and we believe there are few
people now who believe him guilty, even in the
neighbourhood where prejudice against him is
very strong. Whether the police or Sir A. Conan
Doyle, or both, succeed in nailing the real male¬
factor, the fact remains that an innocent man
has already suffered for a crime which it was
obvious all along to scientific minds he had not
committed. The question has been discussed over
and over again in these columns, but the share
taken by the Medical Press and Circular in
protesting against the Edalji conviction, and
petitioning for his release has been eclipsed and
forgotten in the sensational events of the last
few months.

LEADING ARTICLES.

AN EXPERIMENT IN SCHOOL MEDICAL
INSPECTION.

The question of the medical inspection of
schools has of recent years come definitely within
the range of practical politics. On all hands its
importance has been recognised not only as a
means of checking the spread of communicable
diseases, but also of controlling the physique of
rising generations and of supervising the condi¬
tions of school environment. An important ex¬
periment in this direction has been made by Dr.
Myer Coplans, Medical Inspector of Schools,
Gloucestershire Education Committee, who com¬
municated a valuable paper on the subject to the
recent International Congress of School Hygiene.
The local County Education Committee in ques¬
tion desired to improve the condition of certain
elementary schools in which the attendances, and,
consequently the grant-earning capacity, had been
seriously impaired by reason of the continued
prevalence of contagious skin affections among the
scholars. Under then-existing legislation, however,
there were no statutory powers enabling an
official medical examination of the children to be
made without the consent of parents. It there¬
fore became necessary to devise some means of
ascertaining the facts of the case as regarded the
skin diseases mentioned, at the same time re¬
specting the rights of the parents. This difficulty
was overcome by Dr. Coplans circularising the
parents of some 8,000 children, with the result that
97 per cent, of them agreed to his proposals. His
plan was to issue a card, which was intended to
accompany the child through his or her school 1
life. On one side of the card were particulars filled
in by the parents concerning the child’s ailments,,
the medical history, and questions as to tuber¬
culosis in the family. On the other side were
notes made by Dr. Coplans at regular intervals
concerning the child’s physical and mental de¬
velopment, condition of skin, state of vaccination,
together with remarks when necessary on the
special senses. For each of the sixty schools under
observation there was instituted a medical register

ioogle

D

Sept. 4. 1907,

CURRENT TOPICS.

The Medical Tress. 233

in which was tabulated standard by standard the
condition of individual scholars as shown by the
card. He found the columns relating to the
records of zymotic disease of great assistance in
determining the probability of spread of any
particular form of disease in any standard, de¬
partment, school, or even village, and he recalled
one case of a village concerning which the columns
relating to measles showed at a glance that there
had been no instances of that disease for more
than seven years. He was therefore prepared to
advise school closure on the appearance of the
first case of measles in that particular village.
The advantages of the scheme thus outlined are
conspicuous. One of the chief recommendations
is the continuity of record which is secured in the
case of each individual child. Further, an accu¬
mulation of statistical data would be secured that
could hardly fail to be of the greatest value in the
future study of the complex conditions of school
life. Early and continuous information, more¬
over, would be furnished of affections of the special
senses, and of those abnormalities of mind and
body which render a separate classification im¬
perative in any well-organised educational system.
So far as private schools are concerned, it may be
anticipated with a fair amount of confidence that
it is only a matter of time for them to fall into
line with the movement that is now being
established in State schools. Probably one of the
chief obstacles in the way of general medical in¬
spection will result from financial considerations-
In dealing with infectious diseases, notification
alone is useless without the corollaries of isolation
and disinfection. So in educational life medical
inspection without accompanying powers and
available classifying and remedial agencies, would
be of little value. It is one thing to inspect the
eyesight of a million of school children, but another
matter altogether to provide spectacles for those
who need them. A similar observation, mutaiis
mutandis, applies to other physical and mental
defects. As a sound contribution to the attack
on a complicated problem, Dr. Coplans’ Gloucester¬
shire experiment is worthy of the attention of
the medical profession.

CURRENT TOPICS.

Value of Science in Montgomery.

There are few counties which have yet recog¬
nised the value of the powers their Councils are
endowed with for appointing medical officers of
health. There are, however some which have
availed themselves of the privilege, and though
the salaries paid are seldom such as to entice men
from other posts, in some counties the medical officer
of health is.paid a moderate living wage. Of late a
new plan has been adopted by a number of these
authorities which desire to be considered at once
enlightened and economical, namely, to appoint
as medical officer a man engaged in other work
and to pay him a small salary and certain fee 3
for such work as the Council commission him to
do. The salary is usi-ally exceedingly small and

the fees nominal, but the county escapes the
reproach of not having a medical officer of health.
As the result of the pressure of public opinion, the
Montgomery County Council have decided that
they, too, shall have a medical officer of their
own ; so they have advertised for one and laid
down an elaborate scheme of duties for the success¬
ful candidate. The salary was not specifically
stated, but it turns out that these responsible and
arduous duties are to be performed for the am¬
bassadorial salary of five-and-twenty guineas a
year ! How such a post is to attract anyone who
proposes to do his work thoroughly no reasonable
person can conceive, and it is absurd to suppose
that anything but the most nominal compliance
with any of the specified rules is required. In a
word, the policy of the Montgomery County Council
appears to be one of throwing dust in the eyes of
the public by swaggering off a medical officer
of health, when for all practical purposes such an
officer does not exist. County medical officerships
should be among the prizes of the profession, and
should be paid so as to attract the very best men ;
in hardly any county is their salary more than
moderate, but in Montgomery it is farcical.

Inebriates’ Homes.

The report for last year of the Inspector under
the Inebriates’ Act has just been issued, and it is as
careful and suggestive as usual. It is noticeable
that whereas the number of men committed to
institutions under the Act has increased from
91 to no, the number of women has fallen from
352 to 294. There have been many signs lately that
magistrates are losing faith in inebriate retreats
for women, and it is not altogether surprising that
this should be so, for the number of “ cures ” is
exceedingly few. The reason for this is that priso¬
ners can only be committed after four convictions
within a year, and this safeguard to individual
liberty successfully assures that none but the
most confirmed inebriates are arrested. Now,
with all respect to individual liberty, it is beyond
reason to expect cures or any efficient reclamation
among women of this class, and it is not wonderful
that magistrates are getting to lose faith in retreats
and to send fewer women to them. It is a striking
fact, as shown in the inspector’s report, that three-
quarters of the crimes perpetrated under the in¬
fluence of drink for which women are committed,
consist in neglect of children. The numbers
actually are 291, out of 364 total crimes. Of the
other crimes, those of violence are remarkably
small, there being only one conviction for man¬
slaughter, two for malicious wounding, and seven
for assault. At the present day, when so many
beneficent measures are taken to promote tem¬
perance, it is a pity that the law does nol give
greater opportunities to officials to enter the homes
of drunken mothers and protect the children.

Alcohol and Mountaineering.

No better example of the altered attitude of the
public mind toward the use of alcohol can be
adduced than the fact that it is rapidly passing

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234 The Medical Press.

CURRENT TOPICS.

Sept 4, 1907-

out of use by mountaineers. It is but a few
years since brandy was regarded as a requisite in
every climbing expedition, and it was a rash
climber who ventured out without it. Nowadays,
it is not used at all as a beverage while climbing,
and it is only carried for use in case of accident
or to sustain life in case of prolonged exposure.
Dr. Schneider, an Austrian physician, has re¬
cently administered interrogatories to some 1,200
climbers with a view to discovering their experience
and opinions based on their personal use of alcohol.
They are practically agreed in believing that
alcohol should be reserved for special occasions,
and is to be regarded as a hindrance rather than
as a help in the ordinary course of climbing. This
is, indeed, what might be expected, when it is
remembered that there are few occupations which
demand a truer eye, a steadier nerve, and a cooler
head than does mountain-climbing. The bever¬
ages which have taken the place formerly occupied
by alcohol are cold tea and cold coffee, which are
stimulating and refreshing without possessing the
incoordinating effects of alcohol. We have no
doubt that another few years will see the dis¬
appearance of the brandy-flask from the hunting-
field as it has already gone from the glacier and
the rock.

Deaths Under Anaesthetics.

The proportion of deaths under general anaes¬
thetics, as already insisted upon in these columns,
varies in different hospitals to such an extent as
to suggest the desirability of careful scientific
investigation. That there will always be an
irreducible minimum of fatalities under such
circumstances appears to be more than likely.
There are certain obvious points that are capable
of reduction to systematic and detailed statement,
such as, for instance, the experience of the ad¬
ministrator, the nature of the anaesthetic, and the
kind of apparatus used in each given case. In
some quarters it is customary to assume that ether
is absolutely safe, and writers upon chloroform
deaths are wont to ignore deaths from the former
drug. Attention may be drawn to a case reported
in the news columns of our present issue, in which
death resulted after four ounces of ether had been
administered. Dr. Waldo, the City of London
Coroner, has taken up the question of deaths under
anaesthetics with his usual vigour and thorough¬
ness, and we may hope for extended and authori¬
tative investigation on a point of the utmost
practical importance, not only to medical science
but also to the welfare of the public.

Opening of the New Wing at the Rotunda
Hospital, Dublin.

The new wing, which has been lately added to
the Rotunda Hospital, was formally opened on
Tuesday of last week by Her Excellency Lady
Aberdeen. The new wing adds to the older
buildings six additional wards, by setting free the
entire top-floor of the Plunkett Caimes Wing,
which up to this had been used as a nurses’ home.
It also provides a new lodge, and residential
quarters for lady students, a disinfecting chamber

| for bedding and patient’s clothes, and an ample
supply of bath-rooms and lavatories. The Master
of the Hospital, Dr. Hastings Tweedy, in the
course of the statement with which the proceedings
on Tuesday commenced, referred to the urgent
need which existed for providing additional accom¬
modation on the midwifery side of the house. The
number of applicants for admission has increased
enormously, with the result that the existing wards
are overcrowded. The Rotunda Hospital has
always boasted that no patient has ever been
turned away, but had it not been for the new
wards such a course would inevitably have had to
be adopted. The new wing, which connects the
central portion of the hospital with the lodge, cost
over £8,000, and by its completion the claim of
the Rotunda Hospital to be in the first rank in the
United Kingdom, both in its accommodation for
patients and for students, is made more patent than
ever. The Master of the Hospital deserves the
very greatest credit for the energy which he has
shown in bringing about this new addition to his
hospital.

Tuberculosis and Work on Farms.

The problem of the eradication of tuberculosis,
like many other social matters, is more or less
closely associated with the land question. Other
things being equal, it can hardly be doubted that
country air is far less conducive to tubercular
affections than that of towns. So far as actual
treatment is concerned, open-air sanatoria are
available for only a small proportion of consump¬
tives. Under present conditions the cost of main¬
taining such patients indefinitely is simply pro¬
hibitive to local authorities. Any proposal, there¬
fore, which suggests any way out of the difficulty
deserves the earnest consideration of sanitarians.
From this point of view Dr. Robertson, the
Medical Officer of Health at Leith, makes a prac¬
tical suggestion that is worth attention. Dealing
with the difficulty of effecting cures in the majority
of cases of tuberculosis, he expresses an opinion
that what we really want is farm accommodation
where patients, after a specified period of residence
in hospital, may be sent to work in the open-air
for several months. This proposal is excellent
from various points of view. It would, for in¬
stance, not only be the best of all occupations for
the patient, but it would isolate the infection in a
place where it would be harmless, and would supply
the farmer with labour at moderate wages. It is
not unlikely that the system of farm colonies has
a future in various maladies other than tuber¬
culosis. Under good management the plan might
be made to a great extent self-supporting.

Medical Man Shot Dead by a Lunatic.

The special perils of medical professional life
have been once again demonstrated by the tragic
murder of a medical man in Leeds. With much
regret and sympathy we have to record the fact
that on Saturday last Dr. Walter C. Hirst, of
Chapeltown, Leeds, was shot dead on his own
doorstep by a man named Harrison, who imme¬
diately afterwards shot himself. It appears that the

Sept. 4, 1907.

PERSONAL.

The Medical Press. 235

assailant had been attended by Dr. Hirst for a
week or so for some affection of the brain, and
was about to be certified for admission to a lunatic
asylum. A letter sent by Harrison to a friend
shows that he was the victim of delusions. It
refers twice to the fact that the doctor struck
him on the knees and knee-caps, and asserts that
the proceeding in question brought on “ terrible
epileptic fits.” The man went to the house at
six o’clock in the morning, when Dr. Hirst,
thinking the servants would not be up, went
down to the door himself, and instantly received
two shots from a revolver through the front of
the chest. There were no eye witnesses of the
event, but both bodies were found a few minutes
later lying about five yards apart. Dr. Hirst
was 28 years of age, and had been married only
three months. The delusion as to the blows on
the knees appears to have arisen from the ordinary
testing of the activity of the knee-jerks. Fuller
details of the tragic occurrence will be found in
our news columns.

Notification of Epidemic Cerebro-spinal
Meningitis in London.

Some time since we ventured to predict that
the invasion of London by epidemic cerebro¬
spinal meningitis was simply a matter of time.
The gradual spread of the malady in Ireland,
Scotland, and certain provinces in England
suggested that inevitable conclusion. The recent
occurrence of several cases in the metropolis
tallies with the usual history of invasion in
in which these herald cases are the invariable
precursors of an extended outbreak. The gravity
of the position appears to be recognised by the
London County Council extending the notifica¬
tion of this special form of meningitis for eighteen
months further from September 13th, 1907,

the date of expiry of the present order. It is
expressly intimated that the term “ cerebro¬
spinal fever” does not include meningitis due to
tuberculosis, syphilis, middle-ear disease or
injury.

The Tuberculosis Exhibition in Dublin.

The main features of the scheme for the Tuber¬
culosis Exhibition, which is being organised
by Her Excellency the Countess of Aberdeen,
were put before a meeting of the Consultative
Committee last week, and met with cordial
approval. The Consultative Committee consists
of representatives of the various public health
authorities, of the various medical corporations
and societies, and of other bodies likely to be
interested in the matter, and Lady Aberdeen
has acted with her usual wisdom in thus enlisting
the sympathy and interest of many representative
men. The present plan is that the exhibition,
which is to open in October, shall consist of seven
sections: “ Diagrams and Statistics,” ‘‘Pathologi¬
cal and Bacteriological,” “ Dietary,” “ Literature,”
“Appliances bearing on Treatment,” “Veteri¬
nary,” and “ Lectures and Demonstrations.”
Each section is in the hands of an organiser, and
the list of organisers shows a very careful and

proper selection. Among them are the Registrar-
General, Dr. Alford Boyd, Dr. Lily Baker and
Professor Witham, of the Royal Veterinary
College. The organisers gave to the Consultative
Committee brief sketches of their plans, which
were sufficient to show that the exhibition cannot
fail to have educative effects of great importance
in many directions.

PERSONAL.

Major V. H. W. Davoren, from Devonport, has
taken over the duties of Medical Officer at Bury St.
Edmunds, vice Lieut.-Col. R. Anderson, F.R.C.S.Edin.,
retired under the age clause.

Dr. M. Cameron Blair has been promoted to be
senior medical officer in Southern Nigeria. Mr. W. H.
Langley, C.M.G., has been appointed principal medical
officer of the Gold Coast.

Dr. E. I. Spriggs has been elected Dean of St.
George’s Hospital Medical School.

At St. George’s Hospital the Medical School
Committee have decided to place a brass tablet in
the new pathological laboratory in memory of the late
Dr. Robert Barnes.

The death of Dr Seneca Powell, of the New York
Post-Graduate School of Medicine, is attributed to his
investigations into carbolic acid poisoning He had
irequently experimented on himself, and this s
believed to have undermined his constitution.

Dr. Henri de Rothschild, who goes out to Tangier
in charge of the hospital he is to establish there, is
the elder of two sons of the late Baron J ames Edward
de Rothschild, of London, who. in his turn, was the
elder of the two sons of Nathaniel, the third son
of Nathan Mayer, the founder of the English house.
The Rothschild hospital in Paris, which he superin¬
tends and works by himself, is open to all, irrespective
of religious creed. About nine months ago he added
to his other benevolences the gift of 100,000 francs
to start a Cancer Research Institute.

Sir T. Lauder Brunton will deliver the inaugural
address of the winter session of the London School
of Tropical Medicine, on Monday, October 21st, when
the chair will be taken by Mr. R. L. Antrobus, Assistant
Under-Secretary of State for the Colonies.

Earl Grey, Governor-General of Canada, recently
opened a consumptive sanatorium in Toronto, to be
known as the King Edward Sanatorium.

Director-General Sir Alfred Keogh, K.C.B., has
been appointed Honorary Physician to H. M. the
King.

Much to the regret of the Executive Committee of
Winsley Sanatorium, Dr. Lionel Weatherly has re¬
signed the chairmanship on the grounds of ill-health
and his removal to Bournemouth.

Dr. Moure, the famous Bordeaux surgeon, will in
a few days be summoned to the Miramar Palace, where
he will operate on King Alphonso for adenoids.

We beg to offer our warm congratulations to Sir
Henry Alfred Pitman, who has just entered upon his
one-hundredth year, and is the oldest physician in the
United Kingdom. Sir Henry took his M.D. at Cam¬
bridge in 1841. From 1858 to 1889 he was Registrar
of the Royal College of Physicians, and is still the
Emeritus Registrar. Sir Henry, who enjoys good
health, and is very active considering his great age,
resides at Enfield.

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CLINICAL LECTURE.

Sept. 4, 1907-

236 The Medical Press.

A Clinical Lecture

ON

ABORTIVE FORMS OF TABES.

By PROFESSOR F. RAYMOND, MJX,

/ \

OI the Faculty of Medicine, Paris; Physician to the Salpetriere Hospital, Paris.

[specially reported for this journal.]

Physicians who have opportunities of studying
cases of locomotor ataxy and of observing them oyer
long periods of time are forced to the conclusion
that the classical description with which text-books
have familiarised us does not cover the whole ground.
Each patient makes a selection, so to speak, from the
symptomatology and presents a special group of
symptoms which thereupon assumes an individual
aspect so that no two tabetics are exactly alike.

This polymorphism is particularly misleading in
the praataxic period. It is indispensable that we
should be acquainted with the various forms in which
the disease may present itself at the onset, and I
propose to discuss three cases in which the diagnosis
offered some difficulty.

Our first patient is a woman, aet. 37, a dressmaker,
whose past history is pathologically uninteresting, ex¬
cept that she admits alcoholic excesses. One afternoon
last winter she was returning home on foot when she
noticed a sudden numbness which started in the left
foot, gradually extending to the whole limb then
spread to the hand and arm, in short, all the left side
of the body except the face was similarly aflected.
The side seemed " dead ” and felt very cold. She
felt giddy and had to lean against the wall to avoid
falling down. It passed off in about ten minutes
and she went home. .

Three days later the same thing occurred, but this
time on the right side, when the face and tongue were
affected. For a few minutes she was unable to speak
and had to lean against a wall, but again in a few
minutes the sensation passed away. Four days
later, still in the afternoon, she had a similar attack
at home, the face not being involved.

She has had no further recurrence of the symptoms,
but at every sudden movement she feels jerks and
trembling in the left foot, and more recently a tremor
of the left side of the face. These are the symptoms
that brought her to the Salp6tri6re. Her general
health is good, she does not suffer from headache or
disturbances of the special senses and motility is

^Now this patient presents none of the stigmata of the
neurotic subject, nor a trace of hysteria, and if I raise
this question it is only in order to impress upon you
that you must never omit to ask yourselves the ques¬
tion, in presence of nervous manifestations, whether
these are not purely functional.

The organic origin of these symptoms having been
established there is only one term to describe a sensory
crisis which starts at the distal end of a limb, spreads
all over the body and ends in a brief lapse of con¬
sciousness. viz. : Jacksonian epilepsy. This term
may suggest to you the idea of a convulsive motor
manifestation, but such attacks are often preceded
or accompanied by sensory phenomena, pain, numb¬
ness, tenderness, etc. This localised epilepsy may
indeed assume a purely sensory form of which I have
seen numerous instances, mostly followed by an
•• absence of mind ” or vertigo, rather than by comatose
loss of consciousness with stertor. This case belongs
to the latter category. ,

The pathogenesis of the syndroma has not as yet
been cleared up, but we know at any rate that the
cause must be looked for in irritation of the grey
cortex in the sensory motor zone. In this patient,
however, we do not at first sight find the aetiological
factor which would explain this irritation. She has
had no recent or previous injury to the cranium

since there is no headache, no vomiting, no vertigo,
no ocular phenomena. It is not an exogenous in¬
toxication, there is neither diabetes nor renal in¬
adequacy. In fact we have no objective sign to guide
us so we must trust to close examination of the patient
to reveal some symptom which will put us on the track
of the underlying cause, for though it is not mechanical
or toxic it may be reflex or vaso-motor.

The woman tells us that she has no trouble in
walking, and, as a matter of fact, od superficial ex¬
amination, her steps are regular and she even walks
straight. But if we make her turn round suddenly
or tell her to go down stairs without looking at her
feet she is embarrassed and hesitates. Id the erect
position too, things look normal, yet when she is told
to stand on one foot she sways, showing a disturbance
of equilibrium. There is then some slight inco¬
ordination, and this constitutes Romberg’s sign.

Muscular strength is intact in all her limbs, but
when she is told to shut her eyes and put a glass to her
lips she goes wide of the mouth. Let her try to place
the left heel quickly on the right knee—she cannot do
it 1 These are the means which enable us to diag¬
nose ataxy at the onset.

We may add that the ankle and knee jerks are
abolished and those of the upper limbs are very feeble.
There is nothing wrong with objective sensibility,
but the area of the ulnar nerve is hyper. sthetic.
Lastly, examination of the eyes reveals two signs of
the greatest importance, the Argyll-Robertson pupil
on the one hand and, on the other, traces of old standing
optic neuritis, manifested by irregularities and pallor
of the optic nerves. One little detail to complete the
picture—for no point must be overlooked—she has
false teeth and she tells us that some years ago her
teeth became loose and in a short time came out
though not decayed. This shedding of the teeth
is evidence of a trophic disturbance comparable
with shedding of the nails, perforating ulcer, etc.,
and it is a comparatively rare sign of the disease
under consideration. In view of these various signs
we need not hesitate to diagnose Duchenne’s disease,
but it is not yet true locomotor ataxy for the patient
is still in the pre-ataxic stage.

Now, among the abnormal manifestations of tabes
are certain cerebral symptoms which as a rule occur
during the prae-ataxic period, viz. : apoplectiform or
epileptiform attacks which may resemble complete
essential epilepsy or Jacksonian epilepsy, hemi¬
plegia or localised paralysis, which have this in common
that they all exhibit a tendency to clear up rapidly
and spontaneously. This fugitive character justifies
ns in putting them down to vaso-motor disturbance,
possibly dependent upon medullary or protuberous
lesions of tabes.

However this may be, these symptoms suggest a
malady affecting the cerebrum. You cannot but be
struck by the unlikeness of the principal medullary
type of tabes. If you bear in mind the extremely
insidious invasion of these symptoms you will under¬
stand how easy it is to make a mistaken diagnosis
of some cerebral disease, cerebral syphilis, etc.

There is one other point to which I must call atten¬
tion ; among the somatic troubles of the prodromal
period of diffuse meningo-cephalitis ODe of the most
important is the sudden, unexpected supervention of
epileptiform attacks, either general or local. These
may be motor or sensory, but the latter possess a
special significance and must be looked upon as one

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Sept. 4, 1907.

CLINICAL LECTURE.

The Medical Press. 237

of the most characteristic signs of the onset of pro¬
gressive general paralysis.

Now in this woman we shall find that certain symp¬
toms accompanied her attacks of sensory epilepsy
which escaped our attention just now, viz. : a little
trembling of the tongue a little “ mouthing ” and
some blurring of words. Though but slight these
signs must make us hesitate awhile as to the diagnosis.

I should not be surprised indeed, if, within the rear
future, this woman gave unequivocal signs of general
paralysis.

This is not the moment to enter upon the discussion
■of the relationship of general paralysis to tabes.
This view was first suggested in France by Baillarger,
and the co-relationship was set forth by my pupil,
Dr. Nageotte, in his thesis, under the term " Cerebro¬
spinal Tabes,” a term which Dr. Fournier gives to
cases in which the two manifestations run their course
together.

We will now pass to the second patient, a strong
man, -et. 39, who is still employed as a messenger.
He comes to us for chronic, recurrirg ulceration of
the soles of both feet, which started eight years ago.
When 31, he had a perforating ulcer on the right little
toe which led to painful suppuration ard was followed
by the shedding of two phalanges. Five years ago
another ulcer formed on the first phalanx of the
left big toe. There is another on the metacarpo¬
phalangeal joint underneath. Another similar ulcer,
this time associated with symptoms of general in¬
fection, occurred on the left little toe, and the third
phalanx came away. A fifth ulcer started in 1902 on
the right big toe, necessitating amputation and last
year a sixth made its appearance on the fifth left
metatarsal bone. There is very distinct perforating
ulcer on the left foot, there is a circular loss of sub¬
stance with punched-out edges made up of stratified
epithelium, and the base is irregular and granular
and is bathed in scanty muco-purulent secretion. There
is no inflammatory reaction round the ulcer, it is
everywhere anaesthetic, and the sound touches bare
bone and can be pushed right into the joint, the
synovial membrane whereof is thickened and granular.
Then, too, the feet are cold and livid and the skin
is covered with cold sweat. There is some oedema
in the left leg and the skin of both feet shows a ten¬
dency to hypertrophy.

Since N£laton first described what we now know
as perforating ulcer, its pathogenesis has undergone
many modifications. Without troubling you with
the history of the question I may state that the affection
is no longer looked upon as a purely local lesion due
to mechanical causes. Some, Pean, for instance,
ascribe it to arterial lesions, others, like Poncet,
Duplay, and Morat, believe it to be of nervous origin
and attribute it to degenerative changes of the nerves.
The latter view is the one that holds the field at present,
so that we need not waste time in the endeavour to
elucidate a mechanical aetiology. That prolonged
pressure may be a determining and localising factor
is but probable in view of the improvement that follows
rest, but the fundamental trophic disturbance must
be looked for elsewhere. First we must look to dis¬
eases of the spinal cord, especially tabes, then infantile
paralysis, Freidreich’s disease, myelitis, syringomyelia,
etc. Perforating ulcer may even be one of the trophic
disturbances affecting the foot consequent upon
medullary compression, as in Pott’s disease, spinal
tumours and spina bifida. Sometimes we must go
even further afield to diffuse meningo-encephalitis.
Not uncommonly the cause is a primary or secondary
affection of the peripheral nerves. All nervous
lesions may give rise to the same trophic distqrb-
ances—wounds, bruises, incised wounds, various
compressions, all kinds of neuritis, whether infective
or toxic, changes in nerves consequent upon varicose
dilatations, and phlebitis of the intra-nervous veins
and so on.

Still- more, the aetiological factor in the production
of perforating ulcer may be even more general, for it
may be due to a constitutional infection such as
leprosy, mercury or alcohol, to a diathesis such as 1

diabetes or a general dystrophy such as arterio¬
sclerosis. The lesion may occur elsewhere than on the
sole and under aspect of the toes, and you must not
be surprised to find it now and again on the palm,
in the sacral region, over the coccyx, etc.

Let us now discuss the aetiological problem of per¬
forating ulcer. It is only complicated in appearance
and you will soon grasp the nature of the lesion.
If we question the patient we find that at thirty-four
he was under medical care for grave pulmonary
congestion. Seventeen years ago he had a chancre
with the usual sequelae and he underwent several
courses of mercurial treatment. His tongue testifies
to past syphilitic manifestations, so that there can be
no doubt of the syphilitic nature of the infection.
He tells us without being questioned that at twenty-
five he had short sharp pains in both legs which were
put down to rheumatism—a very common error
against which you should be on your guard. Having
reached their maximum intensity these pains subsided
in the course of a few years, a very troublesome
sensation of girdle pain and thoracic constriction
taking their place. These in their turn disappeared,
and for some years all that he complained of has been
of both lower limbs.

Pains of this kind, dating back some fourteen years,
coming on in short, sharp crises, at once makes one
think of commencing locomotor ataxy. But the knee
jerks are present though dull, and even the ankle
reflex, which is usually the first to disappear, can still
be elicited, though not so active as normal and less
marked on the left side than on the right.

At first sight it would be hard to say that the patient
is ataxic, he can turn round promptly and can walk
up or down stairs, etc., without hesitation. Yet
when he shuts his eyes there is some unsteadiness of
gait, especially in starting and stoppirg, and he
throws out the leg. He sways when standing up and
cannot remain erect, i.e., Romberg’s sign.

There is no loss of muscular strength, yet his arms
and legs are peculiarly flaccid and flexion movements
arc unduly ample, in snort, there is hypotonus. Carry¬
ing our examination a step further we find that he has
had some trouble in respect of micturitioo for months
past. He is often obliged to wait awhile and to strain
to set it going, sometimes, indeed, he is obliged to
squat in order to empty the bladder. At other times
there is a slight incontinence, not only of urine, but
also of the feces. Sexual desire is lessened, yet he
has frequent nocturnal emissions. Testicular sensi¬
bility is lessened. All these symptoms are important
in view of their grouping, but we now come to some¬
thing much more significant, vis. : the results of
examination of the eyes. There is no evidence of any
mischief of the fundus, no disturbance of external
movement (never any diplopia), but there is obvious
inequality of the pupils and a diminution of the
pupillary reflex to light.

These then are the principal symptoms and, as you
have seen, it has been necessary to look for them
pretty closely; this fact may explain how it is that
his condition has escaped diagnosis for fourteen years
or so.

Apart from the trophic symptoms which brought
the patient to us l would lay special stress on four
cardinal symptoms; the lightning pains. Rom¬
berg’s sign, the urinary troubles, and the state of the
internal muscles of the eye. Three of these symptoms
occurring together would suffice to establish the
diagnosis, and when we have the fourth it becomes
a certainty. This man, although the disease
has existed for fourteen years, is still in the prae-
ataxic stage. This stage has been of long duration
and it may last much lorger. The special feature
in this case is the tendency to perforating ulcers.
This is a case of trophic tabes ir which the nutrition
of the lower limbs is very markedly modified. The
joirts of the foot share in these changes, one of them
especially, the metacarpo-phalangeal joint of the left
big toe, is much enlarged and grates on being flexed.
Both feet are much flattened and this deformity,
as you know’, is often due to tabes, but it is only the

D

238 The Medical Press.

CLINICAL LECTURE.

Sept. 4. I 9 Q 7 »

outcome of trophic disturbances of the joints, allowing
cf relaxation of the ligaments and fibrous bands that
normally maintain the arches of the foot. As a matter
of fact I do not think that tabes need be invoked
in the present instance for the deformity dates back
to early life and he has been subjected to long standing
and multiple fatigues. Moreover, he had, even young,
a well-marked tendency to varicose veins. His
father suffered from afterio-sclerosis, so that the
conditions were such as to favour nutritive disturb¬
ances of the lower limbs. From its onset the dis¬
ease found a ready-prepared soil and the early nerve
troubles soon gave rise to trophic disturbances. Such
cases are by no means rare, in fact, I wonld impress upon
you that these trophic disturbances are not only a
possible complication of confirmed tabes, but are
often a very early, nay initial, symptom of the
disease. You will see, therefore, that we must not
concentrate our attention too exclusively on the state
of the reflexes.

And now, in order to bring clearly before you the
remarkable polymorphism of tabes. I will show you
a third patient, a woman, *t. 33 years, without
any interesting pathological antecedents. Married
at fifteen, she was divorced, and re-married at twenty-
eight. She only had ore child, who died at two-months
of age. The confinement was followed by some
obscure, probably infective, uterine trouble which
did not pass off, and four years ago the adnexa were
removed. Advantage was taken of the opportunity
to remove the appendix because she suffered at the
time from vomiting. The genital troubles subsided,
but the vomiting persisted so that the appendix was
evidently not to blame.

Six years ago, when aet. 27, she first noticed severe
pains in the legs—a stabbing, radiating pain, “ as
quick as lightning ” as she describes it. The pain
recurred daily just before going to bed and prevented
sleep. The attacks lasted about half an hour and
then suddenly subsided. Here again, and I must
insist upon the fact, the pain was diagnosed as rheu¬
matic and treated as such. Then came on the vomit¬
ing, at first easy and bilious, it occurred at any hour
of the day and had no obvious connection with meals
or with the kind of food. Note that the vomiting
was absolutely pair less. For four years the vomiting
recurred in crises, at variable intervals. Eighteen
months ago (at 31) the attacks began to be accom¬
panied by severe pain in the back, chest and epigas¬
trium. Sometimes the pain was stabbing, like that of
an ulcer, sometimes in the form of girdle pain, sometimes
constrictive. The attacks often coincided with the
periods, which is often the case in these visceral crises.
At first the attack lasted two or three days, then a
week, and recently a fortnight. While it lasts the
patient avoids taking food and, curiously enough,
does not seem to leel any the worse for the abstention,
though of considerable duration ; in short, she seems
to have lost the sense of hunger. The painful attacks
are often followed by diarrhoea. She lost flesh and
became the subject 01 intense nervous depression.
The only thing that did her any good was morphia,
and she drifted into the morphia habit. I shall have
occasion to point out, shortly, the part played by these
injections in bringing about a repetition of the gastric
troubles.

Moreover the pains in the lower limbs had never
quite left her, indeed, they had also made their appear¬
ance in the upper limbs, especially on the internal,
ulnar aspect, the thenar eminence and the little finger.
For five vears these various pains were the sole mani¬
festations of the disease. But during the past year
she noticed that unless she paid particular attention
to her feet in walking she was apt to stumble and she
found going upstairs very difficult. She is subject to a
frequent desire to pass water without necessity,
while at other times she is unable to retain it. On
more than one occasion she has passed motions in¬
voluntarily.

So much for her history ; you will already have
made up your minds as to the diagnosis, but we will
proceed to corroborate it. She tells us that she is

unable to walk in the dark, and you have only to
watch her trying to walk with her eyes shut to see
how matters stand. The ankle reflexes are abolished,
The knee-jerks are diminished, the pupils are unequal,
the left (the larger) being quite insensible to light,
while the right is sluggish. The pupillary reflexes,
however, respond to accommodation ; in short, she
exhibits the Argyle-Robertson phenomenon.

Obviously it is a case of tabes. That is easy enough
to say now, but was it equally so a few years ago ?
Every physician is aware of the fact that gastric
troubles are among the symptoms of the prae-ataxic
period, but what is perhaps less clearly recognised
is that this symptom may usher in, and for a long
time remain the sole and only feature of, the clinical
picture. How many times have the gastric mani¬
festations given rise to an erroneous diagnosis of
gastric ulcer, or gastritis with pyloric stenosis or inter¬
mittent attacks of hepatic or nephritic colic ? It is
very easy to make this mistake, all the more so be¬
cause it is customary to comprise all tabetic stomach
troubles under the term “ gastric crises.” The
student always looks for the picture of the grand
tabetic crisis and loses sight of the diversity of lorm
in which it may present itself. In this case it came
on as painless vomiting, in another it may be gastralgia
without vomiting, “ stomach cramps ”—there is only
one feature in common, e.g., their periodical evolution,
their recurrence in attacks which become more and
more frequent, often monthly, corresponding with the
menstrual periods.

This case enables me to direct attention to a feature
which was clearly defined some years ago by Roux in
his thesis, viz. : the degree in which these attacks
are influenced by anterior dyspepsia, by the nature
of the food and by medicinal gastritis following the
administration, by the mouth or subcutaneously,
of sedative remedies. Under this double influence
the characteristic features of the tabetic crisis—its
suddenness of onset and subsidence—may be lost,
so that the crisis is disfigured so to speak. I need
hardly insist upon the disastrous effects of repeated
injections of morphine on the stomach. The more
frequent the injections the shorter is the interval
between the attacks and the more severe are they.
A large eater, an old-standing dyspeptic, this patient
stood every chance of her tabes commencing by the
stomach. Under the influence of her medicinal
iptoxication the attacks become more protracted.
Nutrition was gravely interfered with and morphia
no doubt had much to do with the intense nervous
depression that followed.

Our first care then must be to demorphinise the
patient reserving the drug for the severest attacks of
pain. We must put her on milk diet for a lew days
and then a lacto-vegetarian diet.

The best means at our disposal to calm the pains
and visceral manifestations is the injection of nitrite
of soda. For ten days following inject one cc. daily
of a 2 per cent, solution of the salt, then ten days rest,
then two cc. daily followed by a period of repose,
then ten days with three cc. daily, and so on until
four cc. daily is being given. This treatment has
yielded very satisfactory results, but not in every
instance. In the event of failure we must not leave
these unhappy patients to their fate, we may employ
electricity, baths of ultra violet rays applied to-
the loins, &c.

An outbreak of infectious disease has occurred in
rural Essex. It is believed to have been caused by the
introduction of London poor children on holidays.
As many of the affected children as can be got into the
isolation hospital there are being so treated, the re¬
mainder being kept at their country lodgings. Efforts
are being made to ascertain the liability of the charity
organisations which sent the children into Essex, and
that of the children’s parents, but it is much to be
hoped that this unfortunate con/retemps will not affect
the good work of the children's holiday funds.

Sept. 4, 1907*

ORIGINAL PAPERS.

The Medical Press. 239

ORIGINAL PAPERS.

SOME OBSERVATIONS ON

THE USE OF CALCIUM SALTS.

By S. J. ROSS, M.D., Viet.

Surgeon, Out-Patients' Bedford and County Hospital.

I need only in passing, remind your readers
of the debt of gratitude we owe to Professor
Wright and Dr. Ringer for the pioneer work
they have done with reference to the value of
calcium salts as therapeutic agents.

My object in writing these notes is to draw the
attention of busy general practitioners to the
value of calcium salts in certain common and
often troublesome conditions.

Childblains. —I have employed calcium chloride,
gr. x., thrice daily and given in a tumbler¬
ful of water, in ten cases with complete success.
The drug was given for two days, then omitted
for three days, and administered again for two
days. The average duration of treatment was
fourteen days.

Ulcers of the Leg. —I have used calcium iodide,
gr. iij., thrice daily in fourteen cases; combined
with rest and low diet. In each case the drug
was administered intermittently, and in each
case the ulcer healed soundly and rapidly. Locally
I employed Ung. Hydrarg Ammon. Seven
of these cases were varicose ulcers. The ages of
the patients ranged from 17 to 86 years. In one
case the patient had remained in bed for two months
but the ulcer refused to heal. After the com¬
mencement of the calcium iodide treatment the
ulcer rapidly improved, and was soundly healed
in three weeks. I have noticed that for the first
few days of this treatment the ulcer discharges
more freely than before this treatment was
commenced.

Epistaxis. —I had a very severe case of epis-
taxis occurring in a patient, aet. 74 years, with
markedly atheromatous vessels and high tension
pulse. He was freely purged, sent to bed, and
placed on milk diet. His left nostril, from which
the bleeding took place, was plugged with a strip
of cyanide gauze soaked in adrenalin solution.
Haemorrhage persisting, I gave the patient cal¬
cium chloride, gr. xv., twice ; the haemorrhage
ceased and did not recur.

Painless (Edema of the Ankles. —A youth, aet.
20 years, complained of swelling of both ankles.
His heart and urine were normal. I gave him
gr. xv. of calcium chloride thrice daily for three
days and the cedema cleared up. Two months
after this he presented himself with the same
condition, which yielded to similar treatment.

Tertiary Syphilis. —A man, aet. 47 years, had
a syphilitic perforation of his hard palate. I gave
him potassium iodide, but this he could not
tolerate, symptoms of iodism quickly ap¬
pearing, I then put him on calcium iodide,
gr. iij., thrice daily. This he took without incon¬
venience and continuously for two months, at
the end of which time the perforation had healed.

Menorrhagia. —A lady, aet. 30 years, who
was subject to attacks of epistaxis and erythema
nodosum had a very profuse period. She
told me that her skin very readily bruised. I
ordered gr. xv. of calcium chloride ter in die, and
the haemorrhage ceased. Nine months after
this she had a similar attack checked by the
same drug.

A case of Pneumonia with free hcemoptysis .—I

had a case of pneumonia in a patient, aet. 45, a
marked alcoholic. The left lung was solid. He
expectorated blood freely. I gave him calcium
iodide, gr. iij., thrice daily for three days and the
haemorrhage ceased. The patient ultimately re¬
covered.

Remarks. —These few cases have impressed
upon my mind the value of this drug in the
conditions I have indicated. The only un¬
pleasant symptom complained of in three cases
was nausea, which was stopped by increasing
the dilution of the drug. Syrup of orange in
drachm doses renders the mixture more palatable
than if it be given in water only. There are
many other conditions in which calcium salts
have been successfully employed, e.g., rickets,
haematuria, haematemesis, erysipelas, erythema
nodosum, functional albuminuria, haemophilia,
in gall bladder operations where adhesions are
anticipated and as a result free haemorrhage
(I can vouch for its value in these cases when
given twenty-four hours before operation), and in
the rashes following serum injection.

Calcium salts are said to raise the blood pressure.
They certainly did not raise the blood pressure
of the case of epistaxis I have cited. Had the
blood pressure been raised to any appreciable
extent the result would have proved disastrous.

I have personally been most impressed with
the beneficial action of calcium salts in the cases
I have cited. To those of your readers who have
not tried them, I say try them. To those who
have tried them let me ask them to add their
experience to mine, as an ounce of experience
is of more value than a pound of theory.

THE DEFINITION OF BLINDNESS IN
CHILDREN: ITS CAUSES AND
PREVENTION (a).

By ADOLPH BRONNER, M.D.

Senior Surgeon, Bradford Royal Eye andEarHoapital; Laryngologist,
Bradford Boyal Infirmary.

The definition of blindness, as generally accepted, is
that the vision of both eyes is so bad, that the patient
cannot see well enough to find his way about in day¬
time, or count his fingers at twelve inches. Even
adopting this very narrow point of view, we find
that in 1901 there were no less than 25,317 blind
people in England and Wales, or 771 to every
million of the population. These figures are not
very accurate, as there are a large number of
blind persons who do not acknowledge that they
are blind, and, on the other hand, a fair number
who are blind, but whose vision could be improved by
operation or treatment. Of children under fifteen
years, 423 out of every million of that age are blind.
But I think that in dealing with this very important
question we should not only include the blind, but also
all children who suffer from defective eyesight, cer¬
tainly those who do not see well enough to read ordinary
school books. If this were done, the numbers would
be very much larger. And, surely, from a practical
point of view, a child who cannot see to read is nearly
as badly off as a child who is quite blind. I should
suggest that some universal standard of defining the
various degrees of weak-sight be adopted for all
countries, so that our statistics may be of a uniform
nature. Vision of 6/9 to 6/12 to be called “ fair
sight,” 6/18 to 6/24 ” weak sight,” 6/36 to 1/60 " bad
sight,” and “less than 1/60” blind. It would then
be easy to divide the children into different classes for
teaching purposes. At present there are generally
only two classes, for the normal-sighted and for the

(a) Read before the International Congress on School Hygiene,
London, August, 1007 .

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240 The Medical Press.

ORIGINAL PAPERS.

Sept. 4. 1907 -

blind. There certainly ought to be at least one inter¬
mediate class for these children who are not blind, but
can see a little. In time some of these could be drafted
into the first class, and some into the third, or blind
class.

Most cases of blindness in children are due to disease,
about 80 per cent. Magnus examined 3,206 blind
children and found that in 17 per cent, the blindness
was congenital or due to malformation of the eyes,
mostly hereditary or due to congenital syphilis ; in
33 per cent, to diseases of the eyes, including 23.5 per
cent, which were caused by purulent ophthalmia;
in 8 per cent, to trauma; while in 33 per cent, it was
the result of some general disease which had affected
the eyes ; in 7.5 per cent, to small-pox. Roughly
speaking, 8-10 per cent, are due to congenital syphilis.
Cases of trachoma, or granular lids, are very rare in
this country. Harman could only find five cases in
70,000 English children. For many years, 1869 to
1900, contagious conjunctivitis was very prevalent in
the Han we 11 schools, and caused many cases of blind¬
ness. This was, however, stamped out by the untiring
energy of Dr. Stephenson.

These statistics only include children who are quite
blind, and no notice is taken of those with defective
eyesight, or who are blind on one eye only. Thus,
those cases of progressive short-sight, which are so
often met with in school children, cases of ulceration
and disease of the cornea, which are so very common
and cause defective eyesight, and many others, are not
included. There are 25,317 blind people in England,
but how many are there with defective eyesight ? At
least half a million. Even to non-medical men, these
figures are appalling, and one naturally asks, cannot
something be done to prevent so many unfortunate
people from becoming weak-sighted or blind ?

Cohn and others have examined 1,000 blind people,
and assert that in about 40 per cent, of these, the
blindness could have been prevented. That means that
there are more than 12.000 blind people in England to¬
day who need not be blind, but who should be able to
see as well as you or I. And tens of thousands who
are suffering from defective eyesight which could have
been prevented.

1. Congenital Blindness.

Congenital blindness could, to a great extent, be
avoided, if persons suffering from hereditary diseases
of the eye, chiefly cataract, optic atrophy, and retinitis
pigmentosa, were not allowed to marry. When both
parents are born blind, often all the children and their
offspring become blind. In Bradford there is a family
of blind parents with five blind children, all of whom
were in the workhouse. A large number of cases of
congenital blindness are due to syphilis, and many
cases of blindness which occur in early childhood are
caused by the same disease. These could, to some
extent, be avoided, if every case of syphilis were treated
for two years, and not allowed to marry during that
time. An American physician has recently advocated
State regulation of marriage, through a Board of
Guardians. He predicts that if this is not done,
“ Americans will in time be chiefly idiots and imbeciles.”

2. Infantile Purulent Ophthalmia.

Purulent ophthalmia of infants is a very common
cause of blindness. No less than 23.5 per cent, of all
cases ol blindness in children, according to Magnus, are
due to this disease, and 72 per cent, of all cases under
one year of age. It is an inflammation of the inner
part of the lids, characterised by a copious creamy
discharge with swelling of the eyelids. It causes
ulceration of the cornea (transparent front part of the
eye), with consequent opacity, or perforation and com¬
plete loss of the eye. It is due to direct infection at the
time of birth, or at the dirty hands of the midwife, and
caused by a germ called the gonococcus of Neisser.
Fortunately it is not as common as it used to be.
Formerly 30 to 50 per cent, of all babies, at least in the
lying-in hospitals, became affected, now only 0.25 to
0.1 per cent. Thanks to improved methods of treat¬
ment, purulent ophthalmia is not nearly so dangerous
as it was some years ago, when 40 to 50 per cent, of all

cases became blind. Now only about 4 per cent, lose
their sight, and 15 to 18 per cent, have defective vision.
The best methods of treatment are, as soon as the eye
becomes red or there is the slightest discharge, to
inject 2 per cent, nitrate of silver drops between the
opened lids, three times a day, or, better still, 10 to 20
er cent, protargol or argyrol drops every one or two
ours, or peroxide of hydrogen drops, or to insufflate
airol powder, and, in some severe cases, to paint the
everted lids with 10 per cent, nitrate of silver ; also
wash out the eyes with 1 in 3,000-5,000 perchloride of
mercury lotion (warm), and with a glass irrigator, and
not with a dirty sponge, as is so often done. It is very
often difficult to get the drops and lotion between the
lids, as these are very swollen, and it requires the help
of a skilled nurse. All cases, therefore, which cannot
be carefully treated at home, should be admitted into
hospital at once. Most cases occur in the private
practice of midwives. At last a Midwives Bill has been
passed, and many of those dirty, disreputable old
women who called themselves midwives have disap¬
peared, let us hope for ever. According to the rules
of the Central Mid wives Board, “ every midwife must
decline to attend alone, and must advise that a regis¬
tered medical practitioner be sent for, whenever there
is inflammation to even the slightest degree of the eyes
and eyelids." They, however, very frequently do not
do so. Last year at the Bradford Royal Eye and Ear
Hospital I saw no less than five cases of purulent
ophthalmia, in which the midwife had treated the
eyes for several days and not sent for a doctor. Three
of these children are now hopelessly blind. The rule
should be made much more stringent, and the midwife
should be obliged to send for a doctor within
twelve hours, and if she neglect to do so, should be
most severely punished. In America, in some States
at least, they are fined up to 100 dollars, and get up to
six months’ hard labour. Why cannot we do this in
England ?

The parents, especially the mother of the child,
should be told of the great danger of this disease.
Some years ago the Committee of the Bradford Royal
Eye and Ear Hospital communicated with the Registrar-
General, drawing his attention to the prevalence and
danger of purulent ophthalmia, and suggesting that
every registrar should be requested to give a printed
card with instructions to every person who registered a
birth.

'* Instructions Regarding New-Born Infants .”

“ If the child’s eyelids become red and swollen, or
begin to run with matter within a few days after birth,
it is to be taken to a doctor immediately. The disease
is very dangerous, and if not at once treated, may
destroy the sight of both eyes.”

The reply received was very characteristic. “ A
similar request has been made three years ago by the
Ophthalmological Society, but it is impossible to adopt
the suggestion, because the registrars are not salaried
officers, but are paid by fees for the registration of each
birth, and cannot be asked to undertake a duty, the
distribution of such cards, unless they are offered
some additional fee.” Thanks to the kindness of the
local registrar, such cards were for some years dis¬
tributed in Bradford. Similar slips have also been
issued by the Committee of the Gardner’s Trust for the
Blind, 53 Victoria Street, Westminster. I do not
know of any Trust which fulfils its duties in such an
efficient manner as this Trust. Mr. Wilson, the
Secretary, is always pleased to give advice or help in
any matter concerning the blind, and the prevention
of blindness.

As the Registrar in Bradford is no longer willing to
distribute these slips, the Committee of the Hospital
send some to every midwife working in the district,
and also cards with special directions. These are also
distributed among the out-patients of the hospital.

3. Diseases of the Eye.

A large number of cases of defective"*"vicioi. and
blindness are due to disease of the cornea and other
parts of the eye. Ulcers and inflammation of the

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Sept. 4, 1907.

ORIGINAL PAPERS.

The Medical Press. 24I

cornea (which are very common in children), if neglec¬
ted or not carefully treated, cause opacities, more or
Jess marked. The longer the ulcer lasts and the more
frequently it recurs the more dense will the opacity
become, and the more defective the sight. Every
case which cannot be properly attended to at home
should be at once admitted into hospital. The same
applies to disease of such delicate structures as the
optic nerve and retina. These require most energetic
and careful treatment, and, if neglected, cause per¬
manent blindness. If all these cases which occur in
the homes of the poor (where careful nursing is often
impossible) were admitted into hospital, thousands of
children would be saved from defective vision and
blindness. Unfortunately, however, there is not
enough accommodation in our hospitals. In the
West Riding of Yorkshire, with about 3,000,000 in¬
habitants, there are not more than two hundred beds
available for eye cases, and these are nearly all filled
with operation cases. At the Bradford Royal Eye
and Ear Hospital we have only forty-five beds, and
draw patients from a large part of the West Riding.
Last year 1,100 operations were performed, so that
we had very few beds available for cases of disease.

4. Small-Pox.

7.49 per cent, of the cases of blindness, according to
Magnus, are due to small-pox. Before the days of
vaccination 30 to 40 per cent, of all cases of blindness
were caused by this awful disease. In 1901 no less
than 980 cases of small-pox in children of five to
thirteen years were recorded. Of the 2 30 children who
had been vaccinated (some probably most inefficiently)
•only three died, whereas of the 750 who had not been
vaccinated, no less than 141 died. In spite of these
and many other equally convincing figures, we find
that our wise Government is affording still further
facilities for non-vaccination. Fanatics are allowed
in and out of Parliament to abuse vaccination and
incite stupid and ignorant parents not to have their
children vaccinated.

5. Examination and Care of the Eyes of School
Children.

We now come to the important question of the
examination of the eyes of school children. The
State compels all children to attend school, and it is,
therefore, clearly also the duty of the State to see that
these schools are properly conducted, and that the
children are in a fit condition to make use of them.
All schools should be under medical supervision, and
every child should be examined to see if it is fit to
attend school. Bradford was one of the first to
appoint a School Board medical officer, and Dr. Kerr
was elected. Unfortunately for Bradford Dr. Kerr
was soon called to London as the medical officer to the
London School Board. I hope that everyone present,
who takes an interest in school work, reads Dr. Kerr’s
annual reports to the Education Committee o f the
London County Council. They contain most valuable
and interesting information on the medical aspect of
our schools.

The vision of every child should be tested as soon as
it can read large letters. This can be done by the
teachers. Those whose vision is less than 6/9 should
be examined by the medical officer, and a register kept
of all cases. The parents should then be informed
that the eyes of the child are defective, and asked to
«end it to a doctor, or, if the parents are poor, to a
hospital. According to Dr. Kerr’s statistics no less
than 10 per cent, of the London school children have
defective eyesight. The majority of these cases
require glasses. If the parents neglect to send the
children to a doctor or to provide glasses for them
they should be compelled to do so. Dr. Kerr says that
in London, “ only the minority of these cases secure
any further treatment.” How different it is on the
Continent! At Mannheim, of 250 children whose eyes
were reported as defective, all, with the exception of
nine, had been seen by a doctor within seven days.
Many parents are too poor to buy glasses. These
should be supplied by the local authorities. But they

refuse to do this. The result is that hundreds of
children attend our schools who cannot see well
enough to profit by the teaching. In London a
voluntary association has been formed, and they
supply ordinary spectacles at iod. a pair, about one-
fourth to one-tenth of what is generally charged. It
has always struck me as very absurd that medical
men examine the eyes of the poor at the hospitals
gratuitously, and that these patients often then fall
into the hands of unscrupulous opticians, who make a
larger profit on the glasses than the consultation fee of
an ordinary medical man would have been. A large
number of school children and others fall into the
clutches of advertising quacks, who not only rob them
of their money, but ruin their eyesight by supplying
wrong glasses. In my opinion the best method of
dealing with the children of the very poor would be.
that they be examined at the schools by specially
qualified medical men at the expense of the local
authorities, who should also supply glasses free of
charge when the parents cannot afford to pay for
them.

All children with defective eyesight should be ex¬
amined at least once a year, and a record of each case
kept. This is specially important in cases of shortsight.
or myopia. Often the vision becomes rapidly worse, and
special attention should be paid to these children, to
see that they are supplied with proper glasses, and do
not bend their heads when reading and writing. It is
absolutely scandalous to see how the children sit at
some of our schools when writing. They have their
heads down, nearly touching the desk, often supported
on a band, and held sideways. The desks are fre¬
quently most unsuitable, and the light and ventilation
most defective. Luckily myopia, especially the severe
form, is not very common in England. At the Brad¬
ford Royal Eye and Ear Hospital last year, out of
6,000 patients, 1,720 were far-sighted and only 582
short-sighted, and very few of these were of the pro¬
gressive type.

The points to which I should particularly have liked
to draw attention in this very incomplete paper are :—

1. That in the statistics of blind children we should
also include those with defective sight, certainly those
who cannot see well enough to read ordinary school¬
books, and sub-divide these cases into the following
classes:—

(a) Fair vision up to 6/12.

(b) Weak vision 6/18 to 6/24.

(c) Bad vision or nearly blind, 6/36 to

1/60.

(d) Blind, 1/60 and under.

That in all large schools special classes should be
formed for children with defective vision, and that
they should not be taught with the blind children.

2. All mid wives should be obliged to notify every
case of purulent ophthalmia to a doctor within twelve
hours. Should she fail to do this, her licence should be
withdrawn, and she be fined not less than five pounds.

3. The parents should be warned of the great danger
of purulent ophthalmia, by means of pamphlets or
cards, which should be given by the registrar to every
person who registers the birth of the child. The
midwives should also be supplied with similar cards.

5. Greater facilities should be afforded for the
practical and theoretical teaching of ophthalmology at
our medical schools, and practical and written ex¬
aminations should be made compulsory.

6. Abolition of the conscience clause in the Vaccina¬
tion Act. Punishment of all those who publish mis¬
leading statements on vaccination.

7. The eyes of all school children should be periodi¬
cally examined by an expert. A record kept of all
cases with defective vision, and these to be examined
every year. Parents should be compelled to see that
all such children are treated and supplied with glasses,
if necessary'. The poor children should be examined at
the schools, and supplied with glasses free of charge.

8. Every case of reported blindness should be
examined by a medical man, to see if nothing can be
done to improve the vision.

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242 The Medical Press.

ORIGINAL PAPERS.

Sept 4, 1907.

9. People suffering from hereditary blindness should
not be allowed to marry. No person who has had
syphilis should marry for at least two years after he
has contracted the disease.

CHRONIC SUPPURATIVE DISEASE
OF THE MIDDLE EAR,

WITH SPECIAL REFERENCE TO SURGICAL
TREATMENT.

By E. MALCOLM STOCKDALE, M.R.C.S..

A mutant Surgeon, Liverpool Eje and Ear Infirmary.
Jacobson, in the section dealing with surgical
anatomy in Morris’ Treatise on Anatomy, refers to
otitis media as “ this frequent and fatal disease ; ”
and the statement of Wilde that “ when a discharge
from the ear exists we can never tell how, when,
or where it will end, or to what it may lead,” still
expresses the prognosis. The discharge is a constant
source of annoyance to the patient; and the time
spent in attending for treatment over a long period,
with the expense of drops, lotion, etc., may be a
serious matter to the working-man, so that after a
while he is likely to discontinue treatment, and run
grave risks of developing dangerous complications.

In almost every case this disease has its origin
in the mucous membrane of the nose or naso-pharynx,>
the pyogenic organisms extending to the tympanum
along the Eustachian tube. They may be conveyed
by the blood-vessels, the lymphatics, or may perhaps
spread in the form of a superficial catarrhal inf ani¬
mation. The result of this invasion is that the middle
ear becomes a culture chamber for various bacteria,
the micro-organisms most commonly present being
streptococci, staphylococci, or pneumococci. These
cause local pathological changes, varying in their
nature and extent. The mucous membrane alone mav
be attacked, becoming hyperaemic, oedematous, and
exuding a muco-purulent or purulent dischage,
usually the latter. Later, polypi may form, or the
mucous membrane become pulpy and thickened,
or replaced by granulation tissue. The tympanic
membrane may be destroyed, the ossicles shed, the
labyrinth be invaded, and caries or necrosis of parts
of the temporal bone may also occur. In certain cases
the disease may remain localised to the tympanum,
but in almost all, the mastoid antrum sooner or later
becomes involved.

Again, the mastoid antrum may be seriously diseased,
but the tympanum not damaged beyond recovery.
Relating to the extent of the destructive changes
produced, the virulence of the infection is often a
more important factor than the duration of the sup¬
puration. Cases developing during an attack of
scarlet fever are frequently of a severe nature.

The type of case which I wish to discuss is that in
which the chief symptoms are a purulent discharge
of some duration from the external auditory meatus,
with more or less impairment of hearing, and some¬
times pain. In cases of this nature, are we to stand
by until urgent symptoms or dangerous complica¬
tions arise; or. finding conservative treatment
of no effect, shall we interfere ? I am convinced
that when the charge persists in spite of antiseptic
treatment carefully carried out (the nose and naso¬
pharynx having received attention if necessary),
surgical interference is called for. We should not
wait till the mucous membrane lining the tympanum
or mastoid antrum is disintegrated, and perhaps the
hearing destroyed.

When should operation be advised ? The viru¬
lence of the infection and the nature of the lesion
present are the factors in deciding this question, but a
discharge lasting three months under conservative
treatment usually calls for surgical assistance.

What form of surgical procedure should be employed ?
Before a definite answer can be given, it is necessary
to ascertain as far as possible the character of the
pathological changes present. The following points
should be investigated :—

(1) The condition of the tympanic membrane;
(2) the presence or absence of the ossicles ; (3) the
presence or absence of granulations or (aural) polypi;

(4) the amount and character of the discharge;

(5) whether caries or necrosis exists. Since the char¬
acter and position of the chief lesion varies, the nature
of the operation required can only be decided after
investigating the local condition. If the disease is
localised to the tympanum, and can be dealt with
efficiently through the external auditory meatus,
there is no object in opening the mastoid antrum,
nor should removal of the ossicles and drum membrane
be undertaken if treatment of the antrum alone
would lead to recovery.

The chief operative measures at our disposal may
be considered under the following headings :—.

(1) Intra-meatal, which are performed through
the external auditory meatus.

(2) Post-aural, in which an incision is made behind
the ear and the soft parts drawn forwards.

Intra-meatal Operations. —Aural polypi are best
removed by means of a small snare, carrying a fine
pliable wire. The loop should be passed over the
polyp and gently manipulated towards the root of the
pedicle, which should be cut through, as roughly
tearing the growth away may cause serious damage,
since it is impossible to predict its point of attachment.

Granulations projecting through a perforation in the
tympanic membrane should be removed by means
of a small aural curette, the field of operation being
clearly illuminated, so that each movement of the
curette is clearly observed and has a definite purpose.
Removal of polypi or granulations will often arrest
the discharge and effect a cure. The following case
is of interest in this connection. ^

A man, aet. 29, had suffered from otorrhoea and
deafness of the left ear for eight months. One evening
he coughed and something was discharged from his
ear, followed by haemorrhage. He carried the speci¬
men to his medical adviser (Dr. Holmes, Anfield),
who informed him that it was a polypus. When I
examined him six days later his ear was dry and the
perforation in his tympanic membrane appeared to be
healing. A fortnight later no perforation could be
seen, and his hearing was greatly improved by inflation
with the Eustachian catheter. He has apparently
cured himself, having discharged his polyp by a
forcible inflation through his Eustachian tube. Still
operating through the meatus, ossiculectomy calls
for notice.

Ossiculectomy .—Excision of the tympanic membrane,
the malleus, incus, and perhaps the outer wall of the
attic, with the removal of any granulation tissue,
is of value in some cases, being a much less severe
procedure than any post-aural operation, but its
application appears to me to be limited, since in
almost all cases of chronic suppurative otitis media
the mastoid antrum is involved, and in many the
ossicles have been previously lost, as a result of the
suppurative process. My experience of this operation
is limited to four cases. In those selected the dis¬
charge was small in amount, the tympanic membrane
thickened, and the hearing greatly impaired. The
discharge has been arrested in all. and in two the
hearing is somewhat improved.

k iOST-AURAL OPERATIONS.

Heath's Operation .—In the Lancet of August nth,
1906, under the title of ” The Cure of Chronic Sup¬
puration of the Middle Ear without removal of the
Drum or Ossicles or Loss of Hearing,” Mr. Charles
Heath, of London, described an operation and pub¬
lished the result in ten cases. In all. the hearing
power was improved. Briefly stated, the opening and
final stages of this procedure are similar to the radical
mastoid operation, the essential points of difference
t being that the tympanic membrane, ossicles, attic,
and antro-tympanic passage are left intact. Details
of the after-treatment are given.

The title of this paper might convey the impres¬
sion that the removal of the ossicles and tympanic

Sept. 4, 1907.

ORIGINAL PAPERS.

The Medical Press. 243

membrane results in loss of hearing. This, how¬
ever, is not the case, excellent hearing being
retained if the receptive mechanism is in sound
condition. It has even been suggested that the
ossicles and tympanic membrane are chiefly pro¬
tective in function, the conduction of vibrations
being of secondary importance. Heath’s operation
commends itself to me as valuable in those cases
where the tympanum and antro-tympanic passage are
not seriously disorganised, the chief seat of the sup¬
puration being in the mastoid antrum. My experi¬
ence of this operation is limited to two cases, as in
most of those placed under my care the ossicles had
already been lost, or the lining membrane was so
diseased that the radical operation appeared necessary.

Case I.—R. R., boy, zet. 4 years; discharge from
right ear three years ; commenced during an attack
of measles. Hearing ? Heath’s operation, Novem¬
ber, 1906. Antrum found to be very large, and
communicated with some superficial mastoid cells.
The antro-mastoid cavity was filled with stringy pus.
Last seen, March 1st, 1907. Soundly healed. Hearing
good. Watch 12*.

Case II.—E. J., a girl, xt. 10, was admitted to the
Liverpool Eye and Ear Infirmary on May 7th, 1906, with
a history of suppuration in the right ear for two years;
temperature ioo°, and pulse 126. She had a cough,
was emaciated, and looked very ill. After a week
in the infirmary patient was discharged, as her condi¬
tion suggested advanced phthisis. Eight months later
the girl returned, being in better health, but still
suffering from a profuse discharge and severe pain at
times.

As no abnormal signs were now detected in her
chest. Heath’s operation was performed in January,
1907. When last seen her ear was soundly healed,
and she could hear my watch readily at 20’ in
a somewhat noisy out-patient room, which is
excellent hearing. I am inclined to think that the
condition supposed to be phthisis was probably an
attack of septic pneumonia secondary to the disease
in the ear. Skin-grafting was not necessary in either
case. I may perhaps here be permitted to mention
that I have recently employed Heath’s method in two
cases for the treatment of acute suppurative disease
of the mastoid cells and antrum, and think that the
operation will be useful in these cases.

The Radical Mastoid Operation. —This operation is
indicated when the disease is of an extensive and
destructive nature leading to disorganisation of the
mucous membrane lining the tympanum and mastoid
antrum, or caries or necrosis in the deeper parts of the
bone, and when other methods of treatment have
failed. Subsequent skin-grafting by Thiersch’s me¬
thod, although not always necessary, is of the greatest
value when the exposed granulating area of bone
is extensive, as occurs when the mastoid antrum
is large and its lining membrane destroyed, many
months of troublesome after-treatment being avoided
by its adoption. The grafts may be introduced
through the post-aural wound or the enlarged meatus,
according to circumstances. In the case of a boy
who happened to be a bleeder, I used frog-skin with
an excellent result. During the past two years it has
fallen to my lot to perform the radical mastoid opera¬
tion at the Liverpool Eye and Ear Infirmary on sixty
occasions. In this consecutive series of operations
two marked anatomical variations were met with.
In one, the lateral sinus was very superficial and
situated immediately behind the posterior wall of the
meatus,—the bone in each position being less than
I-inch in thickness, and the bony meatus small. In
this case the difficulty in obtaining sufficient room to
use even a small gouge was so great that I performed
the whole operation with a small burr, driven by an
electric motor. In the other, the mastoid antrum
was absent, but below the Fallopian canal there was
a deep recess, which has been termed by Mr. Ballance
the fossa of the aqueduct. Attention was drawn
to the importance of this fossa in a paper on the
“ Surgical Anatomy of the Temporal Bone,” read at
a meetinv of this Society a few years ago by my friend

and colleague Mr. Hugh E. Jones. On this patient
I performed my thirty-seventh radical operation ;
and being unable to find the antrum in the ordinary
way, introduced Stacke’s protector into this fossa,
thinking it to be the antro-tympanic passage, cut
down upon it, and injured the facial nerve. I have
since ceased to use this instrument.

Facial Paralysis. —The abnormal condition I have
just described occurred in a man aet. 38 years of age.
He had suffered from a purulent discharge from the
left ear for nine years, with frequent severe attacks
of pain which kept him awake at night. His discharge
and pain have been cured and his hearing improved,
but he has facial paralysis as a result of the operation.
However, the fact that chronic suppurative disease
of the middle ear often leads to paralysis of the facial
nerve must not be overlooked, since in five patients
it was present from this cause when they first applied
for treatment, and one developed it as a result of the
disease while under treatment. Of these six patients
in whom the nerve was involved by the disease, one
had recovered completely three months after the
operation, and a recent case is steadily improving.

Two cases, when last seen, were in statu quo in
one the greater part of the cochlea was removed as a
sequestrum. The fifth case I mention occurred in a
baby eight months old. It was first seen in November,
1906, and had suffered from a discharge from the left
ear for seven months; this was profuse and very
offensive.

Exploration revealed the fact that almost the whole
of the mastoid and petrous portions of the temporal
bone were necrosed. Removal of the dead bone
brought into view an extensive surface of dura mater
covered by unhealthy granulation tissue both in the
middle and posterior fossae. A considerable portion
of the lateral sinus was exposed, and the internal
carotid artery could be seen as it descended to enter
the cranial cavity. I am afraid the prognosis here is
not favourable as regards the nerve. In the sixth
case the operation was only undertaken a week ago,
so that it is too early to expect recovery.

In considering the risk of life from direct extension
of the disease, I find that in five cases the lateral sinus
was already laid bare, and septic phlebitis might
have originated at any moment. For infection of the
sinus to occur, however, it is not necessary that it
should be directly bathed in pus, as septic organisms
may extend to it along small veins in the bone. In
another case the roof of the antrum was perforated,
the aperture leading to a small extra-dural abscess
in the middle fossa.

THE EFtECTS OF THE DISEASE AND OF THE RADICAL
MASTOID OPERATION UPON THE HEARING.

In a large proportion of cases, chronic middle ear
suppuration leads to a considerable degree of deafness.
Two patients in this series were deaf and dumb as the
result. I have previously mentioned the fact that the
loss of the drum membrane, with the malleus and
incus, does not necessarily cause deafness. On the
other hand, removal of these may lead to a marked
improvement in the hearing. My observations of
the effect of the radical mastoid operation upon the
hearing have been most encouraging. In a large
majority the hearing has been improved by the opera¬
tion, and in many cases to a marked extent. In only
one case do I find a note that it was made worse,
the extent being slight—a diminution of as tested
by my watch. Discharge thirty-eight years.

Does the operation lead to a complete and per¬
manent arrest of the discharge ; and if it fails in this
respect, where is the seat of suppuration ? I will
admit that discharge may be met with after the
radical operation, and proceed to enumerate the
causes I have met with :—

(1) Faulty operation or faulty after-treatment;

(2) Inflammatory exudation from the Eustachian tube ;

(3) Omission to skin-graft when the raw area is exten¬
sive ; (4) Ulceration of weak cicatricial tissue.

Since the above can be prevented or treated, the
final result should be a complete arrest of the discharge.

Digitized by GoOgle

244 The Medical Press.

ORIGINAL PAPERS.

Sept. 4. 1907-

When the radical operation has been successfully
performed and the after-treatment efficiently carried
out, the patient derives the following advantages :—
(1) Freedom from the ever-present risk of dangerous
complications, such as meningitis, pyaemia, or brain
abscess; (2) Arrest of a troublesome and often offen¬
sive discharge; (3) Freedom from attacks of pain
(which are common); (4) Freedom from the risk
of involvement of the facial nerve; (5) and lastly,
my investigations show usually a considerable improve¬
ment in the hearing ; and where this does not ensue,
I hope its further destruction is prevented. I am
inclined to think that when suppurative inflammation
of the middle ear has resisted conservative treatment,
the risk in every respect of allowing the disease to
run its course is much greater than the risk of even
the complete post-aural or radical operation ; and,
further, that if all cases of suppurative otitis media
were carefully treated from the onset, the number
of cases requiring this operation would be considerably
diminished.

ON PHYSIOLOGICAL SINS AND A
HEALTH CONSCIENCE (a)

By J. C. McWALTER, M.A., M.D., D.P.H.,

B&rrlster-at-Law.

By a physiological sin we understand a breach of
the laws of health, and by a “ health conscience,”
we mean a habit of thought which induces us to obey
the dictates of right reason on matters which concern
the health of the community. The stern and awful
voice of duty has hitherto only been listened to in
the moral domain, and has been supposed to have no
jurisdiction in purely physiological phenomena, but
we now begin to see the imperative necessity of
recognising the teachings of science as they point the
means of elevating the physical well-being of a whole
people. Because deflections from the laws of health
i nvariably bring their own punishment there has been
rather a tendency to sympathise with the offender
as one from whom payment to the full would be exacted
—as an unfortunate fleeing from a Nemesis sure to
overtake him—as a debtor pursued by a merciless
creditor certain to exact punishment. The opinion
prevailing is that such a one has done what is foolish,
rather than what is wrong, and is imprudent, but by
no means evil. It now becomes necessary to make
it realised that a physiological sin—an infraction of
the law of health is not merely the unwisdom of the
individual, but an outrage on the community—not
simply a matter of individual interest, but an offence
against the general well-being. As such it is an offence
against society—an anti-social act—and must be pun¬
ished either by municipal law or by the censure of
every right-thinking person. It is obviously an im
portant element in the training of the young that they
should be taught to recognise not only what is morally,
but what is physiologically wrong, and that they
should be encouraged to develop a health conscience
to warn them against offences in sanitary matters as
well as an ethical sense.

Idleness may be an ethical sin, but it is a physiological
sin to work when fatigued. Mental work uses up the
energy of the nerve cells, and fatigue follows. “ Fatigue
in every shape,” says Ribot, “ is fatal to memory.”
The impressions received under such conditions are
not fixed, and the reproduction of them is often im¬
possible. When an organ is over-active, its nutrition
suffers, and halts, and fatigue ensues. When the
normal condition is restored memory comes back.
Over two thousand years ago Plato taught that in
mental matters the half might be greater than the
whole. We now find that in elementary schools
“ half-timers ” progress quite as much as those who
attend full time. Chadwick insists that children from
eight to ten should work only about three hours daily,
and those from twelve to fifteen six hours. I submit

(a) Paper read before the International Oongrew of School Hygiene
at London, Aagoat, 1907,

that to make a child of twelve or fourteen years submit
to six hours mental study daily is a physiological sin.
It is far too much. Fatigue, as Beech points out,
rapidly passes into exhaustion. There is soon loss of
force, both physical and mental, and action is less
easily excited through the senses. Irregular movements
will occur, the fingers will twitch when the scholar
holds the pen, and he becomes not only fidgety, but
nervous and peevish. His eyebrows are corrugated
and he is puffed under the eyes. He is slow in his move¬
ments, and in his physical activity. His face lengthens
through relaxation of the muscles, sighing and yawning
set in, his speech is slow and his voice weak. Plainly,
it is a physiological sin to let such an individual work
at his lessons. He must have fresh air, and sunlight
and rest.

Scrofulous children, and those of consumptive
parents are often apt to learn ; they are quick, sharp,
and clever. But it is a sin, in our sense of the word, to
do so—they must be pushed back, not forced on. We
are sometimes told by a medical pedant that there
is no such thing as the " brain fever ” which novelists
and mothers speak of. This is mere playing with
words, such children get meningitis and die of it, and
the common prejudice which used to exist against
forcing precocious children is only too well founded.
Hundreds still die every year from premature mental
strain. To deprive growing boys and girls of sufficient
sleep is another physiological sin. It is greatly doubtful
if a boy or girl can sleep too much ; it is positively
certain that thousands of unfortunate young people
have died the victims of the “ early to rise ” proverb.
Dr. Duke says that a boy of ten should get eleven
hours daily sleep, and a boy or girl of thirteen years,
ten hours. This rule I submit should be amended by
adding that if they want more they should have it.

Again, it is a physiological sin to build a school, or
to inhabit one, on a clay soil. It is wholly dangerous
to children of a rheumatic, gouty, or consumptive
tendency. A gravel soil should be selected when
possible. I am wickedly tempted to think that it would
be a good thing if a boy who for years has spent his
days with mouth open, and his nights snoring, and
who has been the victim of chronic headache and the
butt of everybody for his stupidity, were to shoot his
parents when he grows up and finds himself deaf and
useless, and hears that he could have been cured if
his mother had troubled to bring him to a surgeon to
get his adenoids removed in time. Ideas of parental
duty are being rapidly recast and fathers and mothers
who are now inclined to deride us as faddists because
we insist on medical inspection of schools and scholars
will shortly be called on to render a terrible account
to their offspring if they find themselves the victims
of defects of vision, or hearing or health, or of deformity,
which the parents could have had corrected if they
had listened to our warning in time. Nothing is more
certain than that in a few years children will demand
satisfaction from their fathers for every evil or incon¬
venience from which they suffer, and which might
have been averted by timely care.

Fifty years ago Herbert Spencer spoke with wonder
chastened with admiration of a friend of his, a physio¬
logist, who declared that his children should be taught
nothing until they were eight years of age. We have
during the half century tortured and killed hundreds
of thousands of children by sending them to school
at three and four and five years, and yet we insist on
a still larger holocaust of victims before we will be
convinced of the folly of our acts. Still, we have learned
something from those hundred of thousands of victims,
and it is now scarcely necessary to argue that it is a
physiological sin to send a child of three or four, or
five years to school; seven years ought to be the lowest
limit, and up to that age the whole energy of the
parents ought to be expended in making the child a
healthy little animal. If it is ill-behaved all the better.
It is simply wicked to punish the natural instincts of
young children in order to make them behave.

It is a physiological sin to make boys and girls keep
quiet unduly much. As motion is the only means of
i practising anything, it ought to be encouraged.

Sept. 4.1907.

ORIGINAL PAPERS.

The Medical Press. 245

Motive action should be cultured and directed to defi¬
nite ends. As children grow older ideal suggestions
have more force so that the memory image of a move¬
ment is apt to produce the movement itself. Fletcher
Beach shows that children can control the muscles of
the limbs before those of the fingers, and it is cruelty to
force a child to write before it attains control of the
limb muscles. There is now less need than formerly
to insist on the physiological wickedness of long
hours of study ; the mind like the body, can only
assimilate at a certain rate, and if you drug it with
facts faster than it can assimilate them they are soon
rejected. Much of the honour for bringirg about a
clearer vision as to the folly of the older system of
protracted study is due to Herbert Spencer, who so
eloquently exposed the fallacy where he says :—

" Once more, the system is a mistake, as involving
a false estimate of welfare in life. Even supposing it
were a means to worldly success, irstead of a means
to worldly failure, yet, in the entailed ill-health, it
would inflict a more than equivalent curse. What
boots it to have attained wealth, if the wealth is ac¬
companied by ceaseless ailments ? What is the worth
of distinction, if it has brought hypochondria with it ?
Surely no one needs telling that a good digestion, a
bounding pulse, and high spirits, are elements of happi¬
ness which no external advantages can out-balance.
Chronic bodily disorder casts a gloom over the brightest
prospects, while the vivacity of strong health gilds
ever misfortune. We contend, then, that this over¬
education is vicious in every way—vicious, as giving
knowledge that will soon be forgotten ; vicious, as
producing a disgust for knowledge ; vicious, as neg¬
lecting that organisation of knowledge which is more
important than its acquisition ; vicious, as weakening
or destroying that energy without which a trained
intellect is useless ; vicious, as entailing that ill-health
for which even success would not compensate, and
which make failure doubly bitter.”

In avoiding one physiological sin we fall into another.
So soon as it had been drilled into the dull head of
the British parent that an excess of mental work was
a mistake, that there was much to be said in favour of
play—that all natural instincts, and all pleasure-giving
instincts subserve a useful purpose—he proceeded
with the zeal of a proselyte to go in for games in the
schools, but instead of letting the lads have whole¬
some play he exorcised the greater part of its joy and
benefit by converting exercise into a formal and rigid
system of gymnastics. Happiness is the most powerful
of torics, and though in a measure gymnastics are
good, and far better than study, for children, they
lack that spontaneity and agreeable excitement which
gives so much value to play. The riotous glee of
children at their games cannot be re-placed by carefully
graded gymnastics.

The feeling that girls should not indulge their sportive
instincts as freely as boys is gradually dyirg out, but
many prejudices against it still prevail. Nothing is
so baseless as the view that games indulged in by the
natural instinct of girls, and not forced upon them,
tend to give rise to unladylike habits. On the con¬
trary, experience proves that they lead to a more
harmonious development of the female organism,
and that the finest female characteristics follow the
development. As Spencer finely says, whoever for¬
bids girls the sportive exercises prompted by Nature
forbids them the divinely-appointed means to physical
development. One might go farther, and proclaim
that it is a physiological sin to forbid a child anything
which it wants to eat or drink. Instinct is a perfect
guide in the lower animals—it is unerring in infants—
it is always useful in invalids ; it is seldom unsafe in
adults leading an ordirary life, and why should we
deem it bad for growing boys and girls ? Our fore¬
fathers had a rough general rule that natural instincts
were the results of some inherited vicious trait and
ought to be checked or denied or extirpated. It
was an article of faith that sugar was bad for children,
that they should behave and keep quiet, and that
the wisest man was he who kept children under the
most severe control. Now we know that the desire

of young people for sugar is most useful for their nutri¬
ment, that it is a blunder to obliterate natural in¬
stincts, and that excessive control is most injurious
in its after effects, but we hesitate to proclaim the
great truth of which these are particular instances—
namely, that all the desires of children are good, and
that none of them should be stamped out, but merely
subjected to some control.

We are told on authority that the effects of casual
repletion are less prejudicial, and more easily corrected
than those of inanition, and that excess is the vice of
adults rather than of the young, who are seldom
epicures. The passion for meddlesome mis-govemment
finds an outlet in the nursery when it can be effectually
resisted elsewhere.

The laws of health must be recognised before they
can be conformed to, and hence the imparting of a
knowledge of the laws of health is a necessity for a
more rational method of teaching and living. Full
robust health is the surest pledge of happiness, and none
can hope to enjoy it who have not some inkling of its
rules. These have not been taught hitherto in the
schools, those who have learnt them have picked up
their information in various by-ways and comers apart
from the orthodox sources. The time has come for the
creation of a national health conscience for the uni¬
versal recognition of the duty of every man not to
injure his neighbour in health no more than in purse.
If the functions of a health conscience were recognised
we should not have one person insisting that the win¬
dow of the tram or train be closed, lest he should get
cold, whilst half a score of others are suffocated or
diseased for want of fresh air. The Public Health
Acts make it penal for persons who suffer from scarlatina
or the like, to travel on public vehicles, but those who
have influenza or consumption may be much more
dangerous and these travel at will. Many travellers
complain that the American laws against expector¬
ation amount to a perfect tyranny, but unless the
health conscience of our people protects them against
indulgirg in this disgusting vice for the future, we must
have as drastic laws for this country. Another plague
which would be exterminated if the health conscience
existed is that of ringworm and the allied skin diseases
which are the bane of every school. Let a mother’s
children get ringworm or whooping cough, or measles,
or any ailment reputed “ catching,” and she is per¬
fectly indifferent if every other child in the town
gets the same—in fact, she not only invariably blames
the school, but she feels rather a grievarce if the
other school children escape the maladies. She will
further exhibit the utmost ingenuity either to keep
her affected children at school, or at least to send them
back before they cease to be sources of danger to
others. That a grave obligation exists in every family
and on every individual not to propagate to others
the disease from which they suffer is a truth which
must be instilled into the mind whilst it is still young
and impressionable. And finally, as there are physio¬
logical sins against individuals, those also commit a
physiological sin against the State who fail to rear a
healthy stalwart race to succeed them. To bring to
the country’s service a large and healthy family is
not only to discharge our duties to posterity, but is
a proof of clean living, and high thinking and fine
ideals. Year after year the Registrar-General's returns
bring irrefutable evidence of an almost widespread
desire for this obligation to be shirked, and morally
it is a pressing duty on every educational system to
instruct each rising generation on the nobility of
paying this debt.

OPERATING THEATRES.

ROYAL FREE HOSPITAL.

Cholecystectomy. —Mr. Joseph Cunning oper¬
ated on a woman. *t. 56, who had been admitted
with the following history : For twenty years she had
suffered from attacks of pain in the region of the gall
bladder. |Two of these attacks of pain many years

Sept. 4 , 1907-

246 The Medical Press. TRANSACTIONS OF SOCIETIES.

ago were evidently typical biliary colic, but the later
attacks of pain were of a different nature ; that is
to say she had attacks of pain, vomiting, and consti¬
pation, lasting for several days, which were evidently
attacks of localised peritonitis. The last attack had
laid her up for three weeks. Another point in the history
was that she had never been jaundiced. Her symp¬
toms since admission consisted only of tenderness on
pressure in the neighbourhood of the gall bladder.
Mr. Cunning, before operation, pointed out that the
patient’s present condition, together with her previous
history was sufficient to diagnose the presence of a
gallstone, without any history of attacks of biliary
colic or of jaundice, for, if there was one large stone,
there was no possibility of its getting into the cystic
duct, and thus producing colic, or of its blocking the
common duct and thus giving rise to jaundice ; every¬
one nowadays admits, he said, that gall stones are a
result of a catarrhal infective inflammation of the
mucous membrane of the gall bladder, the presence
of a stone in the gall bladder having pathologically
the same effect as a concretion in the appendix, that
is to say, the stone produces ulceration of the mucous
membrane, so allowing bacterial invasion of the walls
of the gall bladder and attacks of localised peritonitis,
which may be either adhesive or suppurative, just as
is the case when there is a concretion in the appendix.
Further, even if there are multiple stones in the gall
bladder and the cystic duct is narrowed or-obliterated,
there need be neither colic or jaundice ; but if there
had been definite attacks of pain and rigidity in the
neighbourhood of the gall bladder associated with
vomiting and constipation clearly indicating localised
peritonitis, the surgeon was bound to recognise the
presence of gall stones. The abdomen was opened
through the right rectus by an incision six inches in
length ; the gall bladder was at once seen to be densely
adherent to the liver, omentum and transverse colon-
Packing was put in to protect the rest of the abdominal
cavity, and the adhesions were with difficulty separated.
During this process a fistulous communication between
the fundus of the gall bladder and the transverse
colon was exposed, and separated from the gut by
excising a portion of the intestinal wall and stitching
up the opening. Deeper down between the gall
bladder and the duodenum the cheesy remains of an
old abscess cavity were discovered. The peritoneum
on the sides of the gall bladder was now incised and
reflected so that with the finger the gall bladder could
be stripped from the liver. The cystic duct was next
isolated, clamped in two places and divided, and the
gall bladder now being free was removed ; the stump
of the cystic duct was then ligatured. A drainage
tube was then passed down to the site of the duct in
case any leakage should occur and gauze was packed
round it. The abdominal wall was stitched up in three
layers, leaving just sufficient room for the tube and the
gauze to project at the upper end. Mr. Cunning
remarked that it might have been seen that a pillow
was placed under the lower part of the thorax before
the commencement of the operation to throw the upper
part of the abdomen forward ; he considered this an
important point in the technique of gall bladder surgery,
for it brings the parts concerned in the operation so
much better into view. Another point in the technique
of the operation, he said, was not demonstrable in
this case, that is rotation of the liver : if the right lobe
of the liver is grasped and pulled up through the wound,
so as to rotate the liver on its attachments, the gall
bladder and the cystic ducts are brought prominently
into view; in this case there were so many adhesions
about the right lobe that rotation was impossible.
He preferred cholecystectomy to drainage of the gall -

bladder as the operation of choice when there was no
blockage of the common duct, for it removes a diseased
structure, and so prevents the possibility of the further
formation of stones and the possibility of a fistula
remaining after drainage. Again, it was not safe to
drain a shrunken gall bladder, owing to the difficulty
of bringing it near the external wound. The circum¬
stances,he thought,under which the surgeon would prefer
drainage to cholecystectomy were: if he had unskilled
assistants, or if the patient were very fat; here the
depth of the wound is so great that it is safer to drain
rather than to excise the gall bladder. On opening the
gall bladder which had been removed from the patient
just operated upon, its walls were seen to be a quarter
of an inch thick, the cystic duct was obliterated and
there was one large single stone which was facetted.
The explanation of the facetting and the singleness
of the stone was accounted for by the presence of the
fistulous communication between the gall bladder and
the colon clearly showing that one or more gall-stones
had escaped by that route; the one found in the gall
bladder being about the size of a walnut had evidently
been unable to escape into the colon. A little bile
leaked from the wound during the first two days ;
this probably came from the raw surface of the liver,
from which the gall bladder had been detached. Ten
days after the operation the wound was soundly healed,
and the patient going on well.

TRANSACTIONS OF SOCIETIES.

NEW SYDENHAM SOCIETY.

Forty-eighth General Meeting, held in Exeter
on Thursday, August ist, 1907.

Dr. Osler in the Chair.

The report and balance-sheet for 1906 were pre¬
sented. The report concluded with a recommendation
from the Council that the Society should not be con¬
tinued beyond the end of the current year.

In response to a request from the Chairman,
Mr. Hutchinson said that, though he had himself
written the report adopted by the Council, he was not
wholly in accord with the recommendation that the
Society should wind up its affairs. There were still
nearly 900 members, and his sympathies went with
the proposal that the Society should continue its work
with certain modifications. He would propose to pub¬
lish every year a volume of clinical lectures, snort
monographs or papers, translated from foreign sources,
as promptly as possible after their original issue. The
work of abstract-making which the Society’s Y'ear-
Book used to accomplish was now exceedingly well
done in the medical journals, but not a few of the
papers with which medical literature now teems were
well worthy of reproduction in full, and a valuable
and attractive annual volume might be thus con¬
structed. Secondly, he would like to see the Atlas
continued, but with plates reduced in size and w’ith
less letter-press. It should copy nothing and produce
only original illustrations of new subjects. It might
suitably treat the subjects comprised in the volume of
translated monographs. It might also undertake to
reproduce selected drawings from among those exhi¬
bited at the annual meeting of the British Medical
Association, and for this it might venture to ask for
a subsidy. It might also come to an arrangement with
the Royal Society of Medicine to publish some of the
plates accompanying papers read before the Society,
thus giving them a wider circulation and at the same
time enriching the Atlas. It might be worth a thought
whether a remodelled Society might not become more
international in character, and enter into close relations
with all English-speaking communities. He much
hoped that the Society would not be given up, but that
it should be remodelled somewhat on the above lines.

Dr. Leon proposed that a circular be sent round to

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Sept. 4, 1907.

CORRESPONDENCE.

The Medical Press.

247

the members, in which they should be asked whether
they were in favour of the recommendation made by
the Council that the Society should not be continued
beyond the end of the current year, or of carrying cn
the Society on the lines suggested by Mr. Hutchinson.
This was seconded by Fleet-Surgeon Bassett, and
carried unanimously.

Dr. Baildon then urged that, in view of the im¬
portance of this step, it would be well that a statement
of the outstanding liabilities and of all the assets of 1
the Society should accompany the circular. This was
seconded by Dr. Gibson, and carried.

Dr. Coombes proposed that the statement should be :
made by a chartered accountant. This was seconded
by Dr. Gibson, and carried.

Mr. Power pointed cut that many subscribers were j
more than satisfied with the atlas, and that some had
paid for several years in advance.

Dr. Russell drew attention to the fact that the
income of the Society had steadily diminished for
several years past. There was unfortunately no indi¬
cation of any recovery, as a large number of resigna¬
tions had been received this year. At the present
moment the Society was solvent, and if no further
diminution in its members occurred, it could just be
carried on, but with any further shrinkage a deficit
would have to be faced, or its output would have to
be diminished.

The meeting terminated with the usual vote of
thanks.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Pari*. Sept, let, 1907.

Abortion.

It is not always easy to make a correct diagnosis
of abortion, certain circumstances, more or less
frequent during the first two months, where the
existence of pregnancy cannot be affirmed, may
present themselves, and the question arises as to
whether the case is really one of miscarriage or due
to some other cause producing the symptoms ob¬
served. The diagnosis becomes thus very difficult,
as no certain sign of gestation is observed, nor the
usual symptoms generally accompanying the accident.

It is frequently thus with women who menstruate
irregularly, or who become pregnant during the
period of nursing, and who cannot reckon on the
cessation of the menses. Sometimes also, local
examination is rendered very difficult by the presence
of subcutaneous abdominal adipose tissue.

In abortion the haemorrhage, say Lepage and
Ribemont, generally precedes the uterine contraction ;
the os presents certain modifications, it is patent,
softened, and the clots are abundant. In dysmenor
rhoea the pains precede the flux, the os is closed, the
uterus is small.

In cases of fibroma complicated with metritis the
diagnosis is almost impossible, at least for some time.

The question, has abortion taken place, appears
simple enough at first sight, but it is not always
easy to solve it, and even frequently impossible.

In the third or fourth month an error is impossible
if the foetus can be obtained ; but in the first weeks
the ovum is so small that it passes unperceived in
a large number of cases. The majority of women
believe simply in a more or less turbulent return of
the menses which had been retarded. On the other
hand it frequently happens that before the doctor
has arrived, everything has been thrown away ;
clots and membranes, or the patient, seized with
an imperious need to go to the lavatory, allows
the whole mass to escape without paying much
attention. The difficulty is still further increased
from the fact of the death of the foetus and its more
or less prolonged retention in the uterine cavity.

Even when the physician has the parts under his
eyes, it is often difficult to pronounce during the

five or six weeks of gestation on account of the small
volume of the ovum. The clots and different dfebris
should be carefully examined under a stream of water
and, where possible, the microscope should be em¬
ployed, especially where the question is one apper¬
taining to medical jurisprudence.

It is not always easy either to know if the abortion
is complete, for the reason already given, but the
general retention of the whole or of a part of the
placenta may be inferred where the haemorrhage
persists when the uterus remains voluminous, and
a priori when the finger can feel a portion of the
placenta in the interior of the uterus.

The four great causes of abortion are:—Criminal
manoeuvres, syphilis, albuminuria, and vicious insertion
of the placenta. Criminal abortion is difficult to
determine and as admission is not easily obtained
it can be only suspected. When it is of syphilitic
origin the foetus is expelled dead and macerated.

If albuminuria is the cause the placenta presents
haemorrhagic spots and the urine contains albumen,
there are signs of nephritis. In case of vicious in¬
sertion of the placenta recurrent haemorrhage is
observed, and the examination of the membranes
will reveal the insertion on the inferior segment.
The prophylatic treatment of threatened abortion
needs no comment: rest in bed, opium by the mouth
! or by the rectum, viburnum prunis folium, ten drops
| of the tincture five times a day.

I Where the miscarriage is unavoidable, where the
i haemorrhage persists, the contractions continue, or
1 the membranes axe broken, or the foetus is dead,
j the case should be treated as an ordinary confine-
I ment—disinfection of the external organs, antiseptic
! injections, and an antiseptic compress over the vulva
1 and events awaited. Several complications are
adherent to cases of miscarriages.

At first the haemorrhage may be so intense that
the life of the patient is threatened. If the ovum
is intact and uterus closed the vagina may be plugged
with antiseptic gauze for eight or ten hours. This
plug excites by its presence the uterine contractions,
and it is not rare to find behind it, when withdrawn,
the ovum or the foetus, the placenta being retained.

The ovum may be infected, although it may be
intact, and here the plug can be used in provoking
contraction. But if no result is obtained at the end
of some hours, the patient should be chloroformed,
the vagina disinfected, the os gently dilated and
the uterus evacuated by digital curettage and ab¬
dominal expression.

Abundant and repeated hemorrhage after expulsion
of the fcetus may be also treated by the plug, but it
is frequently badly done and inefficacious, allowing
the hemorrhage to continue behind it, retaining
the clots and favouring infection.

To obviate this inconvenience, Auvard recommends
intra-uterine plugging, which can render service in
cases of extreme urgence, or where the patient is so
weak that she is unable to support a curettage. Other¬
wise this .method should be rejected as it might be
the cause of accidents: digital curettage is much pre¬
ferable, it suppresses the haemorrhage by emptying
the uterus and affords complete security.

Where the placenta is partially detached, or
has fallen into the vagina, one is tempted to extract
it either with the fingers or with a forceps, pulling at
it with the hope of taking it out. Such a practice
is reprehensible unless the operation is fully com¬
pleted. Otherwise the placenta is broken and the
haemorrhage continues to endanger the life of the
patient.

Frequently the placenta is retained after the fcetus
is expelled with no other complications, neither
haemorrhage nor infection. Under such circum¬
stances, expectancy is the rule. In the majority
of cases, at the end of some hours the contractions
recommence and the placenta is expelled.

The limits of this expectancy are difficult to deter¬
mine ; the placenta can remain several weeks in the
uterus without provoking any infection and is finally
expelled. In any case if it is decided to await events,

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248 The Medical Press.

CORRESPONDENCE.

Sept. 4, 1907.

the patient must be subjected to constant surveillance,
the temperature taken morning and evening, vaginal
antiseptic injections ordered, and everything held in
readiness for artificial delivery in case of infection.

Even in cases where there is neither fever nor
haemorrhage prudence commands that the placenta
should not be left in the uterus more than four or five
days. The two methods employed for extracting
the organ are instrumental and digital curettage.
Each of them has its partisans and adversaries.
Some prefer the curette during the first two months
because the uterus is not much developed, the walls
are sufficiently resisting, that there is no danger of
perforation, that it is easier to penetrate the uterus
without dilating the os, and that properly handled
the instrument is cleaner and more easily disin¬
fected than the finger.

Others reproach the curette with working in the
dark, that it runs the risk of perforating the uterus,
that it does not inform the operator on the complete
and perfect cleaning out of the cavity in which debris
of the placenta might be left.

The majority of surgeons of to-day reject the
curette, among whom may be cited Pinard, Budin,
Lepage. Every time that digital curettage is possible
it should have the preference. If, as is customary
with some surgeons, the curettage is done an’hour, or
two after the expulsion of the foetus, no previous
dilatation with Hegar’s instruments is necessary.
One or two fingers are passed into the uterus and
the placenta extracted

Antiseptic irrigation follows to remove any small
pieces, and finally the uterus is swabbed out with
tincture of iodine or glycerine and creasote (1-5).
After another antiseptic injection of the vagina a
plug of iodoform gauze is passed into the uterus to
ensure drainage. This plug is removed after twelve
hours, and the intra-uterine injections repeated.

GERMANY.

Barilo. Sept, let, 1907.

At the Hofeland Society, Hr. Westenhoeffer gave an
address on

The Practical Significance of the Throat Affec -
TION IN CEREBRO-SPINAL MENINGITIS.

He said it was now generally recognised that in
cerebro-spinal meningitis the tonsillar affection was
the primary one. It was maintained by Hr. Goeppert,
Kattowitz, that the whole respiratory tract was the
point of entrance for the meningitis. This disease
might easily escape observation, as the inflammation
was seated in the upper part, hidden by the velum
palati and was not on the tonsils. The cause of the
primary localization lay in the lymphatic apparatus.
The majority of the children attacked were such
lymphatic characters. From this the rule should be
drawn that the throat should be examined in all sus¬
picious cases. Cases of meningitis were originated
from the nasal passages, but not by the meningococcus,
but by pneumococci and streptococci. On the other
hand tuberculous meningitis did not set up a similar
disease in the nares.

The attempt had been made to eliminate the disease
from these parts by means of all kinds of gargles and
washes for the nose and fauces, but without success.
Menirgococci seated in the mucous membranes were
very resistant. Even removal of the tonsils had not
been followed by any good results. Attention had
very properly been drawn to the fact that a large
bleeding wound only made more room for the bacteria
to enter.

It was remarkable that the throat affection disap¬
peared very quickly. It was present in the first days of
the disease only and then showed intense redness and
oedematous swelling.

The throat affection was, however, the cause of the
extension of the disease. The germs must enter with
the air respired and settle on the first suitable spot.
The further spread occurred through expectorant
material. As, however, children did not expectorate
the schools were never the carriers of the infection.

Although epidemic meningitis was exceptionally a
children’s epidemic, 90 per cent, of those who suffered
from the disease being children, the spread took place
through adults affected with the disease who expecto¬
rated the disease germs. All the people of industrial
or colliery districts had a tendency to spit more than
others, the possibility of the spread of the disease
was, therefore, so much the greater amongst them.

There might be cases in which there was no throat
affection. What, from a sanitary point of view,
should be our attitude in respect of such cases, as such
patients did not expectorate? The speaker related
the case of a young man who had had his lumbar spine
cocainized on account of an operation for piles who in
some unexplained way developed cerebro-spinal menin¬
gitis. The throat was intact.

The epidemiological significance of the naso-pharyn-
geal affection lay in the fact that in all the cases the
meningococcus could be found in the naso-pharyngeal
space and the disease carriers determined. The
infection passed along the nerve tracts, especially that
of the trigeminus, and from here deep in to the muscles
of the pharynx. The disease gradually lost itself
towards the periphery. Suppuration very rapidly
attacked the muscles of the eye and the ciliary ganglion.
As a rule, at least, there was no homogeneous infection
of the brain. Before anything was seen in the meninges
suppuration was seen round the arteries. The epi¬
demics differed fundamentally ; exactly as the clinical
course might be, the anatomico-pathological appear¬
ances might differ j ust as much.

In the face of this disease treatment was powerless.
Lumbar puncture was useful in some cases in others
not. It only mitigated the symptoms. The same
applied to other methods of treatment but in a higher
degree. There were cases in which recovery took
place during the first week. The cases are then as
well as before, but a great number died during the
i first week and of the general intoxication. The
remaining group was divided into those that recovered
but with grave lesions of the nervous organs, especially
those of sense, and those that died later. For these
varied courses varied methods of treatment must be
adopted.

Meningococcus serum had been recommended in
the acute stage. Some favoured, others rejected it.
The views were also most varied as to whether it
should be used subcutaneously, or by the rectum, or
spinal canal. Injections into the canal of the cord
were the most deserving of confidence. The mortality,
independent of treatment, was varied. In the Upper
Silesian epidemic the mortality was from 50 to 70 per
cent., in that then on it was 44 per cent. The injection
of serum certainly did no harm.

When the disease had advanced into the second
stage that of pyocephalus surgery was more in place
than the injection of serum.

The speaker then showed how by trepanning at two
spots the suppuration at the descending cornu could
te drained. He had suggested methods of performing
the operation and it had already been put into practise
with success.

AUSTRIA.

Vienna, Sept, let, 1907.

Lipoid Bactericide.

Landsteiner and Ehrlich have now completed
their experiments with fatty material and give the
following report: “ We have carefully examined

fatty haemolytic substance in the form of organic
extracts and found in every one of the experiments
a positive result as a bactericide. We have found
the extracts powerful toxines, for bacillus anthracis,
vulgaris Bayeri, etc., as well as the fatty acids obtained
from these extracts in the form of an emulsion. If
this fatty acid be presented along with serum and then
warmed it becomes inactive as bacterio—or haemo¬
lytic—serum, but if this fatty acid is prepared in an
aqueous solution and warmed in the same manner
the bactericidal property is still retained and die
results positive. _

zed by Google

Sept. 4, 1907.

CORRESPONDENCE.

The Medical. Puss. 249

In the same manner we examined tissues with viru¬
lent Milzbrand bacilli after having treated them with
the lipoid extracts and found them powerfully resisting
the bacilli and therefore protective.

These experiments were carried on in the blood
of animals with the same results in the leucocytes and
medullary substance of bones.

We have also observed that Towel’s bone marrow
in a physiological solution of salt with the serum of the
animal has a decided bactericidal action. This effect
also disappears on gently warming the aether and serum
mixture, but is retained if the component fluids be
warmed separately.

They conclude with an assumption that bactericidal
properties of the marrow of bones will yet play an
active part in the treatment of germ disease or the
intracellular bacteriolysis of the body.

Congenital Cerebral Motor Defects.

At the present time we have a large number of
dreamers. The motor power of the brain only requires
to be aroused to impart activity to the human organism,
but very few apply themselves to investigating the
real cause of this defect before commencing this
resuscitating stimulant. We hear of many being
bom tired and unfit to continue the struggle for
existence. Some attribute this primary agenesia
to a congenital inhibition of the central ganglia
of the brain, like Heubner, Delille, etc., while Mobius
is inclined to accuse the nerve trunks which are often
damaged by toxic agents that produce an enfeeblement
of the nerve centres with consequent dystasia and
agenesia of the muscular system. Neurath, in his
anatomical research on the subject, has now concluded
that both theories may be correct, and probably
the one is the complement of the other. The loss of
function may be developed in the trunk as well as the
centre and both may be the result of a toxine. Neurath
thinks that many of the cases the dystasia is in the
muscular system itself, making a third source of
production in the developmental inhibition. He is
in doubt, however, whether the defect is in the centre,
trunk or muscular apparatus.

Hereditary Squint.

Licherer records an interesting case of squint with
ocular disturbance, handed down through several
generations. The family seems to have been affected
with strabismus during at least four generations;
the first and second having large families, in whom the
males, nine in number, had all strabismus convergens
in the left eye. Strange to say, the children of those
affected had also strabismus convergens in the left
side with the additional ocular disturbance of hyperopia
and amblyopia, while all the females were emmetropic
and had no squint. The boys throughout these
families confirmed Douder’s assertion that strabismus
convergens is somewhat closely associated with
hyperopia and reduction of acuity of vision. The
eldest son of the first family had three children,
of whom the female was emmetropic, while the bovs
were emmetropic in the right and hyperopic in the left.
Cerebral Fatty Embolus with Tetanus.
The patient was healthy, but after a slight injury
died. The clinical observation convinced Schmidt
that the symptoms were the result of a fatty embolus.
These signs were great disturbance in the circulation,
with other changes in the motor phenomena that
were inexplicable from tetanus alone. This was proved
by many of the symptoms being relieved by removing
the compression and providing collateral circulation,
which improved the mental condition of the patient.
The wound and its secretions were carefully examined
for tetanus bacilli, but all in vain, though animal
vaccination gave positive results. He concluded
that the tetanus bacilli played a very small part in
the toxic condition of the patient.

HUNGARY.

Budapest, Sept, let., 1907 .

Gross Negligence of Two Forensic Doctors.

In Szeged, a large country town in Hungary (seven
months ago), a railway servant took a girl
to a hotel, where she, after enjoying herself fainy

well with the servant, suddenly died. The girl was
carried to the morgue, where two forensic doctors
performed the post-mortem examination. Seeing a
stabbed wound under the left eyelid of the corpse,
they stated that the girl—who, by the way, was
pregnant, being about in the eighth month—was
killed; likely a pleasure-murder had been committed
on her. On account of this statement of the doctors
the servant was sentenced to seven years’ imprisonment.

About two weeks ago the case was brought before
the highest Court of Justice, the so-called Royal Curia,
where the documents were given to Dr. Minich,
member of the Board of Justicial Medical Advisors.
He read the report of the two Szegedian forensic
doctors, and spoke of the seriousness of such
a fatal error as had been committed by them*
He argued that "the man, who had been found
guilty of committing murder, was innocent,
because the cause of death could not have been
the alleged stabbing wound under the eye. We
know that even enucleation of the eye bulb does
not give rise to such fatal bleedings as to cause
death. (The forensic doctors alleged that the arteries
of the bulb got retracted in the skull, and caused a
haemorrhage there, resulting in the death of the girl.)
On the contrary, the apertures through which the
arteries leave the skull, are so tight that the vessels
cannot get retracted there. Besides, they are not
such large vessels that a patient could die on account
of their bleeding. We know that pregnant women,
especially those nearing to the end of gestation,
may get apoplexy in consequence of the bursting
of a cerebral or meningeal vessel.”

According to this opinion of Dr. Minich the Court
ordered the exhumation of the corpse; this was
done on the 17th of this month. The post-mortem
examination has been performed by Dr. Genersich.
professor of pathologcal anatomy. He found
the bony eye hole intact, so that an injury of the
brain at the time of the alleged stabbing could
be excluded. He opined that death had been due
to an apoplexy. As for the injury under the left
eye, he expressed his suspicion that it must have
been done after the death of the girl. This
supposition was now born out by the confession of
two witnesses, who carried the corpse from the hotel
to the morgue. The men alleged that they had not
seen any injured spot on the cadaver when they
transported it from the hotel to the Morgue.

Dr. Genersich thinks that the wound arose either
from rat-bite or was made by the throwing of
the body hither and thither during transport.

The innocent railway servant was set free
immediately after the declaration of Professor Gener¬
sich.

French Doctors in Budapest.

Twenty-six French doctors, all members of the
CEuvre d’enseignement medical ^complementaire,
came on the 16th of August to visit Budapest and its
medical institutions. Although the clinics were closed
— being vacation — several notable professors left
their summer residence and came back to Budapest
to receive the guests in their own clinic. Lectures
were held on different subjects, especially on surgical
matters, and dinners and banquets were given in
abundance during the three days stay of the illustrious
guests.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

BELFAST.

Death ok Dr. Henry Murney, J.P. — One of the
oldest, if not the oldest, member of Ithe medical
profession in Ulster passed away last week in the
person of Dr. Henry Murney, who had attained the
good old age of 83. His death was rendered rather
pathetic by the fact that his sister, five years older
than himself, who lived with him, and to whom he
was deeply attached, died only a few hours before
him. It was no doubt partly owing to this shock of

Google

250 The Medical Press.

OBITUARY.

Sept. 4, 1907.

her death that the end came suddenly to him. Dr.
Murney was born in Belfast in 1824, and entered
practice in 1849. In 1854 he was elected to the
staff of the General Hospital, now the Royal
Victoria Hospital, and for many years was an
active member of it, and honorary secretary to it.
He joined the Ulster Medical Society in 1847, and
was president in 1871. He retired from active
practice about 1884, and went to live at Holywood
in Co. Down, where he lived the remainder of his
life. Dr. Murney was a broad-minded Catholic
Liberal, and a favourite with all classes and creeds.
At one time he was a prominent member of the
Masonic body, and a Justice of Peace for both town
and county.

LETTERS TO THE EDITOR.

MILK AND TUBERCULOSIS.

To the Editor of The Medical Press and Circular.

Sir, —It is quite evident that “ A Family Doctor ”
regards bacteriological experiment in the laboratory
as of more value than clinical observation.

I do deny that it has been demonstrated that tuber¬
culosis has ever been communicated to the human
subject by means of the tubercle bacillus conveyed in
milk. I again ask for a single case.

“ A Family Doctor ” says, “ the possible sources of
infection in the case of the cow have been demonstrated
by Dr. Armstrong." But I ask for the actual sources ;
lor it passes my limited comprehension how a possible
source of infection can be demonstrated. If it be
demonstrated it is no longer a possible but an actual
source. To say that a thing is possible cannot lead
to any conclusion.

I repeat that “ A Family Doctor ” accepts state¬
ments unsupported by evidence.

It is only within a few years that the doctrine of the
infectivity of phthisis has taken hold of the professional
mind. Yet when this question was investigated at
the Brompton Hospital for consumption not a single
case could be discovered in which a servant or nurse
had become infected.

The improvement that has taken place in the in¬
cidence of this disease throughout the country has been
independent of the application of so-called modern
science towards its ousting.

I have already shown that the want of milk plays i .
far more important part in the production of this''
•disease in the young than so-called infected milk.

As it appears to be a hopeless task to wean “ A
Family Doctor " from his views in favour of bac¬
teriological experiment as against clinical observation
I shall not trouble you further.

I am, Sir, yours truly,

August 31st, 1907. Geo. Granville Bantock.

SANITARY ADMINISTRATION.

To the Editor of The Medical Press and Circular.

Sir,—T he Times, of August 26th, publishes a
summary of Local Government Board Reports on the
sanitary condition of numerous Lancashire boroughs
and urban districts. The reports form a terrible in¬
dictment of the various authorities. In every district,
Acts of Parliament, upon which the health of the
people depend, and which it is the duty of the authority
faithfully to administer are neglected or even com¬
pletely ignored. In most places medical officers
and sanitary inspectors are either not appointed,
or are engaged and paid to give only a small and
insufficient part of their time to their duties. Councils
are often wilfully negligent, or, lacking the advice of
skilled and experienced officers, remain ignorant
of the requirements of modern sanitation, and un¬
enlightened as to the nature and importance of the
trust which the Legislature has placed in their hands.
In many instances members of the authority seem
evidently bent upon preventing the administration
of laws in conflict with their private interests. The
state of local government in the areas now reported

on closely resembles that in other parts of the country
which you have allowed me on previous occasions
to criticise. In most of such places public opinion
does not exist; recommendations of the Local Govern¬
ment Board, such as are made in the present reports,
are disregarded, and vast masses of the people through¬
out the land are thus allowed to exist under conditions
which give rise to great preventable mortality with
corresponding injury to the physique of the nation.
By far the greater part of the injury falls upon the
poor. The impossibility of getting milk of fairly
good quality for their infants in the many places
where the adulteration Acts are not enforced, forms
alone a terrible hardship for poor mothers. It
would be easy to paint a picture of misery arising
almost solely from bad government sufficient almost
to Justify the wild and revolutionary demands of the
socialists whose fanaticism is very often roused and
kept up by contemplation of the undeserved sufferings
of the poor, to which society seems so callous and
indifferent. The only cure for these evils lies in the
rousing of the spirit of the nation. We ought to be
all socialists, in the proper sense of the word, now-
a-days. If all that is respectable and intelligent
among every class of the community will not take its
proper share in the working of our democratic institu¬
tions these-will fail and national ruin in the end will
result. Certainly the fanatical socialism of the day
will not save us, for that presupposes before everything
a high level of altruism, to which only the smallest
minority of any class of the people have attained.
In the meantime, and pending the evolution of a
higher level of citizenship, the position of the medical
officer of health will remain in too many places as at
present—ill-paid, precarious, and in every moral
and material sense, unsatisfactory.

I am, Sir, yours truly,

Lancashire. August 28th, 1907. M. O. H.

SOUTHEND AND ITS MEDICAL OFFICER OF
HEALTH.

To the Editor of The Medical Press and Circular.

Sir,— I venture to draw your attention to the
recent action of the Southend Council in relation to
its Medical Officership of Health. As a health resort,
it is clearly a matter of vital importance to the town
to preserve its sanitary standards at the highest
possible pitch of excellence. Moreover, there are special
reasons, owing to the shell-fish industry and the pollution
of the foreshore with sewage, why the sanitary super¬
vision of the place should be one of ceaseless vigilance.
It seems hardly credible that under such circumstances
the local authorities should have resolved to cut down
the salary of their medical officership. Yet such has
been the case and I understand that the present able
holder of the post has very properly refused to accept
a reduced and inadequate salary. The incident has
a much wider significance than the mere unwisdom of
the local Council of a small but hitherto popular
watering-place. It presents the type par excellence
of the penny-wise-pound-foolish policy that has left
most of our watering-places hopelessly out of the race
against their Continental rivals. Yet many of our
British sea-side resorts are of unrivalled beauty—it is
the sordidness of the private and municipal accom¬
modation and the lack of first-rate recreations and
public organisation that repels.

I am, Sir. your? truly,

London, Sept. 3rd, 1907. David Walsh.

OBITUARY.

DR. JOHN WILLIAMS, OF CARNARVON.

We regret to announce the death of Dr. John
Williams, Carnarvon. The deceased, who was seventy
years of age, was a native of Anglesey. He came to
Carnarvon as assistant to the late Dr. Watkin Roberts
many years ago, and subsequently joined that gentle¬
man as partner, and remained in partnership till
Dr. Roberts’s death in 1897. Dr. Williams had been

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' Sept. 4. 1907.

SPECIAL ARTICLE.

The Medical Press. 25 1

in practice tor forty-five years. He was appointed
medical officer of Carnarvon Goal in 1887, and was
also medical officer for several local friendly societies.
He became a member of the town council in 1874.
In 1883 he was elected mayor, and during his mayoralty
the beautiful Carnarvon Park was opened by the
late Mr. Assheton-Smith. In politics the deceased
gentleman was a moderate Liberal, and was a Church¬
man. He married Miss Gregson, of Kirkby Stephen,
by whom he had three sons.

ANDREW GRAY. M.A., M.D.Edin., D.P.H.Vict.

We regret to announce that on August 30th the death
took place at St. Helens, of Dr. Andrew Gray, one of
the leading medical practitioners of the town. On
August 25th Dr. Gray was cycling along Corporation
Street, when another cyclist came up behind, and in
passing came in contact with his wneel. Both men
were thrown off their machines, and Dr. Gray sustained
a fractured skull. The other cyclist, who apparently
escaped unhurt, rode off, and has not yet been identified.
Deceased was the son of Mr. Gray, of Dalkeith, a
member of the Midlothian banking firm, and who
acted as chairman for Mr. Gladstone. Dr. Gray, who
was 43 years of age, studied at Edinburgh, and went
to St. Helens eighteen years ago, having graduated
M.B., C.M. in 1888.

SPECIAL ARTICLE.

A KENT PRACTICE SINCE 1690, WITH A
LETTER ON “HE-SHE THINGS.”

Bv GEO. H. BROCKLEHURST, B.Sc.

The village of Elham—which gives its name to the
verdure-clad valley between Canterbury and Shom-
clifle, which latter Wolfe, whom every schoolboy
loves, selected for a military camp—was, up to the
close of Century XVIII., a town of considerable im¬
portance in Kent. Hasted, in his history of the
county, states that: “ Elham is said to be the largest
parish in the eastern part, extending from north to
south, through the Nailboum valley about three and a
half miles, and from north-west to south-east five and
a half.” He further tells us : “ The town is healthy
and pleasant ; the houses in it being mostly modem
and well-built of brick and sashed.” That the windows
could be let up and down by pulleys, shows how
up-to-date the town was in 1793 ; whilst its relative
importance may be judged by its contribution to the
county rate being £4 7s. 6d. ; that of Sittingboume
being eighteen pence less, and that of Ashford only a
guinea and sixpence more.

John Somner —named after his uncle, on his father’s
side, who offered to give a new Market House to the
City of Canterbury on condition that the Corpora¬
tion would make the market a free one—whose brother
William was the vicar of the neighbouring parish of
Lyminge, died after being in practice at Elham but a
few years. A stone at the extreme east-end of the
chancel of the Parish Church states : “ Here lyes ye
body of John Somner, Gent., son of the learned Mr.
William Somner, of Canterbury, who dyed June the 7th,
1695, in ye 2 9 yeare of his age.” Which William
Somner was the antiquary, author of, amongst other
works, “ Antiquities of Canterbury,” “ A Treatise on
Gavelkind,” and “ Roman Ports and Forts in Kent,”
published in 1693, which is prefaced by a life of Somner
by White Kennett, afterwards Bishop of Peterborough,
who states that “ John practises Chirurgery with good
repute,” and that his mother became a “ mourning
Relict” for the second time, having married " Henry
Hannington, Vicar of Elham.”

The practice had passed into the hands of William
Pettit, surgeon, by 1700, who died, aged 61, on April 30,
1739. Then into those of one, whose name is not
known, though amongst his fees in the year 1747 are
the following :—‘‘Cook; bleeding is., two histerick
draughes 2s., and a nervous tincture 2s.” The next
entry, lets “ the cat out of the bag.” " Cook ” is not
a surname ; but the all-important “ officer of health ”

of a well-ordered household. As the three next
entries are “ Mr. ; the cure of his leg 5s., a cooling
mixture 2s. 6d., and a rhubarb bolus is. 6d., possibly
there had been a little over-eating. A good idea of
a "bolus” and of the dress of this period may be
obtained from H. Taylor’s drawing, ” A Country-
Doctor giving a Bolus to a Patient.” engraved and
published by J. Cary at the comer of Arundel Street
and the Strand, Westminster, on March 25th, 1786,”
where a lady patient looks inquiringly, if not sus¬
piciously, at the bolus—about three times the size
of her thumb-nail, she holds between her thumb and
index finger ; whilst her medical adviser, whose head
is well covered with a bewitching wig and a broad-
brimmed soft felt hat, bracing up her courage evidently
with “ Now then, my dear lady, down with it.”

When the “ Blacksmith ” called the doctor in he
was given “ a Cathartic is. and ointment 6d. ; on the
following day another Cathartic is. ; two days after,
a third Cathartic is , and more ointment 6d.,” whilst
on the fifth day he had *' Phisick is.,” bringing up his
bill to a crown. Probably his wife, for the record
states, “ Wife of Blacksmith ” fell ill just before
Christmas—which it will be remembered was kept in
March at that date—possibly from over-work prepar¬
ing for that “ family gathering," rightly held in such
high esteem by those whose love can extend to each
and every member. She was well in three days;
the items of her account being : A mixture, on the
first, 2S- 6d. ; a Cathartic, on the next, is. ; and a
Bottle of Drops, on the last, is.

Then followed James Miller Church, surgeon, of
whom little can be said with certainty, beyond that
he evidently was a very common-sensed man. One
of his favourite prescriptions was, “ Keep the clay-
cottage of which you are the freeholder for life clean,”
adding, “ then there will not be much wrong with you.”
Probably he was a son of Samuel Church of Sandwich,
who died there on November 18th, 1793, aged 83 ;
and of Elizabeth, his wife, who was buried at Elham
on August 21st, 1796, aged 85. If so, doubtless his
widowed mother passed her latter days under his roof.
As there is no other record in the parish registers
under this name, probably he removed to Sitting¬
boume ; as there was a surgeon of this name in that
town early in Century XIX. During his last years in
Elham, he had as partner, who succeeded him, Charles
Rootes," surgeon, apothecary and man-midwife,” who
appears to have been the son of a Nonconformist
Minister of York, who died on June 8th, 1755. If
so, he was fatherless at the age of 14, and had the
advantage of the up-hill work of making his own
way in the world—the best to bring out the best in a
noble lad. He was in practice in the town by 1778,
which was probably the year he came to Elham.
He was liberal-minded large-hearted, and, as he had
studied midwifery, evidently abreast if not in advance
of his day, as the following shortened letter, addressed
to the Editor of the Sunday Reformer —not the only
Sunday paper of that day, by any means—shows.

‘‘‘When apothecaries’ apprentices are out of their
time, they come to I.ondon to attend Anatomical
Lectures, but instead of studying the whole of the
human structure, together with practical surgery,
they immediately turn their attention to that which
is by no means proper for boys and young men—I
fnean midwifery. . . . The present race of males are
become so effeminate, as to make it their chief prac¬
tice . . . and write ‘ Surgeon and man-midwife ’ over
their doors, and are well employed among the ladies.
In short, Sir. I am persuaded, if something is not done
to put done those multitude of he-she things among
us, called men-midwifes, men-milliners, men-stay-

MAKERS, MEN-MANTUAMAKERS, MALE-LADIES’ HAIR¬
DRESSERS, yea, and washer-men also, who have
started np like mushrooms of late ; I say, if something
be not done to stop this confounding of sex. like the
language at the building of Babel, we shall ere long
have a race of male Ladies’ garter-tiers, Ladies’
bathers, and I know not what . . . and scarce a truly
masculine man, or a real modest woman, will be found.

“ Pray, good sir, think of some remedy for this

zedbyL.OOgle

252 The Medical Press.

MEDICAL NEWS IN BRIEF.

Sept. 4, 1907.

national evil; and, in the application of it you shall
not want the assistance of—

“Your obedient Servant,

“ Cadwallader Evans.”

That the town should have one of these “ He-She
Things ” is another proof of its importance.

Mr. Rootes was a bachelor till September 20th,
1779, when he took to wife by licence—then the
“ genteel ” mode—in the parish Church, Mary Butcher,
without doubt a popular and pretty “ Elamite,” as
the late Canon Robert C. Jenkins, M.A., the widely-
known, courtly, scholarly gentleman—well-known
amongst his intimate friends as the “ Abbot of
Lvminge ”—used to call the inhabitants of this parish.

In April, 1782, their son, William, was baptised, and
two years later another, named after his father. Then
followed four more—George in 1786, James in ’90,
Thomas in ’92, and Richard born on December 8th,
and baptised on December 24th, 1794. his godfather
being Stephen Prebble, blacksmith, son of the above
“ Blacksmith,” and William Noble, mine host of the
“ Rose and Crown,” both exceptional men, his god¬
mother being the wife of the former. Then came
Mary, the flower nipped in the bud, their only daugh¬
ter, who, as an infant, was laid to rest in God’s Acre
in 1797. There was one other son, baptised Edward
in 1799, and possibly another John. With such a
family Mr. Rootes showed his prudence by being a
member of the “ Benevolent Society for the Relief of
Widows and Orphans of Medical Men in Kent,”
founded in 1787, by the usual payment of “ twenty
guineas, being in good health.” His family was one
of the 25 per cent of the families of members, whose
circumstances necessitated the assistance of the
society ; and it speaks well for the generosity of the
members that, during its first twenty years, thirty
families had to do the same. Mr. Rootes lived to the
age of 62, and was buried on February 7th, 1803.

Then followed Thomas Noble Elwyn, M.R.C.S.,
whose brother, George, became Clerk to the Justices
of the Elham Division of Kent about 1808, and who
served the office of Under-Sheriff of Canterbury in
1811. The former year was the one in which Thomas,
joined the above Benevolent Society for Medical Men ;
whilst the latter marked two important changes in his
career. First he left Elham for Sandwich to carry on
the practice of Robert Curling ; then, in November,
he journeyed—and it was a journey at that day, at
that time of the year ; but was he alone ?—from that
ancient port to Bath, where on the 16th of that month
he married, “ Elizabeth, eldest daughter of Sam
Harvey, brewer of Sandwich, and niece of the late
Vice-Admiral Sir Henry Harvey, K.B.”

Then came Doctor Peck (or was it Thomas A.
Pack ?) of whom nothing can be gathered from docu¬
ments ; though he is distinctly remembered by that
venerable inhabitant, Mrs. Court—better known
locally as “ Nurse Court,” as having assisted the pro¬
fession for many years—who attained her ninety-
eighth birthday on February 24th last; and who,
with a merry twinkle in her eye, is proud of never
having been out of Court—though “ I have been
married ”—from her cradle to the present day—her
husband being her cousin Stephen ; and who saw the
Duke of Wellington on his landing at Dover from the
Battle of Waterloo.

The practice then passed to William Pittock, who
took his M.R.C.S.Eng. on May 7th, 1813, and then
practised in Maidstone till 1831, when he removed to
Elham. Here he practiced for over twenty years,
being assisted first by his son, Francis William, who
took his M.R.C.S.Eng., on May 4th, 1838, from that
time till 1843, when he settled at Sellinge, in Kent;
then by William Taylor Tyson—fourth son of Joseph
Taylor Tyson, of Canterbury—who became a M.R.C.S.
Eng., in September, 1834, and a L.S.A. the following
year. In 1845, Doctor Tyson married Miss Regdcn,
of Etching Hill, Lyminge ; and two years later re¬
moved to Church Street. Folkestone, then the fashion¬
able part of that town ; rightly judging it would further
his interests ; and was at once elected Surgeon to. the
Folkestone Dispensary, now represented by the

Victoria Hospital, of which his second son, Joseph Wm.
Tyson, F.R.C.P., is one of the Hon. Physicians.

The Elham practice then passed into the hands of
James Beattie, who took his L.R.C.S.Edin. in 1840,
and M.R.C.S.Eng. fourteen years later. He was
medical officer of Elham Union and sturgeon to the
East Kent Mounted Rifles. Dying in 1859, he was
succeeded by Hubert Beadles, who received his
medical training at Westminster Hospital, qualifying
M.R.C.S.Eng., in 1857, and taking the L.M., and
L.S.A. the following year. Then followed William
Bishop, a native of Chipping Norton, Oxfordshire, a
popular student at University College Hospital ; who
not only devoted himself to his work within the
hospital, but was a devotee in defence of the profession ;
being the ringleader of that gallant little band, which
set out one evening from the hospital to whitewash a
certain lion, erected as an advertisement of a patent
pill. The work was all but completed when “ a
gentleman in blue ” appearing, the valiant, remem¬
bering that “ discretion is the better part of valour,’
took to their heels, soon increasing the distance between
them and their pursuer, who doubtless, having par¬
taken of a good supper provided by a kind-hearted
cook at the expense of her master, soon gave up the
chase. In 1868, he qualified M.R.C.S.Eng., and three
years later took the L.S. A.Lond., and L.R.C.P.Edin.
Having gained some valuable practical experience as
Assistant Surgeon of Sirhowy Iron Works in Wales,
he settled in Elham, and shortly after married the
sister of the present Lord Mayor of London. Besides
holding the various local medical appointments, be
was a member of the Royal Commission on Horse
Breeding, and Hon. Secretary of the East Kent Fox¬
hounds for over twenty years. He was a keen and
true sportsman, loving all nature ; his fellow-man,
the robin and the wren, which he always greeted as
“ God’s Cock and Hen,” to the mushroom, which at
one time he cultivated to such perfection that he
obtained a shilling a pound in Covent Garden for them.
The respect with which he was held by peer and poor
was shown when his body was laid by the side of his
friend, the late Walker Wodehouse, M.A , the beloved
vicar of the parish, who for over half a century had
“ neither changed, nor wished to change, his place.”
The practice, traced for some two hundred and twenty-
years, is now in the able hands of Gordon H. Hackney,
who also received his medical training at University
College Hospital, qualifying M.R.C.S.Eng., and
L.R.C.P.Lond.-in 1901.

Medical News in Brief.

A Vegetarian Manifesto.

The present season of discontent is usually made
glorious in autumn by the sea serpent, the giant goose¬
berry, and “ pater familias.” It is still further enriched
this year by the appearance of the following naif docu¬
ment which is forming a splendid “ fill-up” for sterile
news-sheets.

Medical Manifesto on Vegetarianism.

We, the undersigned medical men, having carefully
considered the subject of vegetarianism in its scien¬
tific aspects and having put its principles to the
practical test of experience, hereby record our em¬
phatic opinion that not only is the practise based
on a truly scientific foundation, but that it is con¬
ducive to the best physical conditions of human life.
The diet of vegetarianism provides all the constituents
necessary to the building up of the human bodv,
and those constituents as proved not by the mislead¬
ing tests of the chemical and physical laboratory,
but by the experience of numerous persons living under
normal conditions are at least as digestible and as
assimilable as the corresponding substances obtained
from flesh. We. therefore, claim vegetarianism to be
scientifically a sound and satisfactory system of
dietetics. Moreover, considering the liability of

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Sept. 4 . 19» 7 -

MEDICAL NEWS IN BRIEF.

The Medical Press. 253

cattle and other animals to ailments and diseases o L
various kinds, and the pure character of food obtained
from vegetarian sources, we are convinced that ab¬
stinence from flesh food is not only more conducive
tojhealth, but from an aesthetic point of view is incom¬
parably superior.

Robert Bell, M.D.. George Black, M.B.Edin.,

A. J. H. Crespi, M.R.C.S., H. H. S. Dorman,
M.D., Albert Gresswell, M.A., M.D., Walter
R. Hadwen, M.D., L.R.C.P., M.R.C.S., J.

Stenson Hooker, M.D., Augustus Johnstone,
M.B., M.R.C.S., H. Valentine Knaggs,

M R.C.S., L.R.C.P., Alfred Bolsen., M.D.,

Robert H. Perks, M.D., F.R.C.S., John Reid,
M.B., C.M., George B. Walters, M.D.

It is a great thing to belong to a free, catholic,
and tolerant profession!

Medical Man Shot by Patient.

Chapeltown, one^of the fashionable suburbs of
Leeds, was startled on Saturday morning by the news
that one of its best known medical practitioners had
been murdered by a patient.

Dr. Walter Clapham Hirst had among his patients
a man named John William Harrison, aged about 40,
who had recently become well known in the district
owing to his eccentric habits. On Friday night last
he visited Dr. Hirst’s consulting room, and was then
very strange in his manner, but after an hour’s talk
with the doctor he became quieter and left. Nothing
more was heard of him until yesterday morning, when
he again proceeded to the doctor’s residence. He
reached the house about six o’clock and Dr. Hirst
appeared at the door in answer to the night bell. As
soon as he opened the door Harrison remarked :

“ You are Dr. Hirst,” and produced a revolver and fired
twice at the doctor, who fell on the doorstep.

The sound of firing roused Mrs. Hirst and some
neighbours, but before assistance came Harrison had
turned the weapon on himself, and, firing into his
mouth, fell by the doctor’s body, his head being com¬
pletely shattered. Mrs. Hirst found her husband still
alive, but he was mortally wounded, for one of the
bullets had struck him under the left side of the breast¬
bone, another penetrating the chest a little lower down
on the right side.

It is clear that Harrison’s mind was affected. In a
letter received by a friend Harrison said :—

" I was suffering terrific, and doctor struck me on
both knees, which brings on epileptic fits. It was
murder to me. He has killed me . I was all right
before, but now am lost. The pains and fits are terrific.
He has killed me wilfully and deserves punishment.
He deliberately struck me on both knee-caps last
Monday. It was murder. Farewell, old friend. No more
happy hours in your garden.”

Harrison added : “ I have given the motive of the
crime to Mr. -

A pathetic feature of the tragedy is that Dr. Hirst
was married about six weeks ago to Miss Nellie Oldroyd,
the daughter of a manufacturer. The bridal couple
only returned a week ago from their honeymoon tour
in Switzerland. Dr. Hirst, who was 28 years of age,
belonged to Dewsbury. He was an M.B. of London,
and an old student of Leeds and St. Bartholomew’s.

DmUi Under Chloroform.

An inquest was held at Bredbury Hospital, last week,
on the body of Emily Riding, three years old, operated
on for double club-foot.

Dr. Thomas Birch, resident medical officer, said the
operation was successfully performed, and the child
was a fit subject for the administration of chloro¬
form. The next morning, however, she showed
symptoms of chloroform poisoning. She became
unconscious, and died the same evening from cardiac
failure produced by the delayed action of chloroform.
The witness added that the child was not given very
much chloroform, and the quantity had nothing to
do with the fatal result. Dr. Birch added that he

made a post-mortem examination which confirmed his
conclusion. The deputy-coroner, Mr. Birch, pointed
out that he had not given permission for a post¬
mortem examination to be made. He also men¬
tioned that the child died on Thursday, and he only
got information of its death Sunday morning. He
did not think that the doctor was justified in giving
his certificate in a case which was not death from
natural causes, and. as might have been expected,
the registrar refused the certificate.

The doctor explained that he was under the im¬
pression that in a case of that kind he was authorised
to make a post-mortem, and that his evidence would
not be complete without it.

The jury returned a verdict in accordance with
the doctor’s evidence in regard to the cause of
death.

Death Under Ether.

Mr. Walter Schroder conducted an inquest
on the 27th inst. at St. Pancras, on Kate Hartshorn,
aged thirty-two.

The deceased underwent a slight surgical operation
at the Royal Free Hospital for cancer, of the breast on
the 17th inst., after which she was sent home in a cab.
Subsequently it was discovered that a more drastic
operation was necessary, and she was re-admitted
to undergo this.

Dr. Charlotte Alice King, house-surgeon at the
hospital, stated that on the deceased’s re-admission
the operation was deferred until the following Friday.
It occupied two hours and a half, and during two
hours ether was being administered. Mr. Cunning,
one of the visiting surgeons, performed the operation.
Signs of cardiac failure were observed, and the ad¬
ministration was discontinued, recourse being had to
stimulants. Ultimately she expired, and, from the
autopsy witness made, she concluded that death
was due to cardiac failure, consequent on the shock
of the operation.

Dr. Florence Elizabeth Willie, senior anesthetist,
said that the inhaler held nearly five ounces of ether.
If she had a similar case she should, perhaps, have
recourse to a stimulating infusion earlier during so
prolonged an operation. Witness had administered
anesthetics in at least a thousand instances.

The jury returned a verdict of death by misad¬
venture.

Inquest ou Malvern Medical Man.

An inquest was held at Malvern, on August 23rd,
by the District Coroner into the circumstances attend¬
ing the death of Dr. Edmund Antrobus, of Great
Malvern, who died after taking an injection of a
sleeping draught. Mr. Guy Antrobus, brother of the
deceased, who was sleeping in the same room at the
time, said he heard Dr. Antrobus moving by the
dressing-table. He got out of bed to see what was
the matter. Deceased stumbled. Witness got him
into bed and sent for doctors, whose efforts were,
however, unavailing, death occurring within about
an hour and a half. Deceased had been seriously ill
from blood poisoning, contracted two years ago,
but had seemed better lately. Evidence was given
that at a post-mortem examination it was found that
an exceptionally large dose of a narcotic containing
opium had been taken, and that this was the cause
of death. Several pricks, such as might be caused
by a hypodermic syringe, were found. The jury-
found that the deceased had died from an overdose
of narcotic, self-administered, to produce sleep.
They expressed sympathy with the relatives.

Society for the Study of Inebriety.

The Second Norman Kerr Memorial Lecture, held
under the direction of the Society for the Study of
Inebriety, will be delivered by Robert Welsh Branth-
waite, Esq., M.D., H.M. Inspector under the
Inebriates’ Acts, on Tuesday, October 8, at 8.30 p.m.,
in the Hall of the Royal Society of Medicine, 20
Hanover Square, London. The subject of the lecture
will be “Inebriety—Its Causation and Control.”

y Google

254 The Medical Press

WEEKLY SUMMARY.

Sept. 4, 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT PATHOLOGICAL LITERATURE.

Vaccine Treatment and Opsonic Control.—A series
of papers of great importance appears in the June-July
number of the Johns Hopkins Hospital Bulletin. Taken
together they seem to place in fresh perspective the
practical relation of opsonic control to vaccine treat¬
ment. I.—Cole and Meakins relate their experience
of twenty cases of gonorrhoeal arthritis treated by
vaccines, and state their general conclusions arising
therefrom. They deprecate the publication of the
histories of isolated cases in which the writer has
undertaken the treatment with great enthusiasm,
and it is as a contribution towards wider statistics
than are yet available that they publish their examina¬
tion of a small group of cases of one disease. In their
technique they followed with slight modifications
the methods of Wright. The initial dose of dead
gonococci was usually three hundred million, and the
amount was gradually increased until a dose of one
thousand million cocci was administered. No ill-
effects were encountered, though a slight local reaction
of pain, tenderness and redness always occurred twelve
to twenty-four hours after the first dose. General
constitutional disturbances following the injections
were very rare. The general course of the opsonic
charts is similar to that observed by Wright and his
collaborators, but the writers did not find the “ negative
phase ” at all marked. The ill-effects of a “ negative
phase ” were not observed clinically, and a cumulative
" negative phase ” was never observed. The notes
of the cases treated would seem to justify a stronger
conclusion than the very moderate statement of the
writers that their “ impression is that the vaccine
treatmen t as carried out, has been of distinct value.”
As regards the value of opsonic control, the writers
point out that •' considering the present almost certain
inaccuracy of opsonic technique, and the absence of
sufficient evidence as to the role of opsonics in immu¬
nity, it hardly seems advisable that the control
of the administration of vaccines by the estimation
of the opsonic index should be persisted in. We di
not feel,” they go on, ‘‘that the danger of cumulative
negative phases is a real one. In no case have we
seen the administration of gonococcus vaccine do
harm, and we feel that these cases offer sufficient
justification for the treatment of gonorrhoeal arthritis
by means of vaccines in doses of 500 to 1,000 million,
administered every seven to ten days.”

II.—Jeans and Sellards deal with tuberculin treat¬
ment and opsonic control. In technique they have
made some important advances. Instead of grinding
the dead bacilli in an agate mortar as recommended
by Wright, they emulsify the living bacilli by rubbing
them up in salt solution with a heavy platinum wire
or a small glass rod. The emulsion is then sterilised
by exposure to direct sunlight for ten hours. In the
preparation of the smears they are fixed with methyl
alcohol for thirty seconds, and stained with carbol-
Fuchsin for one to two hours at 37 0 C., recolouring
with 95 per cent, alcohol for three to four minutes,
and counterstaining with saturated aqueous methy¬
lene blue for five to ten minutes. The writers note
very great variations in the counts obtained from
the same preparations and some from the same slides,
and they regard the limits of error as much wider
than has been hitherto supposed. Thus, by dividing
a slide into three sections by transverse lines it was
found that the section at the end of the smear con¬
tained 282 bacteria, the middle section 107, and the
first section 140 bacteria in 50 leucocytes. In other
cases they got from the same serum indices varying
from 0.4 to 2.34. They think, therefore, that it is
probable that large differences in indices mean differ¬
ences in opsonic control, but they do not believe

that small differences can be held to have any significa¬
tion. As regards diagnosis, they have employed the-
opsonic method in a considerable number of cases
without obtaining satisfactory results. They append
the clinical notes and opsonic charts of nine cases of
tuberculosis treated by vaccines, which justify their
statement that the results obtained by the administra¬
tion of T. R. tuberculin in small, infrequent doses as
Wright advises, have given encouraging results.

III. —Wass reports certain theoretical studies in
opsonics. In the first place he attempts to decide
whether it is possible to raise the opsonic power
of the serum beyond the very low limits with which
Wright has, for therapeutic purposes, contented
himself. The method employed consisted in repeated
progressive inoculation :—(1) intravenously with dead
staphylococci; (2) subcutaneously with living sta¬
phylococci ; (3) subcutaneously with dead staphylo¬
cocci. The animals employed were rabbits. It is not
necessary to describe in detail the experiments which
led to the conclusion that no high degree of opsonic
immunity such as is possible in antitoxic and bacteri¬
cidal immunity can be produced in rabbits by ordinary
inoculation procedures with staphylococcus aureus.

He next discusses the trustworthiness of Wright’s
method of estimating the opsonic variations. He
shows by many examples the variations between
different estimations of the same serum, and the
variations shown even by normal serum. Thus, in
the case of one normal human serum, thirteen obser¬
vations showed variations between the limits of
0.52 and 1.95, and of another between 0.42 and 1.66.

He is therefore led to conclude that none of the present
methods of estimating the opsonic control of the blood
seem sufficiently accurate to be of practical value. He
suggests ” that further efforts should be expended
in finding a reliable technique for clinical purposes
rather than in continuing to pile up statistics which
are so inaccurate as to be misleading.”

IV. —Klein discusses the subject of opsonics in
typhoid immunity, and he shows that the opsonic
index, as determined by Wright’s method, bears no¬
relation to the degree of immunity present, at any <
rate in the higher grades of immunity. The index
seems to rise with the development of immunity, but
with the further development it drops. He suggests

as an explanation of this fact that the ambaceptor-
laden bacteria are much more quickly digested by the
leucocytes, and therefore rapidly become invisible.

V. —Russell discusses the specificity of opsonics
and concludes:—(1) Following injections of bacterial
vaccines, the increase of opsonics is probably due
to the formation of immune opsonics which re-act
specifically; (2) in saturation experiments with normal
sera we are dealing with normal as common opsonics,
and these are not specific, since they can be removed
by saturation with any one of a considerable number
of bodies ; (3) in saturation experiments with immune
sera we have both the immune and the common
opsonics present; the former is quite specific, while
the latter is not ; (4) B. pyocyaneus is quite sus¬
ceptible to spontaneous phagocytosis.

The consensus of opinion which is to be gathered
from the contributions of these several workers attack¬
ing the problem from separate points of view is of
the utmost importance. On one point there is una¬
nimity that the estimation of the opsonic index by
Wright's method is open to such error as to be useless
for diagnosis or treatment. On another point, those
who deal with the subject of treatment are agreed
that vaccine treatment has given such promising results
as to justify its continuance. If these conclusions be
justified then a great stimulus to vaccine treatment

zed by Google

S ept. 4 , 1907.

has been given by freeing it of the dead weight of
opsonic control. R.

Diphtheria Bacilli in Normal Throats. —Anna van
Sholley publishes a painstaking investigation on
the presence of diphtheria bacilli in the throats ot
healthy children (Journal of Infectious Diseases, June,
1907). She examined in the hospitals of New York
the throats of 1,000 children, none of whom had been
exposed to the infection of diphtheria. From 56 ot
the 1,000 cases (5.6 per cent.) diphthena-like bacilli
were separated, and in 18 of these (1.8 per cent.) the
organism was true virulent Klebs-Loffler bacillus. She
also examined the throats of 202 persons who had been
in contact with cases of diphtheria. From them
diphtheria-like bacilli were isolated 20 times, 14 viru¬
lent and 6 non-virulent, or a proportion of 7 per cent,
of contacts were infected with the Klebs-Lolfler
bacillus. The proportion of virulent and non-virulent
is. therefore, exactly reversed in the case of contacts
irom that in the case of non-contacts. The author
concludes :—(1) Diphtheria-like organisms are present
in a certain number of apparently normal throats, even
where exposure to infection cannot be traced. (2) A
certain proportion of these organisms (in her cases
about one-third) are virulent, and the persons thus
infected are a potential source of danger to the com¬
munity while about two-thirds of the organisms are
not true diphtheria bacilli, and are probably harmless.
(31 The other conditions being the same, virulent
Klebs-Loftier bacilli are found in the mucous membranes
of those exposed about four times as often as in those
apparently not exposed. (4) Mild sore throats and
"colds” with bloody nasal discharge, such as are
fairly common in children, should not be lightly con¬
sidered. Cultures should be taken, and if diphtheria-
like organisms are found, their virulence should be
tested. R.

Implantation of Cancer. —Butlin in a popular ad¬
dress discusses (British Medical Journal, August 3rd,
1907) under the term “ The Contagion of Cancer in
Human Beings: Autoinoculation,” the phenomenon
usually known as implantation. He enumerates a fair
number of cases which might be explained in this way
though some of them are capable of other explanation ;
but he by no means refers to all the cases well known in
the literature of cancer. The sites in which he believes
he has evidence of implantation taking place are the
vulva, the larynx, the lips, the lower jaw, the uterus
and vagina, and some others where the affected points
were further distant from each other. R.

Moser’s Serum In Scarlatina. —Langowoi and Egis
have treated four hundred cases of scarlatina with
Moser’s serum and have come to the following con¬
clusions :—(1) In the treatment of severe cases the
mortality is reduced by the use of the serum from 47.1
per cent, to 16.1 per cent. (2) The serum has un¬
doubted anti-toxic properties. (3) It is of little or no
nse against the complications of scarlatina. (4) To
be of any use it should be injected within the first
three days of the sickness, or at latest on the fourth
day. (5) The temperature usually falls by crisis
when the serum has been given early. In complicated
cases, however, a critical fall is not noted. (6) The
usual dose of the serum for an adult is 200 c.cm., and
lor children about half that amount. (7) The different
specimens of serum differ widely in their anti-toxic
properties. (8) Prophylactic small doses seem to
diminish the susceptibility to scarlatina. M.

Chlorosis In Infants. —According to Leenhardt
( Zentralbl. fur Inn. Med., 1907. No. 30.) true chlo¬
rosis is to be met with in the earliest years of life.
He bases this assertion on his own observation of sixteen
cases in children between twelve and eighteen months
°ld. The resemblance of the cases to the torm of anae¬
mia met with at puberty is often quite obvious. The
children are very pale, but with normal development,
and are generally in a good nutritional state. With the
exception of cardiac murmurs, and murmurs in the
^essels of the neck, nothing abnormal can be detected.
The liver, spleen and lymph glands are of normal size,

The Medical Pbess. 2.55

but usually there is constipation. The red and white
corpuscles are normal in number, both relatively and
absolutely, but there is a great deficiency of haemo¬
globin. The resemblance to chlorosis of later life is
heightened by the fact that improvement rapidly
occurs under a course of iron. M.

The Dependence of Respiration upon Pressure
Conditions. —As a result of a large number of experi¬
ments and from the fact that bilateral pneumo-thorax
is not necessarily fatal, Hellin (Miltiilung a. d. Grenz-
(b:it du Medizin. Bd. xvii. Heft, 3 u 4,) claims that
the hitherto received theory of pulmonary movements
is incorrect. Lung movements he maintains cannot
depend upon the difference of pressure upon the inner
and outer aspects of the lungs respectively. Clinical
observations also agree with this inasmuch as a collapsed
lung can again expand even in the absence of a negative
pressure. Lungs also may collapse without any pre¬
existing change in the pressure conditions. According
to Sauerbruch’s investigations in cases of unilateral
pneumothorax, it is not the collapse of the lung that
proves fatal, but the sudden failure of respiration.
Hellin concludes that expiration is not the result of
the pressure of the thorax, and that inspiration is by
no means necessarily influenced by the adhesion of
the lungs to the chest wall. M.

The Blood Pressure In Athletes. —Gordon has in¬
vestigated the blood pressure before and after exercise
^Edinburgh Med. Journal, July, 1907). The subject
of his observations was a champion club swinger, who
had arranged to swing his clubs for twelve hours con¬
tinuously on six consecutive days. The individual was
found to be a perfectly healthy athlete set. 38. The
observations were made by means of a Riva Rocci
and an Erlanger’s sphygmomanometer ; the pressure
being taken immediately before and immediately
after the exercise. It was found that the pressure was
on each occasion raised some 15 mm. ' after the exercise,,
but this rise was invariably gone by the next morning..
More violent exercise, such as playing football, seems,
on the other hand to cause a fall of pressure of about
25 mm. Hg. M.

The Influence of Smoking on the Circulation.—
Hesse has systematically examined (Deutsch. Archiv.
fur Klin. Med., Bd. 89., p. 565) the blood pressure,
systolic and diastolic, and the pulse frequency in
smokers, before and after smoking, with the object of
determining the influence excited by nicotine on the
circulation. He finds that in almost every case a
marked rise of blood pressure takes place after smoking,
and that this is accompanied by an increase in the
pulse rate. The greater the age of the individual, the
more marked is the rise. The rise, moreover, is much
more evident on the systolic pressure, than on the
diastolic. It occurs quite quickly, but does not persist
long. Sometimes the aortic sound becomes markedly
accentuated during smoking. Hesse concludes that the
general effects of nicotine on the circulation are
stimulating rather than the reverse, and he thinks that
some 01 the cardiac troubles met with in smokers may
be the result of cardiac overstrain. M.

The Metabolism in Arthritis Deformans. —King has
studied exhaustively the metabolism of a case of
arthritis deformans (Johns Hopkins Hospital Bulletin,
July, 1907, p. 274), and has come to the following
conclusions:-^!) There is undoubtedly taking place
in the organism an acidosis, due to organic acids and
mild in nature. The actual organic acids were not
identified, but it was shown that neither diacetic
acid or oxvacetic acid were present; (2) the acidosis
is combated chiefly by an increased ammonia pro¬
duction ; (3) throughout the course of the experiment
there was a retention in the body of calcium, magne¬
sium and phosphates; (4) there was no evidence
from the urine of any acid intestinal putrefaction,
and the ratio of the aromatic and perfumed sulphates
remained about normal; (5) an increase in the
organic phosphates in the urine coincides with the
increase of organic acids; (6) the disturbance in
the elements maintaining the alkalinity of the body
was very slight. M.

WEEKLY SUMMARY.

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256 The Mkdical Press. NOTICES TO CORRESPONDENTS.

Sept. 4 , 1907 .

NOTICES TO
CORRESPONDENTS, ffc.

•VCorbespoxdrnto requiring a reply in this column are par¬
ticularly requested to make use of a Dutinctiv Signaturt or
Initial, and to avoid the practice of signing themselves
'■ Reader,” “ Subscriber,” " Old Subscriber,” etc. Muoh oon- 1
fusion will be spared by attention to this rule.

SUBSCRIPTIONS.

Subscriptions may commenoe at any date, but the two volumes ]
each year begin on January 1st and July 1st respectively. Terms |
per annum, 21s.; post free at home or abroad. Foreign sub- *
scriptions must be paid in advance For India, Messrs. Thacker,
Spink and Co., of Calcutta, are our officially-appointed agents.
Indian subscriptions are Rs. 15.12.

South Wales.— We have protested again and again against
the habit of journals calling quacks, herbalists and abortionists
” doctor,” but it seems to make but little difference. The sub¬
editor and the reporter of the ordinary daily newspaper have
little care but for what will make a good head line, and we
must trust to time and education to teach them the difference
between a quack and a qualified man.

THE ETIQUETTE OF CONSULTANTS TOWARD GENERAL
PRACTITIONERS.

General Practitioner. —The relations between Surgeon B and
vour patient appear to us to depend on the position in which
Surgeon B was placed at the first consultation. If you were
prepared to take the management of the oase, and if Surgeon B
was called in merely to give his opinion at the time and to
prescribe treatment, he has acted incorrectly in communicating
any facts to the patient save through you, and he was not en¬
titled to see the patient at his house, even if the patient
requested him to do so, unless you sanctioned such an arrange¬
ment. If, on the other hnnd, it was arranged at the first con¬
sultation that Surgeon B should take on the management of
the case, he is, of course, entitled to adopt any precautions he
thinks necessary to acquaint the patient of the course of his
Case, and to see him as often as is necessary. At the same time,
however. It would only be courteous and proper cn his part to
acquaint you at onoe with any new developments.

Dr. G. F. S.—Tour communication cam* to band as we were “ at
press" ; It will appear In our next.

Weed. —We know that certain efforts have been made to rid
tobacco of niootine, but we believe they have never been thor¬
oughly successful, and no nicotine-less tobacco that we know of
has been plaoed on the market. Dr. Lcsieur, of Lyons, is an
Enthusiast on denicotinisation, and he would doubtless reply
to any letter you might address to him.

Mr. Ht. 8 .—See reply to Dr. G F. 8.

Humanitarian.— Thank you for brochure, which we already
know and value. We fancy you cannot have read all our com¬
ments, as imprisonment for debt was distinctly and specifically
reprobated by us. We hold in horror the praotloe of sending
working men to prison for trumpery debts, and wish you every
success in your efforts to put an end to it.

Houss Surgeon. —Tea, It has been definitely decided by the
■Comnittee lhat women doctor! will be considered no longer eligible
for the post.

G. B.—We think that, so far as four-fifths of Ireland ape
concerned, your religion will effeotnally prevent yon from obtain- ''
ing any suoh post as you seek, no matter what your qualifica¬
tions. So far as the remaining fifth is concerned, your religion
might not be a bar, but we doubt if your qualifications would
be taken into consideration unless there was no local candidate
in the field. Temporary appointments therefore, as a means of
leading up to a permanent appointment, do not appear to pos¬
sess a high value. It may be some consolation to you to know
that the appointments you seek are universally considered to
be not oonducive to the future happiness or welfare of their
holders, and that under the present condition of things you
will be far better elsewhere.

tJarattaeB.

Bridgnorth and South Shropshire Infirmary.—House Surgeon.
Salary £100 per annum, with board and lodgings in the
Infirmary. Applications to the Hon. Secretary, the Infirmary,
Bridgnorth.

West Norfolk and Lynn Hospital, King's Lynn.—House Surgeont
Salary, £100 per annum, with board, residenoe, and washing.
Applications to the Chairman at the Hospital.

Leicester Corporation.—Isolation Hospital.—Resident Medical
Officer. Salary £120 per annum, with board, lodging, and
washing. Applications to 0. Killick Mallard, M.D., Town
Hall, Leioester.

County Borough of Salford.—Fever Hospital.—Assistant Medical
Officer at the Ladywell Sanatorium, Salford. Salary, £150
per annum, with apartments and board. Applications to
L. C. Evans, Town Clerk, Town Hall, Salford.

Egyptian Government.—Kasr El Ainy Hospital.—Resident

Medical Officer. Salary £250 a year, with quarters, servants,
washing, coal, and light. Applications to the Director-
General. Public Health Department, Cairo.

Tork Dispensary.—Two Resident Medical Officers. 8 alary, £120
a year, with board, lodging, and attendance. Applications
to W. Draper, Esq., De Grey House, Tork.

Loughborough and District General Hospital and Dispensary.—
Resident House Surgeon. Salary £100 a’ year, with fur¬
nished rooms, attendance, board, and washing. Applications
to Thos. J. Webb, Secretary, Loughborough.

Carlow Distriot Asylum.—Resident Medical Superintendent.
Salary, £350 per annum. Applications to John Keenan,
Secretary Joint Committee.

National Maternity Hoapitnl, Holies Street, Dublin.—Intern
Assistant Physidian. Salary, £50 per annum. Applications
to the Secretary, Holies Street.

Middlesex County Asylum, near Tooting, S.W.—Fourth Assistant
Medical Offloer. Salary, £150 per annum, with board, lodg¬
ing, and washing. Applications to the Medical Super¬
intendent.

Southwark Union, London.—Second Assistant Male Medical
Officer. Salary, £100 per annum, with board, lodging, and
washing. Applications to Howard C. Jones, Clerk, Union
Offices. John Street West, Blackfriars Road, 8 .E.

Devonshire Hospital, Buxton.—House Surgeon Salary, £100 per
annum, with furnished apartments, board, and laundry.
Applications to the Secretary.

Canterbury County Borough Asylum.—Medical Superintendent.
Salnry, £350 per annum, with unfurnished house, coal, light,
washing, garden produce. Applications to the Town Clerk,
15 Burgnte Street, Canterbury.

Cambridgeshire, etc.. Asylum.—Second Assistant Medical Offloer.
Salnry, £120 per annum, with board, lodging, and attendance
. in the Asylum. Applications to T. Musgrave Francis, Clerk
to the Visitors, Cambridge.

^ppoittttnentg.

Ash. Edwin L., M.B.Lond., M.R.C.S.Eng.. Clinical Assistant «t
Great Northern Centrnl Hospital, London, N.

Ball, W. Girling, F.R.C.S., Assistant Surgeon to the City of
London Truss Society.

Collins, E., M.R.C.S., L.R.C.P., District Medical Offloer of
Bishop's Stortford Union.

GoRnAM, P. C., L.R.C.P., L.R.C. 8 ., Certifying Factory 8 urgesn
for the Clifden Distriot, oo. Galway.

Ellison, Francis Charles, M.D.Dub., Resident Medical Super¬
intendent, Mayo County Asylum, Castlebar.

Gask, G. E., F.R.C. 8 ., Surgeon to the City of London Tuss
Society.

Hebb. J. H., M.B., B.Ch.Oxon., B.A., District Medical Officer of
Bicester and Headington Unions.

Hustler, G. H., M.B., Ch.B.Leeds, Government Medical Officer
for Fiji.

Lawson, T. C., M.R.C.S., District Medical Officer of 8 tratton
Union.

Mair, Gavin D., M.B., B.Ch., Resident Medical Officer, Royal
Albert Hospital, Devonport.

Paul, V. G. J., M.R.C.S., L.R.C.P.Lond., Distriot Medioal Officer
of the Tendring Union.

Ridlet, T., M.B.Melb., Assistant Resident Medical Officer of the
Midwifery Department of the Women's Hospital, Melbourne.

Walfobd, H. R., M.R.C.S., L.R.C.P., Assistant Surgeon to the
Coventry and Warwickshire Hospital, Coventry.

Williams, E. G. H., M.R.C. 8 ., L.R.C.P., District Medical
Officer of the Droitwioh Union.

girths.

Edwards.— On August 28th, at Westcroft, Privett Road, Gosport,
the wife of Lieut, u. B. Edwards, R.A.M.C., of a daughter.

Ltl*.— On A«g. 30th, at “ I’planda.” Bournemouth, the wife of
Lieutenant-Colonel Allan Lyle, R.A.M.C. (retired), of a daughter.

MacCabtht. —On August 26tn, at Glenaveena, ClooDey Park,
Londonderry, the wife of Brendan MaoCarthy, M.D., D.P.H.,
Med. Inspect. L.G. Board, Ireland, of a son.

Pabsons.—O n August 28th, at 26 Parliament Hill Mansions,
N.W., the wife of W. B. Parsons, M.R.C.S., L.R.C.P., of a
daughter.

Walker. —On August 2lBt, at Tewdale, Lee-on-the-Solent, Hants,
the wife of Lewis Walker, M.D.Lond., of a daughter.

JHarriagt*.

Clare—Dorin.— On August 29th, at All Saints’ Church, South
Lambeth, the Rev. Mervyn Clare, Minor Canon of St.
Cantce's Cathedral. Kilkenny, only son of the Rev. Mervyn
A. Clare, of Blackheath, to Florenoe Margaret (Daisy), only
daughter of A. F. L. Dorin, M.R.C. 8 ., of 344, Clapham Road.
London.

Renton—Borman.—O n 8 ept. 2nd, at All Batata’ Parish Church,
Bloomsbury, London,Maurice Waugh Renton, M.D.. of The Bridge
House, Dartford, to Raima Olivia Borman, daughter of Allen
Borman, Eaq., Alexandria, Egypt.

Wright—Tatlor.— On August 28th, at the Pariah Church, Lyons,
Hetton-le-Hole, near Durham, Archibald Franois Wright,
M.B., third son of the late Strethill H. Wright, M.D., of
Ganarew, near Monmouth, to Dorothy Mary, daughter of the
Rev. R. H. Taylor, D.D., Rector of Lyons.

•Barths.

Croft. —On August 96th. at Cheam. Surrey, Anna Maria Croft,
widow of the late Robert Charles Croft, M.D.

Inolis.—O n August 29th, at 2 East Asoent, St. Leonards-on-
Sca, Wilhelmina Slmson, wife of Arthur 8 tephen Ingli*.
M.D.

Wiooins.— On August 25th, at Gt. Misaenden, Brio, the eldest
son of Charles Wiggina, M.R.O.S., L.R.C.P.Lond., of 117
Ladbroke Grove, London, aged 14 years.

The Medical Press and Circular.

“ SALUS POPUU SUPREMA LEX."

Vol. CXXXV. WEDNESDAY, SEPT, n, 1907. No. ir

Notes and Comments.

Of all the learned professions it
Tlw may pretty safely be asserted

Apprenticeship there is none in which the aspirant
of Medicine. finds himself faced with greater
obstacles than in that of medicine.
After being tested as to his general education by
preliminary examination he has to settle down to
five years of hard and systematic study. At cer¬
tain intervals his knowledge of the various subjects
included in the curriculum is severely tested, and
it is only when he has succeeded in satisfying his
examiners on all points that the desired quali¬
fication to practise is granted. In some instances
the student is not able to pass his examinations
within the allotted five years and has to spend a
further period in study. Oftentimes when he is
ambitious of taking the higher degrees and quali¬
fications and of embarking in consultant or
specialist practice he deliberately makes up his
mind to two or three extra years of pupilage.
What with multiplicity of subjects and increasingly
higher standards, the students’ career, as above
outlined, connotes the expenditure of a vast
amount of time, energy and money, ere the goal
is reached and the fully fledged practitioner
enters upon the serious work of his life.

Then the official sanction having
A Noble been acquired, the newly fledged
Profession- practitioner of medicine is

launched upon the sea of pro¬
fessional life. The right has been
conferred upon him by the State to intervene in
the unceasing struggle of mankind against disease
and accident and other adverse influences of
environment. A cynical French physician,
writing some time ago in the columns of The
Medical Press and Circular, reminded a
young friend about to commence practice that his
diploma was written on the skin of an ass. On
this side of the Channel it would probably be
engraved on that of a calf, but in either case it
would not interfere with Dr. Cornu’s advice to
his correspondent not to resent the inference, but
rather to regard it as a tacit injunction to be
patient, courageous and gentle. For these are
high qualities, and they are demanded of all who
would be worthy of a noble profession. Yet the
conditions of society are such that mere abstract
nobility of the kind involved will not become a
satisfactory footing for the struggle for existence.

There is a financial side of the pic-
Ttae Financial ture, the neglect of which will sooner

Aspect or later spell ruin to the most

of Practice. ardent enthusiast in scientific

work, unless, indeed, he is for¬
tunate enough to be in possession of an indepen¬
dent income. The student can afford to follow
science for science’s sake; the practitioner, on the
other hand, has to practise art for something
more than art’s sake. It is all very well for
medical men, who, by the way, are usually
those in possession of a comfortable income,
to deplore the spread of trade-union ideas and to
deprecate the commercial spirit amongst their
medical brethren. There is nothing dishonourable
in taking a proper collective care of the financial
factors of the situation, which have, unfortunately,
in the past been often disregarded, with most
disastrous results. It is not as if the State in
conferring the right to practise the healing art
upon properly qualified men had taken care to
protect them against the inroads of unqualified
pretenders. Members of Parliament are far too
apt to consider that the State has granted an
enormously valuable monopoly to the profession
and is entitled in return to exact as much gratuitous
service as can be wrung from the profession. The
more precise statement of the situation is that
the State has imposed certain restrictions upon
medical men so as to ensure a proper supply of
skilled practitioners in the interests of the public.
By permitting the competition of a whole host of
quacks and patent medicine vendors the State
has betrayed the medical profession and aban¬
doned with cynical shamelessness the wholesome
principle of the protection of the public safety.

The State, as we have already
said, exacts many gratuitous ser-
As Instance ! vices from the medical profession.

As an example may be taken
the death certificate, which is
signed by the medical attendant of deceased, and
for which no fee is payable. The legal document
in question is of importance in many ways, and
may form the crucial proof in various lawsuits.
From no other profession in the world would the
State attempt to exact a similar substantial
service without the payment of a suitable fee in
return. One may fancy the utter contempt
with which the lawyers would resent any attempt
to exploit their profession in a similar way. Such
and such a fee would be demanded for signature,
correspondence would be charged at the rate of
six and eightpence a letter, and other work in

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258 The Medical Tress.

NOTES AND

connection with the required document would be
entitled to corresponding rates of remuneration.
When it comes to medical men. however, the
element of humanitarian kindness is m some
extraordinary way confused with the principles that
eovem an ordinary business transaction, so that
the matter usually ends by the required service
being rendered ‘‘free, gratis, and for nothing.
In many ways this must, in the long run, prove
a bad bargain for the community, for it is only by
maintaining the medical profession in a position
of honourable independence, from the point of
view of average professional income that society
can hope to maintain a high general standard of
professional conduct and competence.

No more glaring instance of the
Mr John Baras attitude of Parliament towards
aad the Birth the monetary interests of the
Certificate. medical profession could be ob-
” tained than that afforded by the

recent Notification of Births
Bill Under the guidance of Mr. John Burns the
measure has passed into law. It provides for the
future notification of all births, an obviously
salutary measure, but it makes no provision for
the payment of the medical mail who sends the
necessary intimation. At one stage of the pro¬
ceedings in the Commons it was determined to
pay the medical attendant the magnificent sum
of one shilling for each signature! At a later
stage of the proceedings, however, even that
frail sum vanished into thin air, and Government,
following the hallowed precedent of centuries,
have framed a law whereby the medical practi¬
tioner under pain of various penalties, is com¬
pelled to sign a responsible document giving
information obtained in his professional capacity
without fee or reward. The incredible meaness
of this transaction is not what one would have
looked for from the President of the Local Govern¬
ment Board, who, of all men, we should expect
S xWiise the principle that the labourer is
worthy of his hire. The medical members of
Parliament in the House protested agamst the
measure but they were not numerically strong
enough to prevail. The lamentable lack of medi¬
cal* 'representatives in the Commons was never
more disastrously in evidenece than in the passage
of Mr. John Bums’ memorable Notification of

Births Bill.

The above is written in no spirit
of mere discontented grumbling
or of unbelief in the future welfare
of what is justly termed a “ noble
profession.” It is written, how¬
ever in the firm belief that
Heaven helps those'who help themselves. From
that standpoint we would urge the medical
student from the outset of his career to pay careful
attention to all organisations that are directed to
the task of protecting the material mter^ts of
the profession to which he belongs There are
various ways in which the general welfare of
medical men may be forwarded In the fore-
front of these agencies we should Pjaje that of
legislation against quacks and quackery. For
nyajiy years past it has been our mission to urge
the desirability of such preventive action not only
in the interests of medical men but also in those
of the great outside public. Of late we have
added to our programme the suggestion of

The Moral
of the
Matter.

COMMENTS. _ Sept. 11. 1907-

Royal Commission to enquire into the terrible
abuses and injury sustained by the public at the
hands of quacks and patent medicine vendors. We
are glad to say that the pharmaceutical profession,
as a whole, is making efforts in the same direction.
During the year we hope to bring this matter of a
Royal Commission before the profession and the
public in concrete form.

The attitude of the Stated-alias the
For the Parpose community—towards medical men
of Acqalriaf is curiously illustrated by the laws
Miami Skill, passed to control vivisection. The
very title of the measure— 1 he
Cruelty to Animals Act’’—begs the question, be¬
cause It tacitly implies that all vivisection is cruel.
With the merits or demerits of the controversy we
are not here concerned. Briefly the attitude of
scientific medicine is that experiments on living
lower animals are necessary to elucidate many
processes of physiology and pathology ; that they
have rendered priceless service in the past to
medical progress ; and that, properly guarded, thev
are absolutely warranted from a moral ■point of
view in the interests of mankind. In the above-
mentioned Act experiments calculated to give pain
to living vertebrate animals are prohibited under
various specific restrictions. Amongst the latter is
one that says they must not be performed for the
purpose of acquiring manual skill! A man may
maim rabbits, hares, and partridges ad libitum
until he becomes a good shot—but a surgeon must
acquire his skill from patients. So says the law—
the wise law—the law passed to satisfy the senti¬
mental anti-vivisectionist. The satire of it all is
that even anti-vivisectionists want surgical opera¬
tions, and then—then—why, they have them, and
their lives are saved as the outcome of vivisection!

Many things wanted to ensure suc¬
cess in practice are not taught in the
Tact. schools. Devotion to duty is one
of them ; not only the patient self-
sacrifice, and the holding to right
because it is right, but the less exalted form which
is prized bv the public, namely, that of promptitude,
and of careful attention to the history of symp¬
toms, however detailed, minute, and wandering.
The latter point is one of the manifold skilful
strokes in the game that in their entirety constitute
that evasive quality which we all know as “tact.”
Sooner or later, it may be at the cost of dire
experience, that faculty has to be acquired by the
medical man who would succeed in the exercise of
his profession. To quote once more from Dr.
Cornu, “ Practising for the public an art which it
is incapable of judging, you must not hope to
create an impression by your knowledge of disease,
but by your knowledge of men. The more illusions
you have brought into your career me more will
the reality have bruised your delicacy of intelligence
and sentiment, the deeper will be your fall, and the
more dangerous the depression which experience is
holding in wait for you.”

There is a rosy side to the pro-
_ fessional life of the medical prac-
Tie Ko*y titioner, in spite of quacks and
Side. quackery, of anti-vaccinators and
anti-vivisectionists, of bad debts, of
harassing wqrk, of hospital competition, and of the
score of other rocks and shoals that strew the sea
of practice. The profession is honourable and
intellectual: it is one becoming the traditions and
the character of a trentleman: *1 is humane, charit¬
able, it is progressive, it is intellectual, and, above

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PERSONAL.

The Medical Press. 259

all other callings in life, it is essentially human.
Well may the line of Terence —Homo sum, humani
nil a me alienum puto —be adopted bv the liberal- !
minded and zealous practitioner of medicine. Yet
must he follow his ideal with no divided affections.
The work of his profession must be his life-work— 1
to be pursued with whole-hearted devotion to the
last day of his life. Nor is the chance denied to
the most remote and humble 'follower of medicine
of contributing some fresh discovery or observation
of value to the sum total of medical achievement.
We have but to remind ourselves that some of the
great things in medicine have come from country ;
practitioners.

|

Cholera is markedly on the increase
The Approach in Russia. It has taken the usual
of course, and is mounting up the

Cholera. Volga, leaving a train of victims in

its rear. That important centre,
N'ijni Novgorod, has now been invaded, fifty-five
cases, with seventeen deaths, being reported there
within the last few days. Nijni Novgorod is a
large trading centre, and there is constant com¬
munication between it and Germany, so that the
authorities in the latter country have naturallv
taken alarm, and rigid inspeotio’n of travellers is
taking place at the frontier. Inspection, however,
in the case of cholera, is not of much service, as
the germs of the disease may be latent in a person
in apparently irood health, 'but who mav rapidlv 1
become a source of extreme danger to others. Now |
that communication between India and Russia is
being opened up more freely, the chances of the
dissemination of cholera are correspondingly in¬
creased, and it may be expected as almost a normal
autumnal event in the future for the disease to
pass into South-East Europe. Probably, however,
the outbreaks, although more frequent, will not
attain the terrible proportions of the epidemics of j
i86q and 1892, which created such havoc in |
European countries, and this country is certainlv I
safe this year from any risk of serious incursion.
On the other hand, however, while India remains |
the endemic centre of cholera, it will be one of
the burdens of (the Empire to seek to limit the i
excursions of the disease, and its rulers must,
among their other troubles, seek to grasp the !
enormous responsibility that rests on them in the
matter.

CURRENT TOPICS.

Public Health in Ireland.

The complacency with which the various ;
public bodies, charged with the control of public !
health in Ireland, regard their own petty actions !
would be amusing were it not tragic. With urban \
death-rates among the highest in Europe, with
infantile mortality out of all relation to the occupa- ,
tion of the people, with tuberculosis decimating j
the youth of the country, every sanitary authority |
persistently plumes itself on its energy and effi- j
ciency. In a debate in the Dublin Corporation, |
last week, we find aMr.Clancy boasting that “out !
of chaos was evolved a city that they were all proud j
of. Out of a city of dirt and squalor and filth there 1
had been produced a city that they were not
ashamed to have people visiting.” We fear it is i
bue that Mr. Clancy and his friends are not '
ashamed that the death-rate in Dublin County J
Borough last year was 25 per 1,000, that the
streets of the city are the filthiest of any city in 1

the Kingdom, that every branch of sanitary work
is neglected. If shame were felt at these things,
there would be more hope of improvement. It is
not the election bodies alone, however, which are
to blame. The Local Government Board, whose
duty it is to lead and advise the local bodies, is as
boastful as Mr. Clancy and as inert as the meanest
district council. Their representatives at a con¬
ference concerning tuberculosis a week or two
ago declared proudly that the Local Government
Board was fully awake to the serious nature of
the tuberculosis problem. The evidence of their
wakefulness was the issue of their circular during
the course of the past thirty-s^x years’. In 1906,
11,756 persons died in Ireland of tuberculosis.

PERSONAL, j

Dr. William Ewart will deliver the annaul inaugural
address at St. George’s Hospital, on Tuesday, Oct.
1st, the subject being “ Res Medica, Res Publica.”
The annual dinner will be held at 7 p.m.. the same even¬
ing, at the Whitehall Rooms, Hotel Metropole.

Colonel P. H. Benson, I.M.S., has been appointed
Principal Medical Officer of the Secunderabad Brigade.

Professor Osler, M.D., F.R.S.. will give the in¬
troductory address at St. Mary's Hospital Medical
School on October 2nd.

The Volunteer Decoration has been awarded to
Surgeon-Major C. A. MacMunn, 3rd (Vol.) Battalion of
the South Staffordshire Regiment, and to Surgeon-
Major George Hollier, 2nd (Vol ) Battalion of the
Shropshire Light Infantry.

Miss Alice Brunton, daughter of Sir Lauder
Brunton. . has been awarded the diploma of Offtcier
de 1’Instruction Publique by the French Minister of
Public Instruction, in recognition of her services to
the late International Congress on School Hygiene.

Dr. D. Newman, Dr. D. C. McVail, Dr. J. C. Renton,
Dr. D Macartney, and Dr. James Barras have been
appointed medical referees for Lanarkshire under the
Workmen’s Compensation Act. 1906.

By the retirement of Colonel James Magill, M.D.,
C.B., the Royal Army Medical Corps will be deprived
of the services of a most capable officer, whose many
years of good work in Egypt and the Transvaal and
other parts of the world, has been highly appreciated.

We have much pleasure in recording the rescue of
a lady from drowning by Dr. Alfred Walker. The
incident occurred at Port Gaveme, in Cornwall, and
Dr. Walker, who was bathing at the time, pluckily
proceeded to the spot where the lady sank and suc¬
ceeded in bringing her to shore

By the will of the late Mr. William Marsh, the West
Bromwich District Hospital has benefited to the
extent of £1,000, while the Birmingham General
Hospital and the Queen’s Hospital, Birmingham,
receive £350 each.

On September 5th the /ahton Board of Guardians
passed a resolution view" g with surprise and alarm
the utilisation by the (. .xporation of the isolation
hospital for the treatmen: of so highly infectious a
disease as scarlet fever, having in view the close
proximity of the workhouse !

The will of the late Sir William T. Gairdner has
been proved at £11,255, of which ^2,604 were derived
from insurance policies.

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26 0 The Medical Press.

ENGLAND—EDUCATION.

Sept, it, 1907-

Educational Summary for 1907-8.

INTRODUCTORY REMARKS.

If the pursuit of medicine is judged by the sneers of
latter-day cynics like Bernard Shaw, or the bludgeon-
blows of literary aliens like Maartens Maartens, it
would appear to be a particularly mean and sneaking
method of extracting coin out of the pockets of
wealthy fools. But these gentlemen and others of
their kidney have little title, as far as we can gather,
to formulate indictments against a profession with
whose members and whose work they must be
strangely unfamiliar. Superior persons who wish to
impress their generation with an idea of their tran¬
scendent perspicacity find a short and easy method of
doing so to consist in sweeping all the dirt they come
across into one corner of a room, and pointing to
that as a sample of the condition of the floor. A
better and more effective method of arriving at the
true estimation in which a calling is held is to apply
to the average man, who lives an average life, and has
no wish to twinkle in the literary firmament as a star
of the first order. It may pretty safely be laid down
that the average man looks to his doctor not only as
a trusty counsellor, but as a particularly good friend
in time of trouble, and the practical reliance of such
a man on his medical adviser is a better testimony
to the latter’s worth than all the problem-plays and
six-shilling novels of a lustrum. It is a fact, and
one worth noting, that in ordinary middle-class and
upper middle-class society a medical man is not only
always sure of a cordial reception, but he is always
regarded among his patients as a peculiarly intimate
friend, and one whom they are especially pleased to
honour. 'Now, inasmuch as a medical man has no
ready-made position of authority such as has a clergy¬
man, nor the prestige of one of the destructive pro¬
fessions, such as the army or navy, nor the prospect
of wealth that may be garnered from business, but
simply his own attainments and personality to rely
upon, it follows that the calling of medicine must
attract men of higher potentiality than other lines of
life, and endow them with an unusual degree of
urbanity and kindliness, for them to attain such
a position as we have indicated. If the ordinary
general practitioner were possessed merely of a
technical knowledge of bodily ailments, he might
find rank and comradeship! proportioned to his
special attainments, but he would not gain that
all-round respect or friendliness which is undoubtedly
his. Thei cause for this social estimation lies
largely in the humanising influence that the practice
of medicine exerts on its followers; the knowledge of
men and women at their best and at their worst, a
knowledge which fails to make doctors cynics, but
succeeds in making them sympathetic friends. They
know how much may reasonably be expected cf
human nature, and are not soured with mankind
when they find the popular general on his sick-bed
wincing before the scalpel, the philanthropic peer
grumbling at the flavour of his medicine, the anti¬
vaccinationist tub-thumper slinking round after dark
to have the poisoned lymph inoculated in his arm, or
the blatant anti-vivsectionist begging for antistrep¬
tococcic serum when he has a cut on the finger. All
these things come in his day’s work, and he early
learns that disillusionment is a matter for happy
mirth rather than for acid sarcasms on his fellows
and their shortcomings. Moreover, his work soon
shows him more clearly than that of anyone else
where true valour and real goodness are to be found.

He knows that the plucky little mother who labours
for her family of six, and wears a perpetual smile, is
never free from pelvic trouble that no one guesses
at, and he knows that the shuffling shopman, whose
clumsiness excites the ire of his customers, is making
a brave struggle not to let his mitral disease break up
the business he has put together himself. In the
doctor’s view of life the mother and the shopman
more than outweigh the shrinking general and the
testy lordling. The reward of the medical man’s work
and the pleasure of his existence is to be measured,
then, by the benignity he acquires as he grows older,
and certainly not by his balance, if balance there be,
at the banker’s. The man who sets out in practice
with the intention of making a fortune and •‘found¬
ing a family ” is rapidly undeceived ; the conditions
of work and its /remuneration leave no scope for
such tokens of worldly success. If, through a happy
combination of private means, professional success,
and influential friends he finds himself attached to
the Court and the recipient of a baronetcy, the highest
external honours available for a medical practitioner
will have been attained, but he will figure but
ignominiously in the eyes of society when he sits
down to dinner with an Archbishop, a Lord Chan¬
cellor, a Field Marshal, a belted brewer, and a bacon
king. In fortune, in influence, in importance in the
councils of the State, the medical man can compare
with none of these.

Let him make his goal, then, the accomplishment of
small things and the advancement in the degree
nearest his hand of the sum-total of medical know¬
ledge. Let him seek to be an accomplished and
resourceful practitioner, willing and able to lend a
hand at any time and place to the sick and sorry,
and to his brother practitioner; aiming at making an
honest livelihood through upright and sturdy
methods, and not hoping what he can never expect,
namely, to rise to dignities and honours which are
reserved for other callings than that of tending the
sick.

Choice of a School.

The first decision that a student has to make, once
he has irrevocably mated himself to the study of
medicine, is as to where he shall carry out his inten¬
tion. He would indeed be ungrateful if he grumbled
that a wide enough choice was not provided for him,
for with fifteen or sixteen Universities in the British
Isles, many of them provided with several constitnent
schools, surely only a misanthrope could complain
that his tastes, wishes, and predilections were cot
catered for. As practically all these Universities and
schools are badly off for money, and not too rich in
students, he may calculate on finding himself wel¬
comed wherever he finally decides to go, which is
indubitably an advantage at the outset of a career.
There is, as a rule, a certain tendency for a man to
look to his immediate vicinity for the maturing of
his genius, and in these days, when Universities are
cropping up with bewildering prolixity, most students
will probably find one within fifty or sixty miles, of
their homes. As the medical curriculum is laid down
carefully by the General Medical Council, there is
not much variation in that of the individual schools,
and a good all-round education can be relied on in
practically every one. On the other hand, some have
teachers of established ability and reputation, whilst
others are seeking to obtain that enviable notoriety,
and while some men may be attracted by the spirit of

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Sept, ii, 1907.

ENGLAND—EDUCATION.

The Medical Press. 261

adventure to cast in their lot with the new and
struggling, others will prefer the security of well-
trodden paths. The object of this number of The
Medical Press and Circular is to present ini-
partially the claims and attractions of all schools,
and if parents and their wards study its pages care¬
fully they will, we feel sure, be convinced that there
are none that have not their own special charms.
The outlay on actual necessary educational expenses
does not differ very materially in different places,
the higher cost of certain centres being chiefly
due to the greater cost of living. It is obvious
that in London, for instance, where rents are high,
the cost of lodgings must be considerably more than
in many smaller and less favourite towns, while, on
the contrary, a student living in his parents’ home
in London will not be so much expense to them if
he goes to a London Hospital as if he takes up his
abode at a northern university. But, other things
being equal, it is a most important point for the
average student to choose that school at which he
is most likely in after years to obtain a resident post,
and in this vital respect some of the less fashionable
schools can present much greater advantages to the
average man than can their more popular rivals.

Choice of Qualifications.

In a millennial state the question of the choice of
qualifications will not arise, as every man will
either be a doctor or not a doctor, without further
ado. It so happens, however, that in the course of
ages, among the anomalies surrounding the practice
of the art of medicine, there have grown up a number
of rival interests, both pecuniary and scholastic,
which it is very difficult to break down, with the
result that students are offered all sorts of qualifying
diplomas, conferring on them the right to append
almost every conceivable alphabetical combination to
their names. It may be laid down in general terms
that the shortest and least picturesque of these desig¬
nations will generally be found the most serviceable,
both from the expenditure of time that it will save in
signing certificates, and in the greater ease by which
it will be understanded of the people. Happily, or
unhappily, a qualification even of the highest order
has, as a rule, but small relation to success in
practice, and many practitioners of light and lead¬
ing will be found to have laid the foundations cf
their success on a more solid basis than that of
academical triumph. The degree of M.D. of a British
university should be the ordinary ball-mark of a
British practitioner as much as a native M.D. is of
his American confrere, but while those holding such
a degree consider their market value would be lowered
by its being “cheapened,” the south countryman will
be placed at a certain disadvantage as compared with
his northern rival.

Course of Study.

Although there are certain individual variations, the
course of study pursued at all the medical schools
is pretty much the same. One or two of the univer¬
sities are a little exacting in the number of special
subjects they pile on to the crouching backs of their
alumni, but in course of time it is generally found
that the other centres of instruction follow their lead.
Still, it is well to remember that from the moment the
student pays his fee to the dean the disposition of
each moment of his time for the next five years has
been laid down with procrustean exactness, and that
any diversion in the shape of amusement, illness, or
failure in examination connotes a corresponding addi¬
tion to the length of his pupilage.

Choice of Career.

The freshly-qualified man has the world open be¬
fore him, and he may content himself with the reflec¬
tion that his skill will be of as much service in

Greenland’s icy mountains as on India's coral strand,
and he can ply his art with as beneficent results,
though not with equal financial advantage, in Bethnal
Green as in Grosvenor Square. He can therefore
consult his predilections in some degree as to where
he will practise his profession, though he will pro¬
bably find the choice somewhat narrowed by the
pecuniary resources at his disposal and the meagre
opportunities offered for enterprise in the vicinity of
popular, established practitioners. If he be averse
from the struggle for existence in the troubled waters
of private practice, he may turn to the comparative
haven of competency afforded by the services. The
Army, Navy, Indian, Colonial, and West African
appointments may tempt him abroad, or the poor-law
infirmaries, lunatic asylums, public health officerships,
or fever hospitals may prevail on him to remain at
home. In all the official Government services there
is a career, even if a limited one, with graduated pro¬
motion and certain pension, whilst in the local services
at home promotion is very uncertain, the pay, except
in a few instances, very poor, and a pension either not
provided or calculated on a studiously thrifty basis.
One of the special advantages of medicine is that its
votaries are nearly always sufficiently in request to be
able to pick up a living as long as health lasts, but the
prospects it affords of an old age of dignity and
ease earned by professional diligence alone are some¬
what dim.

Summary.

Medicine, then, may be recommended chiefly to
those who have a strong turn for prying into the
hidden things of nature, and find great pleasure and
refreshment in so doing. To such the profession of
healing will offer numberless opportunities for apply¬
ing their peculiar powers, and will give much enter¬
tainment by the elusiveness of its secrets. The other
class of man who finds satisfaction in the practice of
medicine is he who regards the welfare of others
before his own comfort and convenience. These rare
beings, less rare probably in the medical profession
than in any other, make devoted practitioners among
the poor, and do not account their labour wasted if
their patient gets well but cannot afford through
stress of his illness to pay his bill. The man who
does not get on well at medicine is he who wishes to
account for all his services on a cash basis, and to
make his practice a purely business concern. As a
matter of fact it is not possible to translate personal
services into an exact money equivalent, and much
unpleasantness pursues the path of him who tries to
do so. The best that many men hope for is .hat a
reasonable number of honest and grateful people will
be found so far to appreciate his services that he is
relieved of financial strain for the next half-year.
Those who make ample incomes in medicine are few,
and the rush only lasts a few years. The man who
enters the medical profession as a path to fortune
is by way of being disappointed, though he who
seeks an honourable competency has a fair chance of
obtaining it.

THE ENGLISH UNIVERSITIES,

The English Universities are nine in number, viz..
Oxford, Cambridge, London, the Victoria, Durham,
Liverpool, Leeds, Sheffield and Birmingham. The choice
of a University is usually determined by social, geo¬
graphical, and financial considerations. Students
whose parents are able and willing to incur the
necessary expense will do well to select one of
the ancient Universities, since their degrees confer
upon their holders a status not accorded by the
public to the degrees of more modern institu¬
tions, To those less favoured by fortune, but blessed
with energy and a fair share of intelligence, the London

Digitized by GoOgle

262 The Medical Press.

ENGLAND—EDUCATION.

Seft. it. 1907.

University offers ample scope, and its degrees are recog¬
nised as the outward and visible sign of high profes¬
sional attainments. A capable and industrious student,
however, may equally well lay the foundations of
success in one of the newer provincial Universities.

OXFORD.

There are two degrees in medicine, B.M. and D.M.,
and two degrees in surgery, B.Ch. and M.Ch, The
B.M. and B.Ch. degrees are granted to those members
of the University who have passed the second (B.M.)
examination. Graduates in Arts, B.A., are alone
eligible for these degrees. In order to obtain the
degrees of B.M. and B.Ch., the following examinations
must be passed:—1. Preliminary: Subjects:—Mechanics,
and Physics, chemistry, zoology, and botany. 2. Pro¬
fessional (a) First examination (held twice a year):
Subjects :—Organic chemistry, unless the candidate has
obtained a first or second class in chemistry in the
Natural Science School; Human physiology, unless he
has obtained a first or second class in animal physiology
in the Natural Science School; Human anatomy ;
Materia medica with pharmacy, (b) Second examina¬
tion : Subjects :—Medicine, surgery, midwifery, patho¬
logy, forensic medicine with hygiene. The approxi¬
mate dates of the examinations are as follow : —Pre¬
liminaries:—Physics, chemistry, and botany. December
and June ; Zoology, March and June ; Professional
(First and Second B.M.), June and December.

The degree of D.M. is granted to Bachelors of Medi¬
cine of the University who have entered their
thirty-ninth term on presenting a dissertation
approved by the appointed professors and examiners.

The degree of M.Ch, is granted to Bachelors of Sur¬
gery of the University who have entered their twenty-
seventh term, who are members of the surgical staff of
a recognised hospital, or have acted as dresser or house
surgeon in such a hospital for six months, and who
have passed an examination in surgery’, surreal ana¬
tomy, and surgical operations. This examination is
held annually, in June.

Diploma in Public Health. —The examination for
the Diploma is held about the end of November in
each year, and is open to any registered medical
practitioner, whether he be a graduate of the Univer¬
sity of Oxford or not. It is conducted according to
the statutes and regulations of the University, and
these have been framed so as to be consonant with the
Resolutions and rules adopted by the General Medical
Council for Diplomas in Public Health.

There are many valuable prizes and scholarships,
details of which may be obtained from the University
Calendar.

The examination consists of two parts. In the first
of these candidates are required to exhibit a know¬
ledge of chemistry and physics in the relations of
these sciences to Public Health. In the second part
cf the Examination the candidate is examined in the
subjects of general hygiene and of pathology in its
bearings on Public Health. In all the subjects the
Examination is partly practical. Candidates may
offer themselves for the two parts of the examination
on the same occasion or cn different occasions; but
their admission to the second part is contingent on
their having already satisfied the examiners in the
first part.

Candidates who desire to prepare for the examina¬
tion within the University will be afforded facilities
for doing so in the laboratories of the scientific
departments concerned with the subjects of ex¬
amination ; and arrangements can also be made for
candidates to acquire a practical knowledge of the
duties of Public Health administration under the
supervision of the Medical Officer of Health for the
City of Oxford. Information on these points may be
obtained by application to the Regius Professor of
Medicine, University Museum, Oxford.

UNIVERSITY OF CAMBRIDGE.

At the University of Cambridge five years of medical
study are required for the M.B. and B.C. degrees. The
candidate must have resided nine terms (three years) in

the University, and have passed the " previous ” exami¬
nation in classics and mathematics, There are three-
examinations : The first in (1) chemistry and physics,
and (2) biology; the second in human anatomy and
physiology; and the third in (1) pharmacology and
general pathology, (2) in surgery, midwifery, and
medicine. The first and the third examinations are
divided into two parts, which can be taken separately,
Subsequently to the third examination an Act has to-
be kept which consists in reading an original thesis,
followed by an oral examination on the subject of the
thesis. As the subjects for the examination for the
degree in surgery are included in the third examination ,
for the M.B. degree, candidates are admitted to the
degree of Bachelor of Surgery on passing the third ex¬
amination for Bachelor of Medicine.

The M.D. degree may be taken three years after the
M.B. An Act has to be kept, including the presen¬
tation of an original thesis, with oral examinations
and an essay to be written extempore. There is also
the degree of Master of Surgery, for which the candidate,,
having already passed for B.C., or being M.A. has
otherwise qualified in surgery, has to pursue extra
study in surgery, and has a special examination or
submits original contributions of merit to the science
or art of surgery. The yearly expenditure of a student
who keeps his term by a residence in a college is from
^150 to £200 a year, This, however, may include all
payments to the University and the College—all fees as
well as clothes, pocket money, travelling expenses, &c.
Non-collegiate students have only to pay the University
fees, which are not large. They lodge and board as
they like ; their expenses, therefore, are entirely in-
their own hands.

The University grants a diploma in public health
without the necessity of residence, the examina¬
tion being in so much of State Medicine as is comprised
in the functions of officers of health, and subject to the
latest requirements of the General Medical Council.
These examinations are held in Cambridge the first
week in April and October. Candidates, whose names-
must be on the '* Medical Register ” of the United King¬
dom, and need not be members of the University, should
send in their applications to the Secretary of the State
Medicine Syndicate a fortnight in advance. Every
candidate who has passed both parts of the examination
to the satisfaction of the examiners will receive a
testimonial testifying to his competent knowledge of
the subjects comprised in the duties of a medical officer
of health.

There is also a special examination in Tropical Medi¬
cine and Hygiene, held annually in August. It is
open to qualified practitioners under certain conditions-
as to previous study and experience. Successful
candidates receive a University Diploma.

An abstract of all Regulations may be obtained upon
sending a stamped directed envelope to the Assistant
Registrary, Cambridge. Full information is contained)
n the University Calendar.

UNIVERSITY OF LONDON.

The Medical Faculty’ grants the degrees of Bachelor
of Medicine and Surgery’, Doctor of Medicine and
Master in Surgery. Under the new regulations the
students are divided into “ Internal ” and “ External.”
An internal student is one who has matriculated at the
University and is studying in a school approved by that
body, or under the teachers of the University’. An
external student is one who has adopted an alternative-
course of study’. The regulations differ somewhat in
their application to the two groups of students. We
only propose to deal with them as they affect internal'
students, since the special information required by the
others had best be obtained direct from the Registrar.
Under no circumstances will a student be admitted
to the final examination for a degree until at least five-
years have elapsed since matriculation or other exami¬
nation entitling to registration as a medical student.*

0 May obtain registration as Internal or External students on presen¬
tation of documentary evidence as to their condition and a payment
of £2 ; Graduates ot such British, Colonial, and foreign Universities
as are approved by the Senate for that purpose, and those who hare-

Sept, ii, 1907.

ENGLAND—EDUCATION.

The Medical Press. 263

The Matriculation Examination takes place thrice
yearly—in January, June (or July), and September.
Application for admission to it must be made on
a special form about six weeks beforehand, and the
candidate must have completed his 16th year at the
date of the examination. Candidates must show a
competent knowledge of five subjects, among which
must be English and elementary mathematics.

The Preliminary Scientific Examination takes
place twice in each year, in Jaiiuary and July, and
consists of papers on inorganic chemistry, biology,
and physics, and there will be a practical exami¬
nation in each subject. Examiners will also be at
liberty to test candidates viva voce. A student may
present himself for examination in each of the three
subjects, separately or in all at the same time. Part I.
of this examination includes papers in inorganic
chemistry, physics, and biology, with practical ex¬
aminations ; Part II. is an examination in organic
chemistry. Six months must elapse after passing
Part I.

The Intermediate Examination in Medicine will take
place twice a year, January and July. Candidates
must have passed the Preliminary Scientific Examina¬
tion at least two years previously. The subjects of
examination are Anatomy, Physiology and Histology,
and Pharmacology, including Materia Medica. Can¬
didates who have failed in one subject only at this
examination may offer themselves for re-examina¬
tion in that subject, if permitted to do so by the
examiners. Three scholarships, one of the value of
£40 in Anatomy, another of the same amount in
Physiology, and one of £30 in Pharmacology may be
awarded by the examiners to any candidate who has
passed the whole of the examination at one time.

Provincial Examinations for Matriculation. —These
examinations are appointed by the Senate from time
to time upon the application of any city, institution,
or college desiring to be named as a local centre for
one or more examinations in London under the super¬
vision of sub-examiners also appointed by the Senate.
Candidates wishing to be examined at any centre must
give notice upon their forms of entry to the Principal
of the University. Besides the University fee a
fee usually varying from £1 to £3 is charged by the
local authorities and must be paid at the local centre
before the commencement of the examination.

The Final M.B., B.S. Examination takes place
twice a year, in October and May. No candidate
is admitted to this examination unless he has com¬
pleted the course of study prescribed in the schedule or
in less than two academic years from the date of passing
the Intermediate Examination in anatomy and
physiology.

The subjects of the examination are Medicine (includ¬
ing Therapeutics and Mental Diseases), Pathology,
Forensic Medicine and Hygiene, Surgery, and Mid¬
wifery and Diseases of Women. The subjects may be
divided into two groups, one of which shall comprise
Medicine, Pathology, Forensic Medicine and Hygiene ;
and the other Surgery, Midwifery and Diseases of
Women. Either group may be taken first at the option
of the candidate, or the groups may be taken together.

Doctor of Medicine. —The examination for the degree
of Doctor of Medicine is held twice a year, in
December and July. Every candidate must have
passed the examination for the M.B., B.S., of this
University. Candidates may present themselves for
examination in one of the following branches : (1)
Medicine, (2) Pathology, (3) Mental Diseases, (4)
Midwifery and Diseases of Women, (5) State Medicine :
and if they wish, may pass also in another branch at a
subsequent examination. Candidates for Branches
1 to 4 who have taken honours at the M.B., B.S.

passed all the examinations required for a degree in those Universities,
also women who have obtained Tripos certificates granted by the
University of Cambridge, and women who have obtained certificates
showing that, under the conditions prescribed by the Delegacy for
Local Examinations at Oxford, they have passed the Second Public
Examination of that University or have obtained honours in the Oxford
University Examination for Women in Modem Languages, and students
> who hold the Scotch School Leaving Certificate, having passed on one
and the same occasion, in the Higher or Honours Grade in all the
subjects required by the regulations for the Matriculation Examination.

examination in the subject in which they present them¬
selves for the M.D. degree, or who, subsequently to
taking the M.B., B.S., have conducted a piece of
original work approved for the purpose by the. Univer¬
sity, or have had special experience approved by the
University, may present themselves for the M.D,
examination one year after taking their Bachelor’s
degree. Candidates in Branch 5 (State Medicine) must
show.that they have taken the degrees M.B., B.S. not less-
than two years previously, and that subsequently to;
taking those degrees they have had (1) six months’
practical instruction in an approved laboratory ; (2) six :
months’ practical instruction from a medical officer of
health, 01 which three must not coincide with the labora--
tory work, and three months’ practice at a hospital for'
infectious diseases. The interval between passing the
M.B., B.S. and proceeding to the M.D. State Medicine
may be reduced to one year, subject to conditions
corresponding to those affecting Branches 1, 2, 3, and 4,

Master of Surgery. —The examination for the degree"
of Master in Surgery will take place twice in each year,
commencing on the same dates as the foregoing, anct
the general regulations already quoted with regard to-
the M.D. will practically apply to it, surgery being
substituted for medicine. The examination will consist
of (1) two papers on surgery (one of which may be a
case for commentary); (2) an essay to be written on one'
of two subjects which may be selected from any branch
of surgery ; (3) two papers on surgical pathology and
surgical anatomy; (4) a clinical examination; (5)

operations on the dead body; (6) a viva voce at the
discretion of the examiners. Competent knowledge in
every subject of the examination must be shown in
order to pass.

Fees. —For Matriculation, £2 for each entry. Pre¬
liminary Scientific Examination.—Part I : £$ for each
entry to the whole examination, and £2 for each subject
when less than the whole examination is taken at one
time. Part II. : No fee for first entry, £2 for each
subsequent one. Intermediate Examination.—£10 for
each entry to the whole examination, and £$ for re¬
examination in one subject. M.B., B.S. Examina¬
tion—£10 for each entry to the whole examination r
and £$ for examination or re-examination in either
group. M.D. and M.S. Examinations.— £20 for each,
entry.

This University has established centres for pre¬
liminary and intermediate studies at University and
King’s Colleges, and students who purpose taking the
London degree should make themselves acquainted
with the details attached to external and internal
students. Information on these points may be had
of the Academic Registrar, University of London,
South Kensington.

UNIVERSITY OF DURHAM,

One diploma and six degrees in Medicine and Hygiene
are conferred, vis., the degrees of Bachelor in Medicine,
Bachelor in Surgery, Master in Surgery, Doctor in
Medicine, Bachelor in Hygiene, and Doctor in Hygiene,
and Diploma in Public Health, These degrees are open 1
to both men and women.

For the degree of Bachelor in Medicine (M.B.) there
are four professional examinations. The subjects for
the first are: Elementary anatomy and elementary'
biology, chemistry, and physics. For the second:
Anatomy, physiology, materia medica, therapeutics,--
and pharmacology. For the third : Pathology, medi¬
cal jurisprudence, public health, and elementary
bacteriology ; and for the fourth : Medicine, clinicab
medicine and psychological medicine, surgery and 1
clinical surgery, midwifery, and diseases of women and 1
children.

It is required that one of the five years of professional-
education shall be spent in attendance at the University'
College of Medicine and the Royal Victoria Infirmary,
Newcastle-upon-Tyne. First and second year students-
(dating from registration) are not required to comply
with the regulation regarding attendance on hospital
ractice. Candidates who have passed the First and
econd Examinations of the University will be exempt
from the First and Second Examinations of the Conjoint
Board,

iOOQ le

o

F

264 The Medical Press.

ENGLAND—EDUCATION.

Sept, ix, 1907.

For the degree of Bachelor in Surgery (B.S.) every
candidate must have passed the examination for the
degree of Bachelor of Medicine of the University of
Durham, and must have attended one course of
lectures on operative surgery, and one course on
regional anatomy, Candidates will be required to
perform operations on the dead body, and to give proof
of practical knowledge of the use of surgical instruments
and appliances,

For the degree of Master in Surgery (M.S.) candi¬
dates must not be less than twenty-four years of age,
and must satisfy the University as to their knowledge of
Greek or German. In case they shall not have
passed in either of these subjects at the Matricu¬
lation Examination for the M.B. degree, they
must present themselves at Durham for examina¬
tion in it at one of the ordinary examinations
held for this purpose before they can proceed to
the higher degree of M.S. They must also have ob¬
tained the degree of Bachelor in Surgery of the Univer¬
sity of Durham, and must have been engaged for at
least two years subsequently to the date of acquirement
of the degree of Bachelor in Surgery in attendance on
the practice of a recognised hospital, or in the naval or
military service, or in medical or surgical practice.

For the degree of Doctor in Medicine (M.D.) candi¬
dates must be of not less than twenty-four years of age,
and must satisfy the University as to their knowledge
of Greek or German. In case they shall not have
passed in either of these subjects at the Matricu¬
lation Examination for the M.B. degree, they
must present themselves at Durham for examina¬
tion in it at one of the ordinary examinations
held for this purpose before they proceed to the
higher degree of M.D. They must also have obtained
the degree of Bachelor of Medicine of the University of
Durham, and must have been engaged for at least two
years, subsequently to the date of acquirement of the
degree of Bachelor of Medicine, in attendance on the
practice of a recognised hospital or in the naval or
military services, or in medical or surgical practice.

Each candidate must present an essay which has
been prepared entirely by himself, and which must
be typewritten, based on original research or observa¬
tion, on some medical subject selected by himself, and
approved by the Professor of Medicine, and must pass
an examination thereon, and must be prepared to
answer questions on the other subjects of his curriculum,
so far as they are related to the subjects of the essay.

For regulations for degrees in Hygiene and for the
diploma in Public Health see Calendar 1907-8.

Candidates for any of the above degrees must give at
least twenty-eight days’ notice to the Secretary of the
College of Medicine, Newcastle-on-Tyne, In the case
of the M.D, (Essay) Examination, candidates must send
in their essays six weeks before the date of the examina¬
tion,

A new wing has been added to the College of
Medicine to accommodate the departments of
physiology and bacteriology. It also contains
students’ union rooms and gymnasium.

The New Royal Victoria Infirmary, containing 400
beds, was recently opened by H.M. the Kin^.
In the new infirmary adequate accommodation is
provided for the study of the various special sub¬
jects, in addition to the ordinary clinical work.
Practical midwifery can be studied at the Newcastle
Lying-in Hospital. Opportunities for practical study
are also afforded by the Dispensary, City Infectious
Diseases Hospital, Eye Infirmary, and at the North¬
umberland County Lunatic Asylum.

There are various appointments open to students,
whilst the scholarships available are numerous and
of considerable value.

Fees. —(a) A composition ticket for lectures at the
college may be obtained—i. By payment of 72 guineas
on entrance, 2, By payment of 46 guineas at the com¬
mencement of the first sessional year and 36 guineas at
the commencement of the second sessional year. 31 By
three annual instalments of 36, 31, and 20 guineas, re¬
spectively, at the commencement of the sessio n al year,
A Composition Ticket for the course of lectures an d prac¬

tical work of the first two years of the curriculum may
be obtained by the payment of 40 guineas on entrance.
(6) Fees for attendance on hospital practice : For three
months’ medical and hospital practice, five guineas;
for six months, eight guineas; one year, twelve
guineas composition fee in one payment, twenty-five
guineas; or by three instalments at the commence¬
ment of the sessional year, vie., first year, 12 guineas :
second year, ten guineas; third year, six guineas ;
or by two instalments, vie., first year, fourteen guineas ;
second year, twelve guineas. In addition, two guineas
yearly "up to three years must be paid to the Committee
of the Royal Infirmary.

Residence can be had in a separate hostel for female
students at moderate inclusive fees for board, &c,,
particulars of which and any other college information
will be given on application to Prof. Howden, Secretary,
University of Durham College of Medicine, Newcastle-
on-Tyne,

MANCHESTER UNIVERSITY.

Candidates for degrees in medicine and surgery must
attend classes in the University during at least two
years.

The Degrees in the Faculty of Medicine are Bachelor
of Medicine (M.B.), Bachelor of Surgery (Ch.B.),
Doctor of Medicine (M.D.), and Master of Surgery
(Ch.M,), All candidates for Degrees in medicine and
surgery are required to pass the Matriculation Examina¬
tion, or to have passed such other examination as may
from time to time be recognised for this purpose by the
University.

The suDjects of the Matriculation Examination are—
1, Latin; 2, mathematics; 3, mechanics; 4, English
and history; 5, one of the following:—(a) French;
(6) German ; (c) Greek ; ( d) Italian ; ( e ) Spanish ;
(/) any other modern language, permission to present
which has been obtained from the Joint Matriculation
Board. Notice of intention to present either Italian
or Spanish must be given to the Secretary, Joint
Matriculation Board, Manchester, before March 1st in
each year.

Before admission to the Degrees of Bachelor of Medi¬
cine and Surgery candidates are required to send in the
usual certificates of age and study as at the other
Universities. All candidates for these Degrees must
pass four examinations, and must have attended
courses of both lectures and laboratoiy work.

The final examination is divided into two parts,
which may be passed separately or on the same occasion,
but the first part cannot be taken before the end of the
third year, and the second part cannot be taken less than
two years after passing Second M.B., or before the fifth
year of medical study in accordance with the University
regulations. The subjects of examination are as fol¬
lows : x. Pharmacology and therapeutics ; 2, General
pathology and morbid anatomy ; 3, Forensic medicine
and toxicology and public health; 4, Obstetrics and
diseases of women ; 5, Surgery, systematic, clinical, and
practical; 6, Medicine, systematic and clinical, includ-
ing mental diseases and diseases of children. Candi¬
dates may select as a first part of the examination two
or three of the subjects 1, 2, and 3,

> The certificates required from candidates at the Third
and Final examinations are practically the same as for
the Final examination at the London University, and
only those who have previously passed the Second
Examination are admitted to it. The regulations re¬
lating to the M.D, and Ch.M, Degrees can be obtained
on application to the Registrar,

Fees. —Matriculation examination, £2. First Exami¬
nation, £5 ; for any subsequent e x a min ation, £ 2 . The
fees for the Second Examination, for the Third and Final
Examinations, and for the examination for the degree of
CtuM, are the same as for the First Examination. A
fee of £10 is payable on the conferring of the degree
of M.D,, a fee of £5 on the conferring of the degree of
Ch M*

The I Matriculation Examination is held in July
and in*September. The first M.B. and Ch.B. is held
in Tune; also about the end of September. The
second examination is held in December, or in January

dbyGoooIe

y O

Sept, ii, 1907.

ENGLAND—EDUCATION.

The Medical Press. 265

or March; the Final in July and March; the exam¬
ination for Ch.M. in July only.

The medical school buildings, which include large
laboratories, dissecting-rooms, library and reading-
rooms, are on the most modern principles, and students
wishing to engage in anatomical, physiological, or
pathological research will find excellent opportunity
for study in the complete and well-furnished labbra-
todes. Hospital practice is taken out at the (a) Foyal
Infirmary, which contains 300 beds. The Cheadle
Lunatic Asylum, St. Mary's Hospital, the Southern
Hospital, and other special hospitals also afford
teaching facilities of great importance.

The appointments open to students are numerous
and of considerable monetary value, and there are
probably more here than are available at any other
medical centre. The principal are :—Nine Entrance
scholarships, the Leech fellowship of ^100 ; Entrance
scholarships in medicine, £100 (towards College and
Infirmary fees); Manchester Grammar School scholar¬
ships, two or three of not less than £15 or more than
£30 per annum for three years ; Turner scholarship of
£20 to students who have completed a course of medical
study in the University; Platt physiological scholar¬
ships, two of the value of £$o each ; Platt zoological
and botanical scholarship, £50 ; Professor Tom Jones’
memorial surgical scholarship of £100, awarded trien-
nially; two Dauntsey medical entrance scholarships,
value £35 ; John Henry Agnew scholarship in diseases
■of children, value £30, awarded annually ; Graduate
scholarship in medicine, £25 to £$o, awarded annually ;
and many others.

Fees.—-Composition fee, 83 guineas, in three instal¬
ments of 23, 30 and 30 guineas. Hospital practice :
Composition fee, £42, or two instalments of £22 each.

Dental Fees.— Composition fee, £60, payable in two
sums of £30 each. Hospital practice, £21. ... ^ ^

UNIVERSITY OF BIRMINGHAM.

The University of Birmingham grants Degrees of
M.B., Ch.B., M.D., Ch.M., and also a B.Sc. in the sub¬
ject of Public Health. As a rule, in order to obtain
Any of these Degrees it is necessary that a student shall
have passed at least the first four years of his curriculum
in attendance upon the classes of the University, but
the Senate has power of recognising attendance at
Another University as part of the attendance qualifying
for these degrees.

Degrees of Bachelor of Medicine and Bachelor of
Surgery. —The student must have passed either the
Matriculation Examination of the University or one of
the following examinations, which will be accepted in
lieu thereof for the present:—(a) The previous examina¬
tion of the University of Cambridge ; ( b) Responsions
of the University of Oxford ; (e) The matriculation
examination of any other University in the United
Kingdom ; ( d ) The leaving certificate (higher) of the
Oxford and Cambridge Boards ; (e) The Oxford or
Cambridge junior local examination (first or second
class honours); (/) The Oxford or Cambridge senior
local examination (honours).

Matriculation Examinations are held in June and
September each year*

Degrees of Doctor of Medicine and Master of Surgery «—
At the end of one year from the date of having passed
the Final M.B., Ch.B. Examination, the candidate will
be eligible to present himself for the higher Degrees of
■either Doctor of Medicine or Master of Surgery or both,
the regulations for which may be had upon application
to the Dean. The University also grants a Degree
and a Diploma in Public Health, and provides adequate
instructions for the same.

Dental Department. —The University grants the
Degrees of Bachelor and Master of ’ Dental Surgery
(B.D.S. and M.D.S.), and a Diploma in Dental Surgery
(L.D.S.). The whole of the instruction for which may
be taken out in the University, with which is associated
the Birmingham Dental Hospital.

The General and Queen’s Hospitals, —The prac-

( a ) A new loflrmar? is In course of erection, within • few minutes'
walk from the University, which, when complete In 1908, will oontain
all the latest Improvement! of modern times.

tices of these hospitals are amalgamated for the purpose
of clinical instruction under the direction of the
Birmingham Clinical Board, by whom all schedules will
be signed and all examinations conducted* The hos¬
pitals have a total of upwards of 45° beds. 8,000 in¬
patients and 80,000 out-patients are treated annually,
and many valuable posts are open to students at both*

Further information can be obtained from Professor
Gilbert Barling, Dean, Medical Faculty.

THE UNIVERSITY OF LIVERPOOL.

The Degrees in the Faculty of Medicine are Bachelor
of Medicine and Bachelor of Surgery (M.B. and Ch.B.),
Doctor of Medicine (M.D.), and Master of Surgery
(Ch.M.). The course of study for the Degrees of Bache¬
lor of Medicme and Bachelor of Surgery is of five
years’ duration, and of this period two years must be
spent at the University, the remaining three years
can be taken in any medical school approved by the
University.

For the Degree of M.D., a thesis is required which
may be presented not earlier than one year after
graduation, as M.B., Ch.B.

The degree of Ch.M. is given after a period of at
least one year of further study after graduation as
M.B., Ch.B., on the results of an examination.

Diplomas .—Diplomas have been instituted in Public
Health (D.P.H.), Tropical Medicine (D.T.M.), and
Veterinary Hygiene (D.V.H.). Special diplomas are
also granted in Anatomy, Bacteriology, Bio-chemistry,
and Parasitology after a course of study of three
terms in the subject chosen and allied subjects.

Students may enter for the degrees of the University
of Liverpool, or may study for the degrees, diplomas
and qualifications of the other licensing bodies.

Hospitals .—The Clinical School of the University
now consists of four general hospitals—the Royal
Infirmary, the David Lewis Northern Hospital, the
Royal Southern Hospital, and the Stanley Hospital;
and of five special hospitals—the Eye and Ear In¬
firmary, the Hospital for Women, the Infirmary for
Children, St. Paul’s Eye and Ear Hospital, and St.
George’s Hospital for Skin Diseases. These hospitals
contain in all a total of 1,127 beds. The organisation
of these hospitals to form one teaching institution
provides the medical student and the medical prac¬
titioner with an unrivalled field for c linic al education
and study, and all are within easy access from the
University. The period of hospital practice extends
over the last three years of medical study. During
the first two years no student will be permitted to
change his attendance from one general hospital to
another except at the commencement of an academic
term. It is a regulation of the school that not more
than five of the six terms of these two years shall be
spent at any single General HospitaL Daring the final
year of hospital practice a student is permitted to
attend the practice of all the general hospitals without
restriction. The regulations demand only that his
attendance shall be regular and to the satisfaction of
the Hospital’s Board. There are a large number of
appointments to House Physicianships and burgeon-
ships both at the general and special hospitals, which
are open to qualified students of the School. These
appointments (20) in most cases carry salaries varying
from £60 to £100 per annum.

Fellowships and Scholarships. —Fellowships, Scholar¬
ships, and Prizes of over ^800 are awarded annually.
A Holt Fellowship in Pathology and Surgery, of the
value oi £100 for one year, is awarded annually by the
Medical Faculty to a senior student possessing a
medical qualification. The successful candidate is
required to devote a year to tutorial work and investi¬
gation in the Pathological department. A Holt
Fellowship in Physiology, awarded under similar con¬
ditions, also of the value of £100 for one year. A
Robert Gee Fellowship in Anatomy, awarded under
similar conditions, of the value of £100 for one year.
An Alexander Fellowship for Research in Pathology
of the annual value of £100, renewable. A Johnston
Colonial Fellowship in Pathology and Bacteriology
(£100 a year, renewable). A John W. Garrett

266 The Medical Peess.

ENGLAND—EDUCATION.

Sept, ii, 1907.

International Fellowship in Physiology and Pathology
(£100 a year, renewable). An Ethel Boyce Fellow¬
ship in Gynaecological Pathology (/100 a year, renew¬
able). A Stopford Taylor Fellowship (£100 a year,
renewable) in Dermatological Pathology. A Thel-
wall Thomas Fellowship (^100 a year, renewable)
in Surgical Pathology. A scholarship in Surgical
Pathology (£50 a year renewable). Two Lyon
Jones scholarships, of the value oi £21 each for
two years, are awarded annually—a Junior Scholar¬
ship, open at the end of the first year of study to
Liverpool University students in the subjects of
the first M.B. Examinations, and a Senior Scholar¬
ship, open to all students in the school at the end of the
second or third year of study, in the subjects of Ana¬
tomy, Physiology, and Therapeutics. The Derby
Exhibition oi £15 for one year is awarded in Clinical
Medicine and Surgery in alternate years. Students
may compete in their fourth and fifth years. In 1908
the subject will be Clinical Surgery. The Torr
Gold Medal in Anatomy, the George Holt Medal in
Physiology, the Kanthack Medal in Pathology, and
the Robert Gee Book Prize, of the value of £$, for
Children’s Diseases.

Entrance Scholarships .—Two Robert Gee Entrance
Scholarships, of the annual value each of £2$ for two
ears, are offered annually for competition. The
older is required to take out the First M.B. Course
for the University Degree in Medicine.

The University also grants a Diploma in Dental Sur¬
gery (L.D.S.) and Degrees in Dental Surgery (B.D.S.
and M.D.S.) The courses of systematic instruction are
given in the University buildings, five minutes walk
from the Dental Hospital.

Communications should be addressed to the Dean,
Professor Benjamin Moore, M.A., D.Sc., the University,
Liverpool.

Liverpool School of Tropical Medicine, and
Diploma of Tropical Medicine, University of
Liverpool.— The school is affiliated with the Uni¬
versity of Liverpool and the Royal Southern Hospital
of Liverpool. Three courses of instruction are given
every year, commencing on January 14th, May 1st,
and October 1st, and lasting for the academical term
of about ten weeks. Each Course consists (1) of a
systematic series of lectures on tropical medicine and
sanitation delivered by the Professor of Tropical
Medicine at the University ; (2) of additioral lectures
on cytology, special African diseases and special Indian
diseases delivered at the University ; (3) of systematic
lectures and demonstrations on tropical pathology,
parasitology and bacteriology by the Walter Myers
lecturer, at the University ; (4) of similar instruction
on medical entomology by the Lecturer on economic
entomology at the University; and (5) of clinical
lectures and demonstrations delivered at the Royal
Southern Hospital by the Physician in charge of the
Tropical Ward, the Professor, and the Walter Myers
Lecturer. The instruction given occupies six hours a
day for five days a week during the term. Teaching
under headings 3 and 4 above is delivered in the Labor¬
atory of the school at the University, which contains
accommodation for thirty students with all necessary
appurtenances, including a well-equipped museum, a
class library, and access to the general departmental
library. Teaching under heading 5 is given in the
Tropical Ward, and the attached clinical laboratories
of the Royal Southern Hospital on two or three after¬
noons a week.

At the end of each term an examination is held by
the University for its Diploma of Tropical Medicine
(D.T.M.), which is open only to those who have been
through the course of instruction of the school. The
examination lasts three days, and consists (1) of three
papers ex' tropical medicine, tropical pathology, and
tropical sanitation and entomology respectively; ( 2 )
of a clinical examination ; and (3) of an oral examina¬
tion. The results are declared as soon as possible 1
afterwards. Those who do not wish to undertake the
examination are given a certificate of attendance if 1
their attendance has been satisfactory.

Accommodation for a limited number of students i

■ may be had at the Hall of Residence (for terms, apply
to the Warden, 44 Upper Parliament Street).

The fee for the full course of instruction is ten
guineas, with an extra charge of ten shillings for the-
use of a microscope, if required. The fee for the exami¬
nation is five guineas. Applications should be made
to the Dean of the Medical Faculty, University of
Liverpool, from whom prospectuses may be obtained.

Two University Fellowships of £100 a year each are
opeo to students of the school, amongst others. Accom¬
modation for Research work is to be had, both at the
University laboratory of the school, and at its Research
Laboratories at Runcorn (sixteen miles distant from
Liverpool).

Since it was instituted nine years ago the school
has employed twenty-five different investigators paid
out of its funds, and has despatched to the tropics
seventeen scientific expeditions, many of the workers¬
having been taken from among its students. The
work done by them has been published in twenty-one
special memoirs with many plates and figures, besides
text books and numerous articles in the scientific
press. From the beginning of this year, however,
the Memoirs have been succeeded by the Annals of
Tropical Medicine and Parasitology, published by the
Committee, and open to outside contributors (apply
to the Secretary, Bio, Exchange Buildings, Liverpool).
The Mary Kingsley Medal is awarded by the School
for distinguished work in connection with tropical
medicine, and has been given to Colonel Bruce, Pro¬
fessor Koch, Dr. Laveran and Sir Patrick Man son.

UNIVERSITY OF BRISTOL.

4 The lectures and instruction given in the Faculty
of Arts and Science of University College, Bristol,
are adapted to the various preliminary science examina¬
tions, and students can complete in Bristol the entire*
course of study required for the medical and surgical
degrees of the University of London and the Royal
College of Surgeons of England, and of the Apothe¬
caries’ Society of London. Well-equipped labora¬
tories arc now provided for anatomy, physiology,
bacteriology, and pathology. Students of the college
are admitted to the clinical practice of those very
important and well-equipped institutions, the Bristol
Royal Infirmary and the Bristol General Hospital.
The infirmary and the hospital comprise between them,
a total of 470 beds, and both have very extensive out¬
patient departments, and special departments for the
diseases of women and children, and of the eye, ear, and
throat, besides large outdoor maternity departments-
and dental departments. Students of the college also
have the privilege of attending the practice of the
Bristol Royal Hospital for Sick Children and Women,
containing 104 beds, and that of the Bristol Eye
Hospital, with 40 beds. The total number of beds
available for clinical instruction is therefore 614. Very
exceptional facilities are thus offered to students for
obtaining a wide and thorough acquaintance with all
branches of medical and surgical work, and the whole-
curriculum is now open to women as well as men.

Appointments .—At the Royal Infirmary, and also at
the General Hospital, clinical clerks and dressers reside
in the house in weekly rotation. A pathological clerk
is appointed every three months. Also obstetric clerks-
and ophthalmic dressers. Clinical lectures are given
regularly at both institutions.

Scholarships, Prizes, <S-c.—Prizes and certificates of
honour are given in University College in all the-
subjects of the curriculum. There are one medical
entrance scholarship, value £7$, awarded annually, two
Martyn memorial scholarships (pathology and morbid
anatomy) of £10 each, the Tibbits memorial prize,,
value £9, for proficiency in practical surgery, Henry
Marshal prize, £12; Clarke Scholarship, £15; Sanders
Scholarship, £22 10s,; one gold and silver medal
awarded by the committee, and various prizes for
clinical work in surgery and medicine,

Fees ,—School fees for attendance on all'courses of
lectures and hospital practice, and including all fees,
except vaccination and small charge for board of-
midwifery student, I33 guineas. If in two instalments,.

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Sept, ii, 1907.

ENGLAND—EDUCATION.

The Medical Puss. 267

So guineas at first session and 60 guineas in the be¬
ginning of the second year. Dental composition fee,
75 guineas, including all lectures, practical classes,
and hospital practice. Dental mechanical laboratory
fee, 75 guineas. Clinical fees (if the composition fee
has not been paid)—Surgical practice, one year, . 12
guineas; perpetual, 20 guineas. Medical practice,
20 guineas: perpetual, medicine and surgery,
40 guineas.

Prospectus and further information on application to
the Dean, Professor Edward Fawcett, M.D.

UNIVERSITY OF LEEDS.

The school of medicine attached to this recently
incorporated University, was originally founded
more than seventy years ago as the Leeds Medi¬
cal School. The building, erected on a site con¬
tiguous to the infirmary, and opened twelve years
since, contains one of the finest dissecting rooms in
the Kingdom, extensive laboratories for physiology
sad pathology with the most recent improvements
in fittings and apparatus, ample lecture-room accom¬
modation, a large library, and separate museums
for pathology ana anatomy. Professors and lecturers
are attached, and the clinical teaching is given by
the physicians and surgeons attached to the Leeds
General Infirmary, one of the largest in the United
Kingdom, having 524 beds, with a staff of physicians
and surgeons of considerable eminence. Ophthalmic
demonstrations and demonstrations of skin diseases
are given in the infirmary by surgeons in each depart¬
ment, where also are obtainable various clinical
clerkships, dresserships, and other appointments;
and an extern maternity charity is attached, at which
the necessary attendance at labours can be taken,
Besides the infirmary there is a large dispensary, a
large hospital for infectious diseases, a hospital for
women and children, and a maternity home, all of
which are open to students of the school.

Scholarships, Prises, 6-c.—(1) An entrance scholar¬
ship of £73 2S - 6d. There is also a Hardwick
prize in clinical medicine, a M’Gill prize in clinical
surgery, each of the value of £10. Thorp prizes of
^10 and £$ in forensic medicine and hygiene, and a
Scattergood prize of 4 5 in midwifery, besides silver
and gold medals and ether class prizes. The
•composition fee for attendance upon all the required
courses oi school lectures is £73 2S - 6d. for University
students who have attended the preliminary scientific
courses, and the same for non-University students,
exclusive of chemistry and biology,

At the General Infirmary, the composition fee for
medical and surgical practice and clinical lectures is £42
in one sum, or two instalments of £22 each. These
fees are not included in the composition fees for lectures
and are payable separately.

A scholarship of £42 to cover the cost of medical and
surgical practice is offered annually by the Infirmary,

Degrees and Diploma in Dental Surgery are obtain¬
able at this University, being Bachelor of Dental
Surgery (B.Ch.D.), and Master of Dental Surgery
(M.Ch.D.). Candidates for the degree of Bachelor of
Dental Surgery are required to have passed the Matri¬
culation Examination, to have pursued thereafter
approved courses of study for not less than five aca¬
demic years, two of such years at least having been
passed in the University subsequently to the date of
passing Parts I. and II. of the first examination, and
to have completed such period of pupilage or hospital
attendance, or both, as may be prescribed by the
Regulations of the University. No candidate shall be
admitted to the degree who has not attained the age
of twenty-one years on the day of graduation.

Candidates for the diploma in Dental Surgery are
required to present certificates showing that they have
attained the age of twenty-one years, that they have
attended courses of instruction, approved by the
University, extending over not less than four years
And that they have completed a pupilage of three

S ars, two of such years at least, having been taken
fore the First Professional examination. Candi¬
dates are required to satisfy the Examiners in the

several subjects of the following examinations: A
preliminary examination in Arts; a Preliminary
examination in Science ; the First Professional exam¬
ination ; and the Final examination. g j

UNIVERSITY OF WALES. ^ . 1

The Cardiff School of Medicine, which is one'of
the colleges of the University of Wales, has since
its foundation, in 1883. prepared students for
the Preliminary Scientific Examination of the Uni¬
versity of London, and for the corresponding ex¬
aminations of other licensing bodies. In 1893
Chairs of Anatomy and Physiology and a Lecture¬
ship in Materia Medica and Pharmacy were established,
malring it possible for students of medicine to spend
three out of the five years of prescribed study at Cardiff.
Arrangements with the managing committee of the
Cardiff Infirmary give students of the College the privi¬
lege of attending this large and well-ordered hospital,
which is situated within five minutes’ walk of Univer¬
sity College. Many students, especially from Wales
and Monmouthshire, avail themselves of the opportuni¬
ties thus afforded to pursue the earlier part of the
medical curriculum near home. All classes are open
alike to both men and women students over sixteen
years of age. Tne courses of instruction given at
Cardiff are recognised as qualifying for the examinations
of the Universities, Royal colleges, and other licensing
bodies of Great Britain and Ireland. Having spent
two or three years in study at Cardiff, and having
passed the examinations in these years, a student may
proceed to London or elsewhere and complete his quali¬
fying course for a University degree or for a college
diploma.

Students preparing for the first and second examina¬
tions of the Conjoint Board for England, or for the
corresponding examinations of the Conjoint Board for
Scotland, or for those of the Society of Apothecaries,
may compound for their classes by paying a single
composition fee of £41 10s., or by paying £20 and
£24 10s. at the beginning of their first and second years
respectively. Those preparing for the preliminary
scientific and intermediate examination in medicine of
the University of London may compound for their
three years’ instruction at Cardiff by paying a single
composition fee of £$7 ioe., or by paying £13 13s., £28,
and £21 at the beginning of their first, second and third
years respectively.

In 1899 a department of Public Health was estab¬
lished, and lecturers in bacteriology and in public health
and hygiene were appointed. Medical men preparing
for a diploma in Public Health and Hygiene can attend
complete courses of lectures and laboratory instruction
in this department. These courses are recognised by
the University of Cambridge, by the Royal Colleges of
Physicians and Surgeons, and by Victoria University.

In the case of medical students, attendance on the
class of hygiene and public health is accepted by the
Universities of London and Cambridge, and by the
Conjoint Examining Board of England

Courses of lectures to midwives, adapted to the re¬
quirements of the Central Midwives’ Board, under the
Mid wives Act. are commenced in October, January,
and April. The lectures are suitable both for pupil
midwives and practising midwives, as well as for nurses
who desire to enter for the examination for certification
under the Act.

Scholarships, 6*c.—The attention of students about
to matriculate is drawn to the numerous entrance
scholarships and exhibitions which are offered at the
college for competition in September, most of which
may be held by medical students. Full particulars of
the examination for these may be obtained from the
Registrar, or from the Dean of the Medical Faculty, j

UNIVERSITY OF SHEFFIELD.

By the Charter granted in 1905, this University is
permitted to grant degrees in medicine. All its
courses and all its degrees are open, without re¬
striction, to both sexes. The new buildings of the
University, opened by his Majesty King Edward
in 1905, are situated at the west end of the city, over¬
looking on two sides the adjoining Weston Park. The

268 The Medical Press. ENGLAND—EDUCATION.

medical department occupies the entire north wing
of the University quadrangle, and is within easy
reach of the various hospitals, with which it is con¬
nected for clinical purposes.

These are as follows:—The Royal Infirmary con¬
tains 255 beds, with an annual average number of
over 3,800 in-patients, over 8,600 out-patients-, and
over 21,000 casualties; the Royal Hospital, with 165
beds, and an annual number of 2,500 in-patients, over
,000 out-patients, and over 14,000 casualties; the
essop Hospital for Diseases of Women, with 80 beds,
nearly 500 in-patients, and over 2,000 . out-patients;
also a Maternity Department, with over 250 in¬
patients per annum, and over 700 out-patient cases
attended. Special courses on fevers are held at the
City Fever Hospitals (547 beds), and on Mental Dis¬
eases at the South Yorkshire Asylum (1,610 beds).

Clinical Practice. —The practices of the Royal
Infirmary and Royal Hospital are amalgamated for
the purpose of clinical instruction, giving a total of
420 beds for. the treatment of medical, surgical and
special cases.

Appointments. —The following are open to all
students who have passed their examinations in
anatomy and physiologyCasualty Dresserships,
Surgical Dresserships, Medical Clerkships, Patho¬
logical Clerkships, Ophthalmic Clerkships, Clerk to
the Skin Department, etc.

Fees. —Composition fee of /80, payable in three
instalments, viz. :—^24 at commencement of first year
of study; ^28 at commencement of second year of
study; £28 at commencement of third year of study.
This composition fee entitles the student to attendance
on all the courses of lectures and practical classes,
except pharmacy, vaccination, and instruction in
anaesthetics required for a degree course in the Univer¬
sity, or for the ordinary qualifications in medicine
and surgery of the examining boards.

. Composition Fee for Medical and Surgical Hospital
Practice. —Fee for the full period of both medical
and surgical hospital practice required by the
examining boards:—If paid in one sum at commence¬
ment of hospital practice, ^36 15s.; or if paid in
two sums of £ 18 18s., one on beginning hospital
practice, the other twelve months later, £yj 16s.

Dental Department. —In connection with the
University there is a complete dental department,
which is fully recognised by the various examining
bodies, and students are able to get their full curri¬
culum here.

Scholarships and Fellowships. —Women’s Medical
Scholarship, jvalue £100, open to women only;
awarded in September, 1907. Entrance Medical
Scholarship, value ^116, open to both sexes, awarded
in June in each year. Two Staff Medical Scholar¬
ships, each value Z50 ; open to both sexes. One Town
Trustees’ Scholarship, value £50, tenable for three
years, for girls under the age 01 19 years. Two Town
Trustees’ Scholarships, value ,£60 each, for boys or
girls under 19 years of age. Town Trustees’ Fellow¬
ship, value £75, open to graduates of the University,
tenable for one year. Mechanics’ Institute Scholar¬
ship, value £50, tenable for one year, and renewable
for a second year. The Frederick Clifford Scholar¬
ship, value about £50 per annum, tenable for two
years, open to graduates of the University; and the
Kaye Scholarship, value about £22 10s. Gold Medal
offered annually for the best student in clinical medi¬
cine and clinical surgery. Bronze medals are awarded
each year to the students who have gained first place
in the examinations for the full course.

Degrees. —Candidates for a medical degree mnst
have matriculated in the University or have passed
such other examination as may be recognised for this
purpose by the University and sanctioned by the Joint
Matriculation Board. The subjects required by the
General Medical Council must be included in the
matriculation examination, or its recognised sub¬
stitute. The degrees in medicine obtainable are
Bachelor of Medicine and Bachelor of Surgery
(M.B., Ch.B.), Doctor of Medicine (M.D.), and Master
of Surgery (Ch.M.); conditions and particulars of
which may be obtained on application to the Dean.

At the University of Sheffield post-graduate courses
are held annually. The subjects vary from time to

Sept, ii, 1907.

time, and include bacteriology, physiology, applied
anatomy, surgery, operative surgery, ophthalmic
surgery, diseases of ear and throat, dermatology, etc.

THE ENGLISH COLLEGES.

The medical corporations in England are the Roya
College of Physicians of London, the Royal College of
Surgeons of England, and the Society of Apothecaries
of London. The two Royal Colleges now co-operate to
hold a series of examinations, on passing which the
candidate .receives the diploma of Licentiate of the
Royal College of Physicians CL.R.C.P.), and Member of
the Royal College of Surgeons (M.R.C.S.). The Society
of Apothecaries grants a complete diploma (L.S.A.)in
medicine, surgery, and midwifery.

Conjoint Examining Board in England.

Candidates for the above licences are required to
complete five years of professional study at recognised
medical schools and hospitals, after passing the pre¬
liminary examination, of which six months may be
Spent at an institution recognised by the Board for
instruction in chemistry, or one year may be passed at
an institution recognised by the Board for instruction
in chemistry and physics, to comply with the following
regulations and to pass the examinations hereinafter
set forth.

Professional Examinations .—There are three examina¬
tions, each being partly written, partly oral, and
partly practical. These examinations wifi be held in
the months of January, April, July, and October,
unless otherwise appointed, fourteen clear days’ notice
before the dav on which the examination commences
being required, the candidate transmitting at the same
time the required certificates.

The subjects of the first professional examination are
chemistry and physics, practical pharmacy, and ele¬
mentary biology. A candidate is allowed to take this
examination in three parts at different times. Rejec¬
tion entails a delay of not less than three months
from the date of rejection, and the candidate will be
re-examined in the subject or subjects in which he has
been rejected. If referred in chemistry or biology, he
must produce evidence of further instruction at a recog¬
nised institution. Practical pharmacy may be passed
at any time during the curriculum. Any candidate who
shall produce satisfactory evidence of having passed an
examination for a degree in medicine on any of the
subjects of this examination conducted at a University
in the United Kingdom, India, or in a British Colony,
will be exempt from examination in those subjects in
which he has passed.

The fees for admission to the first examination are as
follow:—For the whole examination, £10 10s. ; for
re-examination after rejection in Part I., £3 3s. ; and
for re-examination in each of the other parts, £2 2s.

The subjects of the second examination are anatomy
and physiology. Candidates will be required to pass in
both subjects at one and the same time. Candidates
will be admissible to the second examination at the
expiration of two winter sessions and one summer
session (or fifteen months during the ordinary sessions)
from the date of registration as medical students, and
after the lapse of not less than nine months from the
date of passing Parts I. and III. of the first examination.

A candidate referred at the second examination will
be required, before being admitted to re-examination,
to produce a certificate that he has pursued, to the
satisfaction of his teachers, in a recognised place of
study, his anatomical and physiological studies during
a period of not less than three months subsequently
to the date of his reference.

:.The fees for admission to the second examinations
are : £10 10s. for the whole examination, and £6 6s. for
re-examination after rejection.

The subjects of the third and final examinations are :
—Part I. Medicine, including medical anatomy,
pathology, practical pharmacy, therapeutics, forensic
medicine and public health. Candidates, who have-
passed in practical pharmacy at the first examination
will not be re-examined in that subject at the third
examination. Part II. Surgery, including pathology,
surgical anatomy, and the-use of surgical appliances.

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Sept, ii, 1907.

ENGLAND—EDUCATION.

The Medical Press. 269

Part III. Midwifery and gynaecology. Candidates
may take this examination in three parts separately, or
they may present themselves for the whole examination
at one time.

Fees for admission to the third or final examination
are as followFor the whole examination, £21 os.
Part I.—For re-examination in medicine, including
medical anatomy, pathology, therapeutics, forensic
medicine, and public health, £$ 5s. ; for re-examination
in practical pharmacy (if taken at this examination),
£2 23. Part II.—For re-examination in surgery, includ¬
ing pathology, surgical anatomy, and the use of surgical
appliances, £5 53. Part III.—For re-examination in
midwifery and gynaecology, £$ 3s.

A candidate referred on the third or final examina¬
tion will not be admitted to re-examination until after
the lapse of a period of not less than three months from
the date of rejection, and will be required, before being
admitted to re-examination, to produce a certificate, in
regard to medicine and surgery, of having attended the
medical and surgical practice, or the medical or surgical
practice, as the case may be, during the period of his
reference; and in regard to midwifery and diseases
peculiar to women a certificate of having received,
subsequently to the date of his reference, not less than
three months’ instruction in that subject by a recog¬
nised teacher.

Regulations for Colonial, Indian, and Foreign
Candidates, and University Candidates.

Persons holding a Colonial, Indian, or a foreign
qualification entitling them to practise medicine in thq
country of origin, and conferred after a course of study
and examinations equivalent to those required by the
Royal Colleges, are admissible to the second and third
(final) examinations forthwith.

Members of a University in the United Kingdom are (i
under certain conditions, eligible for admission to the
third (final) examination two years after passing at
their University in the subjects included in the first
and second examinations of the Board.

Royal College of Physicians of London.

Members .—The membership of the College is granted
after examination to persons above the age of 25 years
who do not engage in trade, do not dispense medicine,
and do not practise in partnership. This diploma is
only granted to persons already registered, or who have
passed the final examination for the licence.

Medical graduates of a recognised University are
admitted to a pass examination, but others must have
passed the examinations required for the licence of the
College. The examination, which is held in January,
April, July, and October, is partly written and partly
oral. It is directed to medicine, and is conducted by
the president and censors. Candidates under 40, unless
they have obtained a degree in arts in a British Univer¬
sity, are examined in Latin, and either Greek, French,
or German. Candidates over 40 are not so examined,
and the examination in medicine may in their case be
modified under conditions to be ascertained by applica¬
tion to the Registrar. The fee for the membership is
£42, but if the candidate is a licentiate ^15 5s. is
deducted. In either case £6 6s. has to be paid before
examination.

Royal College of Surgeons of England.

Membership. —The candidates are now subject to
the regulations of the Conjoint Board.

Fellowship. —The Fellowship of the College of Sur¬
geons is granted after examination to persons at least
25 years of age, who have been engaged in professional
studies for six years. There are two examinations—the
first in anatomy and physiology, which may be passed
after the third winter session ; the second chiefly
directed to surgery, which may be passed after six
years of professional study. The second examination
may be passed before attaining the age of 25, but the
diploma is not granted until that age is reached. Can¬
didates for this part of the examination must have
passed the final examination of the Conjoint Board in
England, and have been admitted members of the
College before they can be admitted thereto, except in

the case of graduates in medicine and surgery of recog *
nised Universities of not less than four years’ standing.

Fees.— First examination, £5 5s. ; second examina¬
tion, £12 12s. The total fee payable on admission to
the Fellowship is £31 10s., except for members, when
the fee is £ 21 . (The examination fees to the extent of
£1 7 178. count as part of the total fee.) Further infor¬
mation can be obtained on application to the Secretary
of the Royal College of Surgeons, Lincoln’s Inn Fields,
London, W.C.

There are two examinations—primary and final..
The primary examination is held quarterly on the first
Wednesday, and on the Monday and Tuesday in the
same week, in the months of January, April, July, and
October. The final examination is held monthly.

Society of Apothecaries of London.

Primary Examination. —This examination consist s
of two parts : Part I.—Elementary biology, Chemistry,
Chemical physics, including the elementary mechanics
of solids and fluids; Heat, Light, and Electricity.
Practical chemistry. Materia medica, and Pharmacy.
A synopsis indicating the range of the subjects may be
obtained on application. Part II.—Anatomy and
Physiology and Histology. The examination is held in
January, April, July, and October.

The final examination is held monthly, and is divided
into Sections 1 and 2.

Section 1 consists of three parts.

Part I. includes : Principles and Practice of Surgery,
Surgical Pathology, and Surgical Anatomy, Operative
Manipulations, Instruments and Appliances.

Phrt II. includes : (a) The Principles and Practice of
Medicine, including Therapeutics.Pharmacology,Patho¬
logy, and Morbid Histology, (b) Forensic Medicine,
Hygiene, Theory and Practice of Vaccination ; and
Mental Diseases.

Candidates passing either (a) or (ft) will not be re¬
examined therein.

Part III. includes: Midwifery, Gynaecology, and
Diseases of New-born Children, Obstetric Instruments
and Appliances. ■ Candidates may enter for Parts I.,
II., and III. together or separately.

Section 1 of the Final Examination, or any part
thereof, cannot be passed before the expiration of 45
months from the date of registration as a medical
student.

Section 2.—This section consists of two parts :

• Part I.—Clinical Surgery.

• Part II.—Clinical Medicine and Medical Anatomy.
Section 2 cannot be passed before the expiration of the
fifth year.

Fees .—Primary examination, £5 5s.; final exami¬
nation, £15 15s. ; total fee, £21.

Farther information, with particulars as to the course
of study and of the certificates required, can bfe
obtained from the Secretary to the Court of Examiners,
Apothecaries’ Hall, E.C.

This licence is a registrable diploma in Medicine,
Surgery, and Midwifery, and qualifies the holder to
compete for medical appointments in the Army, Navy,
and Indian Services, also for Poor-law, Civil, and
Colonial appointments.

The Giuson scholarship in Pathology of the annual
valne of £90, tenable for one year, is open to Licentiates
of the Society and to candidates for the diploma who
obtain it within six months of election to the scholar¬
ship. An examination in the art of prescribing
is held annually, in January, at which the following
prizes are awarded :—A gold medal of the value of £6 ;
a silver medal, and a prize of books to the two best
candidates.

LONDON SCHOOLS.

Thi Schools of Medielno in the Metropolis are
the following, the scholarships* prizes, students'
appointments, fees, fltc., being sefcXorth in connec¬
tion with each place named. The names of the
hospital staff, lecturers, residential terms, and
detailed information will be found, as a rule, in
our advertisement columns.

■ St, Bartholomew's Hospital, —This hospital has
750 beds, and for many years past the school attaohed

Digitized by GoOgle

270 The Medical Press.

ENGLAND—EDUCATION.

Sept 11. 1907.

has had a larger number of students than any other
medical school in London. Laboratories have been
specially equipped for the study of pathology, bacteri¬
ology, chemistry, biology, physics, and chemical
pathology, and two additional operation theatres
have just been built. A new block of buildings has
]ust been completed at a cost of £120,000, and
contains new casualty and out-patients’ departments,
eight special departments, quarters for the junior staff,
a dining hall and a common-room for students, &c.
Collegiate residence is permissible, subject to the
ordinary rules.

Appointments. —Ten house physicians and ten house
•surgeons are appointed annually- During the first six
months of office they act as “ junior ” house physicians
and house surgeons, and receive a salary of £25 a year,
.During their second six months they beixune “ senior "
house physicians and house surgeons, and are provided
•with rooms by the hospital authorities, and receive a
■salary of £80 a year. A resident midwifery assistant
.and an ophthalmic house surgeon are appointed every
six months, and are provided with rooms and receive a
salary of £80 a year, Two assistant anaesthetists are
appointed annually, and receive salaries of £120 and
£100 a year respectively, An extern midwifery assis¬
tant is appointed every three months, and receives a
salary of £80 a year. Chief assistants and clinical
assistants are appointed in each of the special depart¬
ments. In-patient dressers, in-patient clinical clerks,
clerks, and dressers to the assistant physicians, and
assistant surgeons, and to the physicians and surgeons
in charge of special departments, are appointed every
three months without fee.

Scholarships, &c. —There are four open scholarships
In science, £75, £75, £150, £50, tenable for one year,
and an Entrance Scholarship in Arts, value £100, and
the Jeafireson exhibition, value £20; at the end of
first year four junior scholarships of £30, £20, £25, £15,
respectively ; Treasurer's prize for practical anatomy;
Foster prize in practical anatomy ; senior scholarship,
value £50, for anatomy, physiology, and chemistry;
Wix prize, Hicbens prize, Lawrence scholarship and
gold medal, value 40 guineas, for medicine, surgery, and
midwifery; two Brackenbury scholarships, of £39, in
medicine and surgery; Bentley prize, for reports of
cases ; the Kirkes gold medal for clinical medicine,
with scholarship of £30. Shuter scholarship of £50;
Skynner prize of £15 ; Sir G. Burrows’ prize of £10;
Matthews Duncan prize, medal and about £20;
Willett medal and Walsham prize ; Holden Research
Scholarship in Surgery, value £105.

Composition Fees. —(1) For students commencing
their medical studies, one sum on entrance, 165 guineas;
or by four instalments of 45 guineas. (2) For students
who have passed an examination in preliminary
science, in one sum on entrance, 145 guineas; or by
instalments. (3) For students who have finished two
years of medical study but have not passed an ex¬
amination completing their anatomical and physio¬
logical studies ; if paid in one sum on entrance, 110
guineas ; or by annual instalments. (4) For students
who have ccmpleted three years of medical study but
have net passed an examination in anatomy and
physiology ; 90 guineas ; or by annual instalments.
(5) University students who have passed an examina¬
tion completing their anatomical and physiological
Studies, in one sum. 80 guineas ; or by instalments.

Fees for preliminary scientific students: —
20 guineas; for laboratory instruction for D.P.H.,
*5 guineas. Fuller details will be supplied on applica¬
tion to the Dean.

Charing Cross Hospital. —The school attached
to this hospital is situated in Central London, and
Contains new physiological, pathological, and bacterio¬
logical laboratories, materia medica and anatomical
museums, an anatomical theatre, enlarged dissecting-
rooms, and chemical theatre. Clinical instruction is
given in medicine, surgery, and obstetrics, and in the
special department, diseases of the skin, diseases of
children, mental disorders, the throat, the eye, nose
and ear, and in the orthopaedic, Rontgen and electrical
departments, _ ‘* r * n

The school is complete in all departments, with
special teachers for all preliminary and intermediate
subjects.

Entrance Scholarships are awarded annually to the
value of £575.

Appointments. —The curator and pathologist are
appointed annually at £100 a year each. Medical and
surgical and obstetric registrars (annual) £40 a year
each with luncheon in the hospital. Six house phy¬
sicians, six house surgeons, and two resident obstetric
officers are appointed each year, after competitive
examinations. They are provided with board and
residence in the hospital.

Fees. —The fees for the five years’ curriculum may
be paid either by composition fee, payable in one
sum, on joining, 115 guineas, or by sessional payment
system—Entrance fee, 10 guineas. In addition a sum
of 15 guineas must be paid at the beginning of every
winter session, and one of 10 guineas at the beginning
of every summer session so long as the student remains
in the school. Payment may also be made for individual
classes and hospital practice when taken separately.
Students of any university in the United Kingdom
who have passed the examinations in anatomy, physi¬
ology, chemistry, and other preliminary subjects, may
here complete their studies (except vaccination and
attendance at a fever hospital) on payment of a fee
of 74 guineas in one sum, or of 80 guineas in two sums,
viz., one of 43 guineas on entry, and one of 37 guineas
a year later.

The fees for dental students for the two years’
curriculum may be paid :—(a) in one sum of 55 guineas
on entry ; ( b) in two instalments—one of 31 guineas
on entry; and the second of 30 guineas at the end of
the first twelve, months.

Prospectus and further information can be obtained
on application to the Dean.

St. George’s Hospital. — This hospital is situ¬
ated in the West End, facing ;Hyde Park. It con¬
tains 351 beds, and special wards for ophthalmic cases
and diseases of women.

Appointments. —Eight house physicians and eight
house surgeons, entitled to reside and board in the
hospital free of expense ; twelve general assistants, six
assistants in the special departments. Candidates for
the above offices are selected quarterly by competi¬
tion horn among the perpetual pupils, sixteen pupils
being in office at any one time. Obstetric assistant
with a yearly salary at the rate of £50 and board and
residence in the hospital; curator of the museum with
a salary of £200; assistant curator with a salary of
£100 ; a medical registrar, with a salary of £200 per
annum ; a surgical registrar with a salary of £200 per
annum ; an administrator of anaesthetics with a salary
of £50 and two with salaries of £30 per annum. All
offices are open to candidates without additional fee.

By arrangement with the University of London, all
students for the first, second, and third years of the
curriculum carry out the necessary courses of in¬
struction at either King’s College or University College.
The entire teaching of the school is devoted to clinical
subjects.

There are two scholarships open to University
students, particulars of which will be furnished by
the Dean.

Fees. —For first year, £21 or £26 5s., according to
the course. For second and third years, £57 15s. in
one sum or £63 in two instalments. Students entering
their names on the books before commencing this
preliminary or intermediate subjects pay no entrance
fee. Entrance fee, 10 guineas; annual composition
fee, 30 guineas.

Guy’s Hospital. —This hospital is situated on the
Surrey side of London Bridge, and contains 602 beds
in constant occupation. There are special wards for
ophthalmic and obstetric cases, eight beds in the
latter being appropriated for difficult cases of
labour. Some beds have also been set apart
for diseases of the ear and throat, and an “ iso¬
lation” ward for cases of infectious diseases arising
in the hospital has been constructed. An obstetric
registrar and tutor and two clinical assistants

Sept, ii, 1907.

and registrars in the ophthalmic department are
appointed to augment the teaching in the special
departments, in addition to those attached to the
general surgical and medical wards. Attached to
the hospital is a large residential college with rooms
for about sixty men, whilst for students who prefer to
live in the suburbs, no other hospital is so conveniently
placed, tho railway accommodation being good and
close at hand. There is a complete School of
Dental Surgery at this Institution, which is recognised
by the Royal College of Surgeons of England; the facili¬
ties thus afforded of completing the whole course of
dental study including tne pupilage in mechanical
dentistry within the walls of one hospital will be
appreciated by those intending to practise dentistry.
A new museum for pathological specimens and addi¬
tional lecture and classrooms were opened in 1906.

Appointments. —Eight house surgeons, eight house
physicians, eight assistant house physicians, six¬
teen out-patient officers, sixteen assistant house
surgeons, eight obstetric residents, two ophthalmic
house surgeons, twenty-four clinical assistants, and
ninety-six dressers are selected annually from the
students according to merit, and without payment.
There are also a large number of junior appoint¬
ments, every part of the hospital practice being
systematically employed for instruction.

Scholarships. —Open scholarships of £100 and £50 in
classics, mathematics, and modem languages. Open
scholarships of ^150 and £60 in chemistry, physics, and
biology, and an open scholarship of £50 for University
students in two of the following subjects :—Anatomy,
physiology, organic chemistry, zoology, physics. The
following are the scholarships, prizes, and medals
open to students of the hospital:—Junior prizes for
general proficiency, £20, £1$, ^10; Hilton prize for
dissection, £$ ; Michael Harris prize for anatomy, £10 ;
Sands Cox scholarship for physiology, £15 ; Woold¬
ridge prize for physiology, £10; Beaney prize in
pathology, £34 ; Golding-Bird prize in bacteriology, gold
medal and £20 ; Treasurer’s gold medal in clinical
medicine ; Treasurer’s gold medal in clinical surgery ;
Beaney studentship in materia medica (tenable for 3
years), annually £31 10s. ; Gull studentship in path¬
ology (tenable for 3 or 5 years), annually £ico. The
Arthur Durham travelling scholarship of the value
of £100, triennially.

Fees. —A new system for payment of composition
fees has been instituted at this school. Particulars
may be obtained on application to the Dean, Guy’s
Hospital, London Bridge, S.E.

King’s College Hospital. —This hospital is cen¬
trally situated, being contiguous to the Royal College
of Surgeons, Lincoln's Inn Fields. The College adjoins
Somerset House and is close to the hospital, in which
there are 220 beds available for clinical teaching ; oph¬
thalmic, ear, throat, skin, and dental departments are
attached to the hospital. Some wards are specially
devoted to children’s diseases. The wards have been
refloored and the electric light is installed through¬
out.

Scholarships. —Two scholarships of the value of
£100 each ; a scholarship, value ^50, is open to students
of a British University who come up to London to
complete their curriculum ; and one of £40 for fifth
year students. In addition, students may compete
for the Carter, Todd, Tanner prizes, and all class and
clinical prizes.

Appointments. —Medical and surgical Sambrooke re-
gistrarships, tenable for two years, each £50 per annum.
Resident hospital appointments, viz., senior and junior
house physicians, assistant house physician, physician
accoucheur’s assistant and assistant house accoucheur,
and three house surgeons with free board and residence
at the hospital; and senior and junior clinical assistants
in special departments.

Special courses of lectures and practical instruction
in the chemical, physical, physiological, and other
laboratories have been arranged for students preparing
for preliminary scientific, intermediate, M.B., and
other examinations of the University of London.

F.R.C.S. Examinations. —Special classes are arranged

The Medical Press. 271

for the final F.R.C.S. examinations. Further parti¬
culars can be obtained from the Dean.

The London Hospital. —This hospital is the largest
in Great Britain, containing, as it does, 914 beds. It
has, moreover wards and a teaching staff for almost
every special department in the domain of medicine ;
the scholarships and prizes are many and valuable.

The additional buildings for the department of public
health, for the biological, chemical, and physical
laboratories, materia medica museum, vaccinotnerapy,
&c., and the new bacteriological department with
general laboratory, research laboratories and class
rooms for D.P.H. work are now open.

Appointments. —The “ House ” appointments, which
are numerous, are made without fee of any kind, and all
resident officers are provided with free board and rooms,
and in some instances with salary also.

Fees. —Perpetual fee for lectures, demonstrations
and hospital practice, payable in three instalments of
45, 45, and 40 guineas at the commencement of the
first, second, and third years respectively, 130 guineas ;
or, if in one payment, 120 guineas. Fee for students
entering in their third year (their first and
second years having been spent at a recognised
medical school, elsewhere) 60 guineas. This fee
is payable by students entering who have passed
the first M.B. Oxford; the second M.B. Cam¬
bridge ; or the Intermediate M.B. London. Dental
students (general hospital practice and lectures), 40
guineas. General fee for dental practice, 10 guineas.

Note. —A reduction of 15 guineas will be allowed to
the sons of medical men from the perpetual fee if paid
in full, or 5 guineas from each instalment.

Special entries can be made either for single courses
of lectures or for hospital practice. Residential
accommodation is obtainable at a very reasonable
rate close by, or in the suburbs a few minutes' distant
by train. Fuller particulars can be obtained of the
Warden, Mr. Munro Scott.

St. Mary’s Hospital. —This hospital is situated at
Paddington, near the terminus of the Great Western
Railway, and at present contains 281 beds. The new
wing, the ground-floor of which, comprising the new
out-patient department, was opened in 1898, is now
completed, and will be opened as soon as funds will
permit; this will raise the number of beds to 350,
and provide additional operating theatres. The Inocu¬
lation Department, instituted in 1906, has greatly
expanded, and has been transferred to a series of
rooms in the New Wing of the hospital.

The Department is under the personal supervision
of Sir Almroth Wright, F.R.S.

The Athletic Ground (eight acres) is situated at
North Kensington, and is easy of access from the
Hospital.

Appointments. —All clinical appointments in the
hospital are free to students of the Medical School, and
the resident medical officers are chosen by competitive
examination. Six house physicians, six house sur¬
geons, four obstetric officers, and two resident anaesthe¬
tists are appointed in each year, and receive board and
residence in the Hospital.

Scholarships, &c. —One scholarship in natural science,
of the value of ^145, open to any gentleman who has
not completed a winter session of study at a medical
school. One scholarship in natural science, of the
value of £7% 15s., and two of ^52 10s., under the same
conditions. Two scholarships, each of 60 guineas,
open to students from any British University. The
scholarships will be awarded by examination on
September 23rd, 24th, and 27th.

Fees. —Fee for attendance on the full five years’ curri¬
culum of hospital practice and all lectures, demonstra¬
tions, and special tutorial classes, £140, paid in one
sum on entering the school; or in instalments, ^145,

Students who have completed their examinations in
anatomy and physiology at the Universities of Oxford,
Cambridge, or other University, are admitted as per¬
petual pupils on payment of a fee of 60 guineas in one
sum, or 65 guineas in two annual instalments. Uni¬
versity students, prior to completing the anatomy and
physiology examinations, pay an annual fee of 25

G

ENGLAND—EDUCATION.

?ed byCjOOglC

272 The Medical Press.

ENGLAND—EDUCATION.

Sept, u, 190;

guineas. After completing the anatomy and physio¬
logy examinations, the inclusive fee may be paid.

Preliminary Scientific Course. —A complete course 1
of instruction in chemistry, physics, and biology,
recognised by the University of London as an approved
course for internal students, is held throughout the
year. Students may join in October, January, or April:

Middlesex Hospital. —This hospital, which is con- i
veniently situated in the centre both of business and j
residential London, contains 340 beds. There are ]
special departments for cancer, and for ophthalmic,
tnroat. aural, skin, dental, children’s diseases, and
electrical ‘reatment (X-ray and Finsen light). |
Wards are a<so devoted to cases of uterine disease. ,
Residence for students is obtainable in the resi- 1
dential college, which has its frontage on the hospital j
garden.

A Bacteriological and Public Health Laboratory
has been added for the purpose of providing instruc- ’
tion for women medical practitioners preparing for 1
the examinations for the Diploma in Public Health 1
and for the M.D. in State Medicine of the University
of London, and of affording facilities to them and ,
other women students desirous of carrying out Re¬
search Work in Public Health, Bacteriology, and !
General Pathology. I

Appointments.— 1 Casualty surgical officer, casualty .1
medical officer, six house surgeons, six house physicians,
and two resident obstetric physicians. The above
officers have residence and board in the college free of 1
expense. Clinical clerks and dressers in all the depart- m
ments are also appointed in addition to the foregoing. '

Scholarships, &-c. —Two entrance scholarships of
the value of £100 and £ 7 S in Arts and Science
respectively. One entrance scholarship of the
value of £$o, open to Oxford and Cambridge '
students only. (Subjects—Anatomy and physio¬

logy. including histology.) *' Emden ” Cancer Re- ,
search Scholarship, ^100. “ Richard Hollins,” '

Research Scholarship, ^105. Two Broderip scholar¬
ships of £6 o and ^40 respectively, for medicine
and surgery; John Murray medal and scholarship, !
awarded every third year ; the Governor’s prize of £2 1
for students in their final year. Hetley clinical prize, j
value £25, awarded annually for proficiency in practical,
clinical medicine, surgery, and obstetrics; the Lyell
Gold Medal and scholarship, value £55, in surgery and !
surgical anatomy ; the Leopold Hudson prize, value
11 guineas, in surgical pathology, including bacteri-'
ology ; Freeman scholarship, £30, in obstetrics and
gynaecology ; an exhibition of 10 guineas for anatomy 1
and physiology to second years’ students as well as
class prizes in all subjects.

Fees. —General fee for the entire course of hospital
practice and lectures, 135 guineas, if paid in one sum on ,
entrance, or by instalments of 60, 50, and 35 guineas,‘
payable at the commencement of the first, second, and :
third years respectively. For those who have completed
their anatomical and physiological studies the fee is 70
guineas on entrance, or in two instalments of 40 and 35 j
guineas. The composition fee for London University :
students is 145 guineas. For those who have passed;
the preliminary science examination 120 guineas. The
fee for the curriculum for dental students is 54 guineas
on entrance, or two instalments of 40 guineas and 20 j
guineas. 1

St. Thomas’s Hospital. — This hospital, with j
medical school attached, is situated on the southern |
Embankment of the Thames, facing the Houses of j
Parliament and contains 602 beds, in constant use. I
The school buildings, which are separated from the;
hospital by a quadrangle, comprise numerous theatres,!
laboratories, and class rooms, which are well adapted;
for the modem teaching of large bodies of students
in all subjects of the medical curriculum. There is
a large library and reading-room, and a very complete!
museum and gymnasium. '

Appointments are open to all students. A resident:
assistant physician and a resident assistant surgeon are!
appointed annually at a salary of £100 with board and!
lodging. Four hospital registrars, two at an annual;
salary of £100 each, and two at £50 -each, are ap 1

pointed yearly. The tenure of these offices may be
renewed for a term not exceeding two years. Four
resident house physicians, two resident obstetric house
physicians, and two ophthalmic house surgeons are
appointed each six months, also out-patient officers,
and clinical assistants in the special departments.

Scholarships, Prizes, S-c .—Three entrance scholar¬
ships are offered for competition in September, viz., one
of ^150 and one of £60 in chemistry, physics, and
biology at the commencement of the second year ; one
of ^50 open to University students who have passed
in anatomy and physiology, for a medical degree in
any of the Universities of the United Kingdom, and
have not entered as students in any London Medical
school. Numerous scholarships, prizes, and medals
are open to competition throughout the whole career
of a student, including a Fellowship of ^100 given by
the Salters’ Company for research in pharmacology,
and the Louis Jenner research scholarship, £60, for
pathological research.

Special courses of instruction for the Preliminary
Scientific and Intermed., M.B.Lond., for the Oxford
and Cambridge examinations, and for the Primary and
Final F.R.C.S. are held throughout the year.

A register of approved lodgings is kept by the
medical secretary, who has a list of local medical prac¬
titioners and others who receive students into their
houses. The prospectus of the school may be obtained
on application to Mr. G. Q. Roberts, Secretary of the
Medical School.

Fees .—A new system for payment of composition
fees is in operation. Full details may be obtained of
the Secretary.

University College Hospital and Medical
School. —The hospital with college opposite are
situated in Gower Street, not far from Euston railway
terminus, and the Medical school in University Street,
connected with the hospital by a subway. The num¬
ber of beds available for teaching purposes is 2 77.

The new buildings for University College Hospital
completed by the generosity of the late Sir Blundell
Maple, Bart., were opened by H.R.H. the Duke of
Connaught, on Tuesday, November 6th, 1906.

The new buildings for the Medical School, erected
through the generosity of Sir Donald Currie, contain
accommodation for undergraduate and post-graduate
students in all departments of medical study subse¬
quent to the intermediate course.

Appointments .—Eight house physicians, eight house
surgeons, four senior and four junior obstetric assistants,
and two ophthalmic assistants are selected annually by
examination from among the senior students, without
fee. The house physicians and house surgeons reside in
the hospital for a period of six months, and the senior
obstetric assistants for three months, and receive their
board and lodging free.

The offices of out-patient physicians’ and surgeons'
assistants, clinical clerks, surgeons’ dressers, and oph¬
thalmic surgeons’ assistants are filled by pupils who are
also students of the college, without additional fee.

Scholarships, <Sc. — Entrance scholarship of the
value of 135 guineas, and two exhibitions of 55
guineas each, and the Epsom free medical scholar¬
ship for proficiency in science, the subjects being
those of the Preliminary Scientific Examination
of the University of London, and two of 80
guineas each, the subjects being anatomy and
physiology; the Atkinson-Morley surgical scholar¬
ship of ^45 a year, tenable for three years ; Atchison’s
scholarship, value £55, tenable for two years ; Sharpey
physiological scholarship, value about £105 a year;
Filliter exhibition for proficiency in pathological
anatomy, value £30; Erichsen prize, operating
case, value £10 10s., awarded for practical

surgery ; Dr. Fellowes’ clinical medals, the Liston
gold medal, Alexander Bruce gold medal, Cluff
memorial prize, Tuke medals for pathology, and other
prizes, as well as certificates of honour, are awarded
after competitive examinations in particular branches of
study. The Tuffnell scholarship of £&o for chemistry
two years; and the clothworkers’ exhibition, in

zedbyGooqle

1 O

SCOTLAND—EDUCATION.

Sept ii, 1907-

chemistry and physics of £30 each, can also be held in
the medical faculty.

Composition Fees. —The following have been grouped
to meet the requirements of the various examining
boards: A.—For the Courses required by the University
of London. 1. For the Preliminary Scientific Course :
25 guineas, entitling to one attendance. 2. For the
Intermediate Course : 55 guineas, if paid in one sum ;
60 guineas if paid in two instalments. 3. For the Final
M.B., B.S. Course : 80 guineas, if paid in one sum ;
82 guineas, if paid in two instalments. This course of
instruction is also suitable for the corresponding exam¬
inations at the Universities of Oxford, Cambridge, and
Durham.

B. —For the Medical education required by the
Examining Board in England and the Society of
Apothecaries: 4. For the Course required for the First
Examination : 20 guineas entitling to one attendance.
5. For the Second : 55 guineas, if paid in one sum ; 60
guineas, if paid in two instalments. 6. For the Course
required for the Third Examination : 80 guineas, if
paid in one sum ; 82 guineas, if paid in two instalments.

The composition fee in each case entitles to attend¬
ance on Lectures and Hospital Practice during three
years.

C. —For Dental Students. Composition fee for the
Courses required for the L.D.S., 65 guineas ; or exclu¬
sive of chemistry, practical chemistry, physics, and
materia medica, 50 guineas.

Students may repeat attendance at the Courses in
chemistry and physics for £3 3s. (inclusive) and in
elementary biology for £2 2s.

It should be noted that under the arrangement
with the University of London, that body controls the
medical science section of the medical school now, while
the advanced medical subjects, that is the subjects
after the intermediate course, are controlled by the
University College Hospital Medical School.

Westminster Hospital. —This hospital is con¬
veniently situated, facing the Abbey, and is readily
accessible from all parts of the Metropolis. It contains
205 beds for general cases, and all tne special depart¬
ments. New school buildings have been erected close
by which afford accommodation for 150 students. The
class rooms, dissecting rooms, and lecture theatre are
excellent samples of modern erections, affording ample
scope for study.

Appointments. —Medical and surgical registrars, each
^50 per annum ; two house physicians, three house
surgeons, one assistant house physician, one assistant
house surgeon, and a resident obstetric assistant.
These officers, except the two first named, are all
boarded free of expense. Qualified students are
appointed to be clinical assistants in the various
departments.

Scholarships, &-c. —(a) Winter Session—The Guthrie
scholarship £ 60 , entrance scholarship £ 40 , entrance
scholarship £30, dental scholarship £20 ; subjects,
Latin, mathematics, English, and either Greek,
French, or German. University scholarships, £60
and £40; subjects, anatomy and physiology.
Natural science scholarship, £ 60 , subjects, same as
for Prel. Sci. of University of London. Natural
science scholarship, £40, subjects, chemistry and
physics. Free presentation, open to pupils of
Epsom Medical College. (6) Summer Session. —
Natural science scholarship, £ 60 , same as winter.
Natnral science scholarship, ^40, same as above.
Arts scholarship, £ 60 , arts scholarship, £ 40 , Uni¬
versity scholarships, £60, subjects same as in
winter session, (c) Prizes, to De competed for by
unqualified men. Chadwick, 20 guineas for students
of any year not exceeding fifth. Bird medal and prize,
^14 for students who have completed fourth winter
session. Sturges prize in clinical medicine, £10, clinical
surgery prize, £$. And class prizes in the various
subjects.

Fees. —(a) For course required by Conjoint Board.
In one payment of 120 guineas, or two payments
of 65 guineas each, payable on entrance and at the
commencement of second year respectively, or by
six payments, distributed over six sessions, of

The Medical Press. 273

24 guineas each. (6) For the entire course
of the University of London the composition fee is
130 guineas. Fees for shorter periods or for single
courses may be learned on application to the Dean.
Fees for dental students, payable in one sum on
entrance, 50 guineas, or in two instalments, of £27 10s
each.

London School of Medicine for Women (Royal
Free Hospital). —The school is situated in Hunter
Street, Brunswick Square, and the Royal Free Hos¬
pital is in Gray’s Inn Road, close by. The school
was re-built in 1898, and the laboratories are fully
equipped for all the work required for the prelimi¬
nary Scientific and Intermediate M.B. examinations
of the University of London. A course of study is
specially arranged for the work required by the Con¬
joint Colleges of Scotland and the Society of Apothe¬
caries. Students are also prepared for the examinations
of the various Universities. The Royal Free Hos¬
pital contains 165 beds available for clinical study;
and there is a large out-patient and casualty depart¬
ment. In addition to the ordinary systematic lec¬
tures at the school, clinical lectures are given at the
hospital in medicine, surgery, obstetrics, ophthal¬
mology. and dermatology. Students hold clerkships
and dresserships in each department.

Appointments .—A house physician, house surgeon,
and a senior and junior resident obstetric assistant
are appointed yearly. There are also non-resident
appointments, including the anaesthetist and assistant
anaesthetists, assistant and clinical pathologists,
medical and surgical registrars, curator of museum
and clinical assistants.

Fees .—-The fee for the Intermediate and Final M.B.
University of London course is ^135 in one sum, or
£145 in the following instalments:—first year, £45 ;
second year, ^40; third year, £40; fourth year,
£20. The fee for the Preliminary Science classes is
£25. The fee for the course for the Conjoint Colleges
or Society of Apothecaries, including Elementary
Science, is £140 in one sum, orin the following instal¬
ments :—first year, £$o ; second year, /40 ; third
year, ^40; fourth year, £20. Particulars as to
Scholarships, &c., can be obtained from the Secretary,
Miss Douie, M.B., 8 Hunter Street, W.C.

EXTRA-ACADEMICAL INSTITUTIONS
IN LONDON.

Royal Institute of Public Health.— The Royal
Institute of Public Health, was founded in the year
1886, with the object of obtaining the registration
of public health diplomas and the further statutory
requirement that all Medical Officers of Health should
possess such a qualification, by which means it has
succeeded in placing at the head of every public health
administration in the Kingdom, a properly trained
and specially qualified medical officer. The Council,
with the object of providing a Central Institution
in London, not only for instruction for the diploma
and for scientific work in connection with public
health, but also one to which those engaged or inter¬
ested in preventive or tropical medicine may resort
have acquired large and important premises in Russell
Square, for the purposes of the Institute, providing
a common room for the use of Fellows and Members,
a lecture room, a reference library, laboratories for
bacteriological and chemical and physical research,
and laboratories in which the course of instruction for
the diploma in public health can be taker, fitted up
with all modern improvements.

The Institute is recognised as a public educational
institution by the University of London, and its courses
of instruction by the Universities and the Royal
Colleges of Physicians and Surgeons. In pursuance
of the above objects, the Institute publishes monthly
The Journal of the Royal Institute of Public Health.
Facilities are also afforded for municipal authorities,
rivate medical practitioners, and others to obtain
acteriological and chemical reports.

The Institute is under the patronage of His Majesty
the King, and the teaching staff consists of the Prin-

by Google

274 The Medicai. Press.

ENGLAND—EDUCATION.

Sept. it. 1907*

cipal, Professor William R. Smith, M.D., D.Sc.,
F.R.S.E., Barrister-at-law; Demonstrator of Bac¬
teriology, Carl Prausnitz, M.D., Breslau; Demon¬
strator of Chemistry, Mr. C. E. Harris, Ph.D. ;
Lecturer on Parisitology, Dr. Louis Sambon.

The next annual Congress (1908) will take place at
Buxton.

The Royal Dental Hospital. —The teaching and
hospital practice at this institution (situated
in Leicester Square) are recognised by the
various examining bodies. The new hospital
and school which was opened six years ago, is complete
in every detail with modem appliances. The clinic
of the hospital is unrivalled, no less than 99,760 cases
being treated in 1906. The following scholarships
and prizes are open to all full term students :—Entrance
scholarship, of the value ol £20, awarded in October.
Subjects : Chemistry and dental mechanics. Saunder
scholarship, of the value of £zO, awarded to the student
obtaining the highest aggregate number of marks in
the various class examinations. Storer-Bennet research
scholarship of the value of ^50, awarded once in three
years ; the Alfred Woodhouse scholarship of ^35, and
the Robert Woodhouse prize of the value of £10, for
practical dental surgery. Class prizes are awarded
by the various lecturers. Provision is made for teach¬
ing mechanical dentistry, as required by the Royal
College of Surgeons, the pupils being unner the guid¬
ance of the staff of dental surgeons assisted by specially
appointed demonstrators. The school cor tains an
excellent library and a well-arranged museum.

Fees .—For the two years’ hospital practice and
lectures as required by the Royal College of Surgeons
of England, the fee is £$$ 3s. in one instalment, or
^55 13s. in two yearly instalments. The fee for the
complete curriculum, namely, two years’ instruction
in mechanical dentistry and two years’ hospital
practice and lectures, is £150 if paid in one instalment,
or 150 guineas if paid in three instalments of 50
guineas. For one year’s instruction in mechanical
dentistry the fee is 50 guineas. For one year’s
hospital practice, £21. The necessary course of two
years at a general hospital can be taken simultane¬
ously with that at the Royal Dental Hospital.
Further particulars can be obtained on application to
the Dean.

National Dental Hospital. —This institution is
centrally situated (Great Portland Street, W.), and
excellent teaching facilities and hospital practice are
here obtainable, special demonstrations being given
by members of the staff. There are also a mechanical
laboratory, bacteriological laboratory, museum, stu¬
dents’ common room, a metallurgical laboratory, extrac¬
tion and stopping rooms, lecture hall, regulations room,
&c., all lighted by electricity, and warmed and venti¬
lated after the most approved requirements ; in fact,
this institution may be pronounced a model dental
hospital and school. The winter session commences at
the same time as at the medical schools, on October 1st.
The medical tutors hold special classes before each
college examination. The prizes include two entrance
exhibitions, value £40 and £20, and the Rymer prize of
£$ 5 S *« the examinations for which are held in May
and October, The fee for two years’ hospital practice
required by the curriculum, including lectures, is £40.
(See advt.)

The two years’ training in dental mechanics, re¬
quired by the R.C.S. Curriculum, can be taken in the
Mechanical Laboratory, and there is a " Composition
Fee ” including all the dental subjects of the curri¬
culum of £ 120.

Women and Children.

The Hospital for Women, Soho Square.—The
hospital contains 61 beds. In connection with this

institution there is now an organised school of gynaeco¬
logy open to qualified medical men and to students after
their third year. Clinical assistants to the physicians
and surgeons in the in-patient and out-palient depart¬
ments are appointed every three months. Fee for the
three months* course, and certificate, £8 8s.

The Samaritan Free Hospital for Women.. Mary-
lebone Road, N.W., offers excellent opportunities to

qualified medical men for clinical study and training
in the details of operative gynaecology. Fee: three
months, £3 3s. The success of the stall in this depart¬
ment has gained for them a European reputation.
There are 5 1 beds.

Medical students are admitted to the practice
of tiie following Metropolitan hospitals.,to which
no medical school is attached. Detailed par¬
ticulars will be supplied on application to the
various secretaries.

West London Hospital, Hammersmith, — This
contains 175 beds, and has an extensive out-patient
department. Dresserships and clinical clerkships may
be obtained, Two house surgeons and two house
physicians are selected every six months. There are
special departments for diseases of the throat, nose
and ear, skin, women and children, and deformities.
Electrical and X-ray departments have also been
added. The practice of this hospital is reserved ex¬
clusively for medical men, junior students not being
admitted.

Great Northern Central Hospital, Holloway
Road. N.—This institution has been greatly enlarged,
contains 167 beds, cases in various special departments
are treated, and the hospital is now recognised for
study during the fifth year by the Conjoint Board.
The practice of the hospital is open to practitioners
and senior students, and clinical and pathological
assistants are appointed in the wards and out-patient
departments, as in the larger general hospitals.

Bethlem Royal Hospital. —In this Royal insti¬
tution only cases of lunacy are received, and students
intending to pursue this special branch have the best
possible opportunities afforded here. The hospital
contains 300 beds, and two resident house physicians
who have recently obtained their diplomas to practise
medicine and surgery are elected every six months,
and are provided with apartments, complete board,
attendance, washing, and an honorarium of 25 guineas
per quarter. The students of certain specified London
medical schools receive clinical instruction in the
wards of the hospital, and qualified practitioners
may attend for a period of three months on pay¬
ment of a fee. Post-graduate lectures are also given.

National Hospital for Epilepsy and other
Diseases of the Nervous System, Queen Square,
W.C.i contains 200 beds. This institution is recognised
by the Conjoint Board where part of the fifth year of
study may be devoted to clinical work, Clinical clerks
are appointed to the physicians for out-patients, and
courses of lectures and clinical demonstrations are given
each year,

London Temperance Hospital. —The hospital con¬
tains 110 beds, and is conducted as its name implies
on non-alcoholic principles by an excellent staff. The
medical and surgical practice is open to students and
practitioners. Appointments (vacancies for which are
advertised in the medical journals): Surgical and
medical registrars, resident medical officer, and one
assistant resident medical officer.

Metropolitan Hospital, Kingsland.—This was
until recently known as the Metropolitan Free Hospital,
is situated in the north-eastern district of the Metro¬
polis, and contains 160 beds. It is a general hospital,
with various special departments for the treatment of
diseases of the eye, throat, ear, &c.

Prince of Wales Hospital Tottenham. — This
hospital contains medical and surgical wards and a
ward for children, having in all 73 beds. There are
special departments for gynaecological cases, diseases
of the eye, ear, throat and nose, and skin diseases. It
has now been authorised by the University of London
to give certificates of post-graduate study for the M.D.
and M.S. degrees.

Hospitals for Consumption.

Hospital for Consumption and Diseases of the
Chest, Brompton.—The largest institution lor the
treatment of affections of the chest in the United
Kingdom, there being 321 beds in the two buildings.
There are four house physicians who reside in the
hospital, each for a period of six months. Lectures and

Sept, ii, 1907.

ENGLAND—EDUCATION.

demonstrations are given bv members of the medical
stall on Wednesdays and Fridays at four o’clock, save
during the vacations. Terms, £2 2s. for three months ;
£$ 53. perpetual. This hospital is recognised by the
Conjoint Board, the University of London, and the
Apothecaries’ Society.

Mount Vernon Hospital, Hampstead and North-
wood.—This institution, formerly called the North
London Consumption Hospital, now carries on its
work at Hampstead with :4s beds, and at Northwood
with 100 additional beds, where treatment is carried
out on the most modern lines, including the “ open
air ” and other systems. Students are admitted to
the practice of the hospital under certain conditions,
and post-graduate courses are regularly delivered
during the year.

City of London Hospital for Diseases of the
Chest, Victoria Park.—This is a large and well-
equipped hospital at the East End, containing 164 beds.
Clinical lectures and demonstrations are given by the
members of an exceptionally experienced staff. Fee
for three months' attendance on hospital practice,
2 guineas ; six months, 3 guineas.

Royal Hospital for Diseases of the Chest, City
Road.—(80 beds.)—This hospital has been enlarged by
the addition of a very complete out-patients’
department, and also by the erection of a new wing,
which provides accommodation for 80 in-patients.

Throat and Ear Hospitals.

Hospital for Diseases of the Throat, Golden
Square, W.—This hospital has been recently rebuilt
and contains 40 beds. Clinical instruction is given
daily in the Out-patient Department on diseases of the
nose, throat, and ear, and systematic courses of lectures
are given during the winter session. There are nine
clinics weekly, and an annual out-patient attendance
of nearly 50,000. Major and minor operations daily
(Mondays excepted) in different theatres. Four senior
and thirty-six junior clinical assistants are appointed
from among the students to assist the surgeons.
Students are admitted to the practice of the hospital
at the following fees:—Three months, £3 5s.; six
months, £7 7s.; longer periods, £10 10s. Further
details can be had by applying to the Dean.

Central London Throat and Ear Hospital.—
This hospital contains accommodation for 22 in¬
patients, and new operating theatre. It has a very
extensive out-patient department (over 50,000 attend¬
ances yearly), which is open daily to all medical prac¬
titioners and students, for the purpose of clinical
demonstration and instruction. Courses of prac¬
tical teaching are held twice weekly by members
of the staff, which are open to qualified practitioners
and advanced students. Each course is of about six
weeks’ duration, and includes hospital attendance for
that period. The fee is 2 guineas.

Operations are performed daily (Saturday excepted)
at 2 p.m.

Special attention is devoted to scientific work in
the newly equipped laboratory. Full particulars will
be supplied on application to the Dean.

Metropolitan Ear, Nose, and Throat Hospital.
—The hospital was founded in 1838, and is situated in
Grafton Street. Tottenham Court Road. The out¬
patient department is open daily at 2.30 p.m. to prac¬
titioners and students for acquiring clinical instruction
and technical knowledge. Operations are performed
on in-patients on Tuesdays, Wednesdays, and Thurs¬
days at 9 a.m. Fee for one month’s attendance at the
hospital one guinea, and for three months two guineas.
During the forthcoming session demonstrations will be
given by members of the staff on the pathology and
treatment of diseases of the ear and respiratory pas¬
sages. Short practical classes will also be held in
clinical pathology and surgical anatomy. Weekly
clinical lectures are given by the staff on the special
disease treated at the hospital.

Royal Waterloo Hospital for Children and
Women. —This important institution, situated in
South London has been in a transition state for some
time past, having been partly rebuilt and appointed on

The Medic al Press. 275

ambitious lines, and when completed, as it is expected
it will be soon, will contain 200 beds.

Hospital for Sick Children, in Great Ormond
Street, Bloomsbury, and Cromwell House, Highgate.
—Fee for three months’ attendance, £3 3s.; perpetual,
£3 5s. There are now 222 beds, besides 38 additional
at the convalescent branch.

The practice of the Hospital is open to qualified
medical men, and to students who have completed four
years of medical study, the Hospital having been
recognised by the Conjoint Board of England as a
place where six months of the fifth year may be spent
in clinical work. There are special ophthalmic, aural,
dental, and electrical departments. There is also a
Museum and Library in connection with the School.
Lectures are given every Thursday afternoon during
session by members of the staff, and certificates are
granted.

For tickets and further information, apply to the
Secretary, by letter, or by calling at the Hospital.

Eye Hospitals.

Royal London Ophthalmic Hospital, formerly in
Moorfields, and recently rebuilt in the City Road, is the
largest hospital devoted to this specialty in Great
Britain, and contains 138 beds. Students and practi¬
tioners are admitted to the practice daily at 9 o'clock.
Operations, 10 o’clock and after. Fee for six months,
3 3s. ; perpetual, £3 5s. Further particulars of the
ecretary.

Royal Westminster Ophthalmic Hospital, ad¬
joins Charing Cross Hospital in King William Street.
It has about 40 beds and a very large out-patient cli-
nique. The lectures and demonstrations are arranged
with special reference to the requirements of practi¬
tioners and senior students. Fee, six months, £3 3s. ;
perpetual, £3 5s.

Royal Eye Hospital, St. George’s Circus, South¬
wark.—There are 40 beds and two cots. Fees, £2 2s.
for three months, £3 3s. for six months, and £3 5s.
perpetual. Courses are held on ophthalmoscopy,
refraction, and diseases of the eye ; fee, £1 is. for each
course, but perpetual students may attend each course
once without extra fee. Pathology class, £1 is. extra
to cover cost of materials.

Central London Ophthalmic Hospital.— This
hospital is situate in the Gray’s Inn Road, has 26
beds and a large out-patient clinique. The post of
clinical assistant is opento both men and women, who
must be duly qualified and registered practitioners.
During the winter session commencing in October
lectures and demonstrations will be given in all the
branches of ophthalmology. For syllabus and further
particulars apply to the Dean.

Skin Hospitals.

St. John’s Hospital for Diseases of the Skin.—
Out-patient department, Leicester Square ; In-patient
department, Uxbridge Road, W. This hospital has a
well-equipped in-patient department, with 50 beds.
It has a School of Dermatology at 49 Leicester Square,
which is conducted by the medical staff of the hospital.
During the past year the free course of Chesterfield
Lectures given by Dr. Morgan Dockrell has proved a
great success, being well attended by the profes¬
sion. The next course (free) will commence on Thurs¬
day, October 3rd, at 6 p.m., in the Lecture Room of
the Hospital, Leicester Square. The subject of the
opening lecture will be “The Present Position of
Dermatology.” The Out-patient Department has
recently been rebuilt at a cost of £10,000, and contains
a spacious laboratory and special electrical depart¬
ment which can be seen in operation every afternoon
except Saturday. Clinical demonstrations arc given
every Monday (Dr. Morgan Dockrell) at 2 p.m. ;
Wednesday (Dr. Savill) at 3 p.m. and Tuesday
(Dr. Eddowes), at 2 p.m., on Selected Cases. (See
Advt.)

One of the oldest institutions of the kind is the
Western Skin Hospital (Great Portland Street), which
was started as long ago as 1851. The practice of the
hospital is open to students and practitioners. Stu¬
dents of this specialty have also the London Skin
Hospital, in Fitzroy Square, with seven beds and an

by Google

276 The Medical Press.

ENGLAND - EDUCATION.

Sept, ii, 1907-

out-patient department of over 1,400. There is also
the Stamford Street Skin Hospital, in the southern part
of the Metropolis, with 10 beds and an out-patient
department of 5.600. so that the students’ needs in
this direction are well catered for.

METROPOLITAN POST-GRADUATE
INSTITUTIONS.

Medicai. Graduates’ College and Polyclinic.—
This institution affords to medical men special facilities
for acquiring technical skill, and advancing their
medical and scientific knowledge. The building, which
is large and commodious, is situated in Chenies Street,
Gower Street, and contains lecture and consulting
rooms, pathological and clinical laboratories, Rontgen
ray room, an ophthalmoscope room, a library and
museum, and reading and smoking rooms. Cliniques,
at which patients are shown, are given every day of the
week except Saturday, at 4 p.m. Lectures on Medicine.
Surgery, and other allied subjects are delivered on
Mondays, Tuesdays, Wednesdays, and Thursdays at
5.15 p.m. Four sessions of practical classes, each lasting
six weeks, and a vacation session of three weeks’ dura¬
tion, are held during the year, the subjects taught com¬
prising ophthalmology, otology, clinical microscopy,
laryngology, urinary analysis, gynaecology, applied
anatomy, nervous diseases, and practical X-ray work.
There are, in addition, extra-mural classes in opera¬
tive surgery and practical anatomy with dissecting.
Special tutorial classes in medicine, surgery, midwifery,
and pathology for gentlemen readirg for the higher
qualifications have recently been instituted, and are
conducted regularly throughout the year.

A complimentary ticket for three days, admitting to
eliniques and lectures, is issued to any medical practi¬
tioner on personal application at the college. The
annual subscription for medical practitioners of either
sex, holding qualifications granted in any of H.M.’s
dominions—wherever resident—is One Guinea. Full
information may be obtained from the medical super¬
intendent, Mr. Hayward Pinch, F.R.C.S., 22, Chenies
Street, Bedford Square.

West London Post-Graduate College. —The
West London Hospital, Hammersmith Road, W.,
contains 160 beds; the post-graduate course was
started in 1895, and this is the original post-graduate
college in London attached to a general hospital.
Instruction is given in the out-patient department
daily at 2.15 p.m. by the assistant physicians and
assistant surgeons. The physicians and surgeons
attend daily at 2.30 p.m., when post-graduates can
accompany them in their visits to the wards. Operations
are performed daily at 2.30 p.m. There are lectures
every evening at 5 p.m. (Saturdays excepted).
Special classes are held in bacteriology, diseases of
the eye, throat, X rays, amesthetics, intestinal
surgery, tropical medicine, cystoscopj, operative
surgery, &c.

Fees .—The fee for the hospital practice including all
the ordinary lectures and demonstrations, is £1 is.
for one week ; £2 2s. for one month ; £5 5s. for three
months ; £8 8s. for six months ; £12 12s. for one year,
and £25 for a life ticket. A course of attendance on
either the medical or surgical practice alone may
be taken out for the fee of £3 3s. for three months.
The fee for three months' attendance in any one special
department, other than medicine or surgery is £2 2s.
A prospectus containing full particulars will be for¬
warded on application to Mr. L. A. Bidwell, Dean.

North-East I.ondon Post-Graduate College.—
This post-graduate school is established in connection
Prince of Wales’s General Hospital, Tottenham, N.,
which is recognised by the University of London as
a place of post-graduate study for the M.D. and M.S.
degrees, and by the India Office for purposes of study
leave. Facilities are here afforded to qualified medical
practitioners for taking part in the work of an active
general hospital, and for attending demonstrations
of various branches of medicine surgery, and gynae¬
cology, with opportunities for clinical instruction in
diseases of the eye. ear, throat, nose, skin, in fevers,
psychological medicine, the administration of anaes¬
thetics, radiography and dentistry. Cliniques, lec¬

tures and demonstrations are given by members of
the teaching staff in the lecture room, in the wards,
in the various out-patient departments, and iD cer¬
tain affiliated institutions. Operations are performed
every afternoon of the week, except Saturday.
Special classes, the attendance at which will be
limited, are arranged in gynaecology, the surgical
diseases of children, including orthopaedic surgery,
diseases of the throat, nose and ear, diagnosis of diseases
of the nervous system, ophthalmoscopy and refraction,
analysis of gastric contents, clinical examination of
the blood, diseases of the skin, abdominal surgery,
radiography, bacteriology, and medical electricity.
The fee for a three months’ course of study, which
may be begun at any time, in any single department,
is one guinea. A fee of three guineas aidmits to the
whole practice of the hospital for a similar term (one
month, 2 guineas), aind a perpetual ticket for the
practice of the hospital may, for the present, be
obtained on payment of a fee of 5 guineas. The opening
lecture of the Winter Session will be given by Dr. W.
Hale White, at 4 p.m., on Thursday, October, 3rd.
Additional information with a syllabus of lectures,
demonstrations, and special classes, may be obtained
from the Dean of the Post-Graduate College, Dr. A. J.
Whiting, 142 Harley Street, W.

London Post-Graduate Association. —This Asso
ciation offers facilities for Clinical Study to qualified
medical men. Joint cards of admission are issued
to the Clurcal Instruction of the following General
Hospitals aiiv. Schools of Medicine :—Charing Cross,
Guy’s, Westminster, St. Thomas’s, University College,
St. Mary’s, King’s College, besides several special
hospitals. Fee. —For three months, 10 guineas;
for six months, 15 guineas ; and for any longer period
at the further rate of 9 guineas for each additional
six months. Further particulars may be obtained
of the Secretary, London Post-Graduate Association,
Examination Hall, London, W.C.

The following are the principal provincial hos¬
pitals having the greatest number of beds, to
which students are admitted where clinical in¬
struction can be obtained, but to which there is
no medical school attached

Bradford Infirmary. —The hospital contains 220
beds. Non-resident pupils are received and abun¬
dance of clinical material is obtainable- One year’s
attendance is recognised by the Examining Boards.
Fee, perpetual, £10 10s.

Liverpool Northern Hospital, which has recently
been rebuilt, now contains 246 beds, and is com¬
pletely equipped with the most modern appliances.
Clinical instruction is given by the staff during the
summer and winter sessions- Clinical clerkships and
dresserships are open to all students without additional
fees. Fees for hospital attendance : Perpetual, £26 5s.;
one year, £\o 10s. ; six months, £6 6s,; three months,
£4 4s.; practical pharmacy, £2 2s,

Norfolk and Norwich Hospital. —This hospital is
recognised by the Colleges, and contains 220 beds.
Fees, £10 10s. for six months, £\5 15s. for twelve
months’ medical and surgical practice. Pupils, resi¬
dent and non-resident, are admitted.

Northampton General Hospital. —This hospital
contains 174 beds ; it has been recently enlarged and
re-arranged. Non-resident pupils are receiv.'d and
have every opportunity of acquiring a pra.. tical
knowledge of their profession. The fee is £10 10s.

Royal Berkshire Hospital. —The town of Read¬
ing, in which this hospital is situated, has a very large
working-class population, and excellent opportunities
for clinical instruction in the wards and extensive out¬
patient department are afforded here. It contains
160 beds, a splendid library, ip which the Reading
Pathological Society holds its mettings.

Wolverhampton General Hospital. —The hospi¬
tal contains 230 beds, attendance at this hospital being
recognised by all the Examining Boards. Pupils are
trained in clinical work by the medical and surgical
! staff. Fees ; Six months, £6 6s,; twelve months,
1 £12128,; perpetual, £21,

Sept. 11.1907.

IRELAND

Irelitnb.

THE IRISH MEDICAL SYSTEM.

The system of medical teaching in Ireland differs
from that in England in important particulars. In
London each clinical hospital has its attached medical
school, which is fully equipped, and which educates the
students of that hospital and very seldom those of any
other. In Dublin, on the contrary, the hospitals and
schools are entirely separate (except that Sir Patrick
Dun’s Hospital is officially connected with Trinity Col¬
lege), and a student of any hospital is free to enter for
the whole or any part of his course at any school or hos¬
pital he pleases.

COST OF MEDICAL EDUCATION IN IRELAND.

The cost of obtaining a medical qualification depends
to some extent on the qualification sought. In this
connection the following tables may be of use to the
prospective student:—

COST OF MEDICAL EDUCATION.

School of Physic, Dub. Univ. .. ^122 6s. 6d.

Royal College of Surgeons School ^ I2 4 I 9 S «

Catholic University School .. ^124 19s.

Queen’s College .. .. About £\ 10

COST OF DIPLOMAS OR DEGREES.

Dublin University .. .. £27 (to this must be

added £83 4s., the
cost of obtaining an
Arts degree),

Royal University .. .. £15.

Conjoint Royal Colleges .. ^42.

Apothecaries’ Hall .. .. £22 is.

Thus, the absolute payment will amount to some
where between £125 and £232 10s, 6d. according as the
teaching of the Queen’s Colleges and the degrees of the
Royal University, or the teaching and degrees of Dublin
University, are taken. For the Conjoint Colleges the
entire cost is £\66 19s., taking the minimum mode of
payment. So that, assuming that extras or voluntary
costs are incurred the total will vary, say. from £\yo to
£200. “ Grinding,” although not officially recognised,

occupies a position almost identical with that of the
extra-mural instruction in other schools. Its cost
must be reckoned among the expenses of the corns?,
for, while not essential, it has become customary
for almost all students to obtain aid in their
studies in this way. As a rule, this private instruction
costs about £5 5s. for each of the four examinations.

The above sum, or something like it, may be expended
by the student or his parent in paying for lectures, &c.,
and examination fees as they fall due, and there is no
difficulty in obtaining the needful information for his
guidance if he likes to pay for his course in this fashion.

All the Dublin schools require fees to be paid in
advance.

DATE OF ENTRY.

The entry of names and commencement of study in
Ireland is supposed to date from the 1st of October in
each year, but the sessioh really dates from the 1st of
November, and the entry of names may be delayed by
the dilatory to the 25th of the same month. It should,
however, be remembered that no credit is given for
studies or attendance until the entry is regularly made,
The student must attend three-fourths of the lectures
delivered, and if he loses a fortnight at the beginning
he must make up for it afterwards by constant attend¬
ance.

The student begins work by attending a recognised
medical school each morning at ten o’clock, and occupy¬
ing his day, to five p.m., between lectures and dissec¬
tions. His vacations are a fortnight at Christmas and
a week at Easter, and he finally returns home at the
end of June,

PRELIMINARY EXAMINATIONS,

The first act of the student is to pass a preliminary
examination, without which he cannot get credit for any
medical studies pursued. The next is to commence
medical study. This he does by entering for lectures
at a medical school, From the school registrar he gets

-ED UCATIO N_ The Medical Press. _2 77

a form of certificate, and his third act is to take it or
send it to the Branch Medical Council, 35 Dawson
j Street, Dublin, unless, as is usually the case, this duty
is undertaken for him by the school registrar. He is
thereupon placed upon the Register of Medical Students
(without fee), and his period of study counts from that
date. • He must register at the earliest possible moment,
or he may lose credit for his work.

The only preliminary examination held specially for
medical students is that held conjointly by the Royal
Colleges of Physicians and Surgeons, but other examina¬
tions, e.g., the public entrance at Trinity College, the
matriculation of the Royal University, the Intermediate
Examination passes in the required subjects, and all
other examinations recognised by the General Medical
Council are accepted as equivalent.

The subjects of examination as prescribed by the
General Medical Council are as follows :—1. English
language, including a specified author, dictation, gram¬
mar, and composition ; also parsing and analysis from
a book specified. 2. Latin, including grammar,
translation from specified authors, and translation of
easy passages not taken from such authors. 3. Ele¬
ments of mathematics,- comprising (a) arithmetic,
including vulgar and decimal fractions ; ( b) algebra,
including simple equations; (c) geometry, Euclid,

Books I., II., and III., with easy deductions. 4. One
of the following optional subjects :—(a) Greek, ( b )
French, (c) German.

THE IRISH LICENSING BODIES.

The Medical Licensing Bodies of Ireland are four in
number, and, as a rule, students gravitate into one or
other of five classes :—a. Those who enter Trinity Col¬
lege, and take a full graduation in Arts in addition to
their professional degrees, b. Those who take the
licence of the conjoint Royal Colleges of Physicians
and Surgeons, c. Those who take their qualifications
at the Royal University of Ireland, where graduation
in Arts is not necessary, d. Those who take the
licence of the Apothecaries’ Hall. e. Those who pursue
their studies in Ireland, but who migrate to London,
Edinburgh, or Glasgow for their licences. Almost all
these last-named emigrants come from the Queen's
Colleges, and the greater number of them from Belfast,
while the Dublin students qualify, as a rule, in Dublin.

We do not attempt to give details as to the requisite
courses of instruction for degrees or diplomata, as our
epitome must necessarily be insufficient for the infor¬
mation of the student, and we can occupy our available
space with information more useful to him. The
official information upon which students may depend
can be obtained by sending a note to the Registrars of
the Licensing Bodies or Schools.

THE UNIVERSITY OF DUBLIN.

The University of Dublin grants the degrees of M.B.,
B.Ch., and B.A.O. to students who have obtained their
Arts degree, and who have been for at least five aca¬
demic years on the books of the Medical School, and the
higher degrees of M.D., M.Ch., and M.A.O. to those who
have held, or have been qualified to hold, for at least
three years, the degree of M.B. and B.Ch. It does not
grant degrees to any but full graduates in Arts, conse¬
quently its degrees hold the highest rank of social and
educational qualifications, and are sought for by those
who look forward to occupying the best positions in the
profession.

The expense of obtaining the degrees of M.B., B.Ch.,
and B.A.O. is approximately as follows -Lectures,
£67 4s. od.; Hospitals, ^55 13s.; Degree Fees, £27.—
Total, £149 * 7 S • od.

The expense of the B. A. degree, amounting altogether
to £83 4s., should be added, making the total cost
£233 is. od.

In addition to its ordinary qualifications the Univer¬
sity grants the following higher degrees :—

Doctor of Medicine. —To obtain this the candidate
must have obtained the degree of M.B., or have been
qualified to have obtained it for three years. He must
then read a thesis before the Regius Professor of Medi¬
cine. Fee for this degree, £13.

Digitized by GoOgle

278 Thf. Medical Press._ IRELAND-

Master of Surgery. —The candidate must be a Bachelor
in Surgery of three years’ standing, and must then pass
an examination in clinical surgery, operative surgery,
surgical pathology, surgery, and surgical anatomy (on
the dead subject). Fee for this degree, £i\.

Master in Obstetric Science. —The candidate must have
passed the M.B. and B.Ch. examinations, and have com¬
pleted, in addition to the courses for M.B., B.Ch., a
course of obstetric medicine and surgery. He is then
required to pass an examination in the following sub¬
jects :—Practice of midwifery, gynaecology, anatomy of
female pelvis and elementary embryology, and clinical
gynecology. Fee for this degree, £$.

Diplomate in Medicine, Surgery, and Midwifery —
Candidates for the diplomas in Medicine, Surgery, or
Obstetric Science must be matriculated in Medicine, and
must have completed two years in Arts and five years in
medical studies. The medical course and examinations
are the same as for the degrees, Fees for the diplomas
in medicine, surgery, and midwifery, £21. A diplomate,
on completing his course in Arts and proceeding to the
degree of B.A., may become a Bachelor by paying
the degree fees.

Diploma in Public Health. —The candidate must
be an M.D. or a Graduate in Medicine and Surgery
of Dublin, Oxford, or Cambridge, must have com¬
pleted, subsequent to registration, six months’ practical
instruction in a laboratory, and also have studied
practically outdoor sanitary work for six months
under an approved Officer of Health.

Degree and Licence in Dental Science. —Candidates
for the degree in dental science must have taken a
degree in Arts, and must have had their names in the
books of the Medical School for five years. Two
examinations must be passed—namely, the Previous
Dental at the end of the second year, and the Final
Dental at the end of the fifth year. Candidates for the
Licence are required to matriculate in Arts,
and pass one Term Examination. The course
of study is the same as for the degree with the excep¬
tion that no lectures in pathology or bacteriology are
required. The total fees for the licence, including the
premium for Dental Mechanics (£100), are £200 17s.,
while those for the degree are about £210, to which
must be added the cost of the B.A. degree.

Post-Graduate Classes. —A short post-graduate course
is now given annually in July in connection with
Trinity College Medical School. It includes special
work on Diseases of the Eye, Nose, and Throat, Gynae¬
cology, Diseases of the Skin, X-ray work. Medicine,
Surgery (clinical and operative), and Clinical
Pathology.

Royal Services School. —The object of this school is to
prepare candidates for the Indian Medical Service,
and Royal Army Medical Service. It is conducted
on a comprehensive scale, and affords special oppor¬
tunities for operating on the cadaver, and for the study
of commentaries. Two sessions are held yearly, each
lasting for about ten weeks.

' THE ROYAL UNIVERSITY OF IRELAND.

The Royal University of Ireland is purely an
examining body. Its degrees are granted on one
year’s acts, i.e., the matriculation examination of this
University and a " first University examination ” at
the termination of the first year. The cost of the M.B.
and M.Ch. of the University, with all the necessary
curriculum, is about £12$. Some of the Arts examina¬
tions are conducted, not only in Dublin, but at certain
local centres.

The University confers the following medical
degrees:—

M.B., B.Ch., B.A.O., and the higher degrees of
M.D., M.Ch., and M.A.O. It also confers a Diploma
in Public Health and a Diploma in Mental Diseases.

All degrees are open to persons of either sex who
shall have passed the Senior Grade Examination
of the Intermediate Education Board for Ireland
in the subjects prescribed for the Matriculation Ex¬
amination of the University, and who shall apply for
exemption from the Matriculation Examination in
the year in which he shall have passed such examination.

Sept, i r, 1907.

The University examinations are held in the spring,
beginning about the middle of April, and in the autumn,
beginning towards the close of September.

All candidates for any degree must pass the matricu¬
lation examination, or the Senior Grade Examination
or the Intermediate Education Board (as above
mentioned) and the first University examination.

The course for the degree of M.B., B.Ch., B.A.O.,
extends over five years.

Students will be admitted to the first University
examination after one year from matriculation. Fee,

l 1 -

The medical course consists of three previous examina¬
tions, one at the end of each year, and one degree
examination at the end of the fifth year. Fee for each
previous examination, £\ ; for the degree examination,
£2 ; for the diploma. £\o.

In addition, the following degrees are granted:—

Diploma in Public Health. —Conferred only on gra¬
duates in medicine of the University of at least twelve
months’ standing. Fee, £2. Subjects.—Meteorology,
bacteriology, chemistry, physics, vital statistics,
hygiene, sanitary engineering, architecture and law.

The M.D. Degree.— Conferred only on graduates in
medicine of the University of three years’ standing.
They must at the same time produce a certificate of
having been, for at least two academical years, engaged
in hospital or private, medical, surgical, or obstetrical

? ractice, or in the military or naval medical service.

he examination comprises medical diseases and
the theory and practice of medicine, including path¬
ology. Every candidate will be examined at the bed¬
side, and be required to diagnose at least three medical
cases, and prescribe treatment, and to write detailed
reports on at least two cases to be selected by the
examiners and to discuss the questions arising there¬
from. Fee, £5.

The M.Ch. Degree. —Conferred only on gradaates in
medicine of the University of three years’ standing, and
who can produce a similar certificate of practice to
that required for the M.D. degree. The examination
comprises surgery, both theoretical and operative;
surgical anatomy; ophthalmology and otology.
Fee. £$.

The M. A. O. Degree. — Conferred only on
graduates in medicine of the University of three years’
standing, and who can produce a similar certificate of
practice to that required for the M.D. and M.Ch.
degrees. The examination comprises midwifery and
diseases of women and children. Fee, £$.

Prizes, &-c. —First Examination in Medicine. Two
first-class exhibitions of £20 each, and two second of
£10 each.

Second Examination in Medicine.—Two first-class
exhibitions of £2 5, and two second-class of £15. and
the Dr. Henry Hutchinson Stewart Medical Scholar¬
ships, value £10 & year for three years.

Third Examination in Medicine.—Two first-class
exhibitions of £30 each, and two second of £20 each.

Medical Degrees Examination. At each of the
two Examinations in the year three Exhibitions of
£21 each in the groups of medicine, surgery and
midwifery. One travelling medical scholarship of
£100. One medical studentship of £200 per annum,
tenable for two years.

The Dr. Henry Hutchinson Stewart Scholarship
for proficiency in the Knowledge of Mental Diseases
for competitions among medical graduates if not more
than three years’ standing. This Scholarship is of
the annual value of /50, tenable for three years.

ROYAL COLLEGES OF PHYSICIANS AND
SURGEONS.

These examinations are held conjointly by the
two Colleges. The course, as in other bodies,
extends over five years, with examinations at the
end of the first, second, third, and final years.
These examinations are conducted by examiners
chosen by each of the Colleges for the subjects
appropriate to them. The curriculum has recently
been revised, and made of a more practical nature. In
common with the English Colleges, the subjects of the

Digitized by GoOgle

Sept, ii, 1907.

IRELAND—EDUCATION.

The Medical Press. 279

First Professional examination may be studied either
at a medical school or at an institution other than a
medical school recognised by the Colleges, after due
inspection, for instruction in these subjects. We recom¬
mend students to apply for the official programme to
the Secretary of the Committee of Management, Royal
College of Physicians, or to the Registrar of either
College. In the case of the Preliminary Examination
seven clear days’ notice must be given to the Secretary ;
fourteen days’ notice is required from candidates
for the Professional examination.

The total of the examination fees, spread over the
four examinations, is £42, while the school and hospital
fees, if taken in Dublin, amount to £124 19s., making
altogether £166 19s., exclusive of re-examination fees,
which have to be paid in case the candidate fails to
pass his examination.

The Conjoint Colleges also confer a diploma in
Public Health, of which information will be found on
page 280.

ROYAL COLLEGE OF PHYSICIANS.

This College issues a Licence in Medicine and a
Licence in Midwifery to Registered Medical Practi¬
tioners.

Licence in Medicine. —The subjects of examination
are:—Practice of Medicine, Clinical Medicine, Patho¬
logy, Medical Jurisprudence, Midwifery, Hygiene
and Therapeutics.

Licence in Midwifery. —The subjects of examination
are:—Gynaecology and Midwifery. A Registered
Medical Practitioner of five years’ standing is exempted
from the examination by printed questions.

Fees. —Fee for the Licence to Practise Medicine
£1 5 15s. Fee for the Licence to Practise Midwifery
iS 5 S.

Membership. —The Membership is open to University
Graduates in Medicine and to Licentiates of the Royal
Colleges of Physicians of the United Kingdom. The
Examinations for Membership are held in January
April, July, and October, and such other times as the
President may appoint.

ROYAL COLLEGE OF SURGEONS
IN IRELAND.

This College grants a licence in Surgery to registered
medical practitioners, Candidates who hold registrable
surgical diplomas, including the licence of the Apothe¬
caries’ Society of London, and the Apothecaries’ Hall,
Dublin, granted since October, 1886, are admitted
to examination without further evidence of study, but
candidates who hold medical qualifications only,
including the L.S.A, and L.A.H., granted before
October, 1886, will be required to produce certificates
of two courses of lectures in anatomy and dissections,
one course of practical histology, one course of
lectures in surgery, and one course of operative surgery,

Candidates are examined in surgery, clinical and
operative; surgical appliances; and ophthalmic
surgery. The fee is £26 5s, The fee for a special
■examination is ^31 10s,

A diploma in Midwifery is also granted after exami¬
nation to registered medical practitioners. Candidates
must produce evidence of (a) attendance on a course of
lectures on midwifery and diseases of women and
children in a recognised school; (6) attendance or six
months’ practice at a recognised lying-in hospital or
recognised dispensary for lying-in women and children ;
and (c) of having conducted at least thirty labour cases.
The fee for the examination is £15 15s,

Fellowship. —Candidates for the Fellowship of the
College must enter their names with the Registrar at
least a month before the date of examination, in order
that the Council may decide whether to approve of the
application. Examinations are held the third Mondays
in February, May, and November, If the application
is approved, the candidate will be admitted to the next
sessional examination or to a special examination
■^except during the months of August and September)
if granted by the Council. Candidates are divided into
two grades:—

Grade 1.—Licentiates or graduates in surgery of less
than ten years’ standing,

Grade 2.—Licentiates or graduates in surgery of more
than ten years’ standing.

Students, not either Licentiates or Graduates in
Surgery, are permitted to present themselves for the
Primary Examination under Grade I,

Candidates in Grade 1 must pass two examinations—
Primary (in anatomy and physiology) and Final (in
surgery). Candidates in Grade 2 need pass but one
examination in surgery, surgical anatomy, and surgical
pathology.

Fees.— Grade 1.—For Licentiates of College ; Pri¬
mary examination, £15 15s.; Final examination,
£10 10s, Licentiates in Surgery of other licensing
bodies: Primary examination, £26 5 s,; Final exami¬
nation, £15 15s. Students of the College: Primary
examination, £$ 53.; Final examination, £21. Students
of other licensing bodies: Primary examination,
£10 10s.; Final examination, £31 10s,

Grade 2.—Licentiates of the College, £26 5s,;
Licentiates in Surgery of other licensing bodies, £42,

LICENCE IN DENTAL SURGERY,

There is probably no specialty in surgery which
gives as great a number of its practitioners a living and
the prospect of an income as dentistry, A young man
who has got his diploma and knows something of his
business, and is willing to attend to it. seldom fails to
get a substantial foothold in Ireland in a few years.
The University of Dublin grants both a Degree and a
Licence in dental surgery. To obtain the former,
candidates must have taken a degree in arts ; the
licence is obtainable by all duly qualified persons who
have passed the Public Entrance Examination of
Trinity College, Dublin. The Royal College of Sur¬
geons in Ireland grants a Licence in Dentistry. •

Course of Study for the Licence in Dentistry. —Candi¬
dates are required to pass three examinations, vis,: —
Preliminary (in General Education), Primary Dental,
and Final Dental,

All information concerning this licence may be
obtained from the Registrar of the College. The
Primary Dental Examinations commence on the
second Monday in the months of February, May, and
November. The subjects of examinations include
physics, chemistry (including metallurgy), anatomy,
physiology and histology, and surgery. The fees for
the primary Dental Examination amount to £10 10s ;
and for re-examination, if rejected, £$ 5s. The Final
Dental Examinations commence on the Thursdays
immediately following the Primary Dental Examina¬
tions. Candidates are examined in dental surgery,
theoretical (including dental pathology), clinical, and
operative; and in dental mechanics, theoretical,
clinical, and practical (including the metallurgy of the
workshop). Candidates must pass in all the subjects
at the same time.

The fees for the Final Dental Examination in the case
of candidates holding the L.R.C.S.I., or students who
have passed the Primary Dental or Third Professional
Examination of the College, £10 10s. re-examination,
£$ 53. The fees for Final Examination of all other
candidates, £26 53., and for re-examination, £10 10s.
The extra fee for Special Examination, £$ 53. A re¬
jected candidate will not be again admitted to examina¬
tion until after a period of three months.

APOTHECARIES’ HALL OF IRELAND.

The Licence of this Hall is granted to students who
present certificates of having fully completed the
course of study as laid down in the curriculum, and
who pass the necessary examinations. The
diploma of the Apothecaries’ Hall of Ireland entitles
the holder to be registered as a practitioner in medicine,
surgery, and midwifery, and he also possesses the
privileges of an apothecary.

There are four professional examinations, the total
fees for which amount to 21 guineas. Women are
eligible for the diploma.

Registered Medical Practitioners will receive the
diploma of the Hall upon passing an examination in
the subject or subjects not covered by their previous
qualification, and on paying a fee of ten guineas; if

Digitized by GoOgle

280 The MrDICAL Pun

IRELAND—EDUCATION. •

Sept. 11,1907.

medicihe or surgery is required, five guineas extra will
be charged.

The lees payable for each examination are as follows :
First Professional, £$ 5s. ; Seoond, £5 5s. 1 Third,
£5 5 s - Final Examination, £6 6s.

A candidate is allowed for each professional exami¬
nation which he has completed at any other licensing
body, except the Final. If he has passed only in some
of the subjects in a given examination, he has to pay
the whole of the fee for that examination.

- The fees for re-examination are : For each subject,
£l is., excepting in the subjects of chemistry, phar¬
macy, surgery, medicine, second anatomy, physiology,
pathology, and ophthalmology, the fees for which are
£a 28. each.

The fee for the Third and Final, or Final alone, is
£15 15s., when the other examinations have been taken
elsewhere.

; AH examination fees are to.be lodged in the Sack-
ville Street Branch of the Royal Bank of Ireland to
the credit of the Examination Committee.

Applications and schedules, together with bank
receipt for the fee, must be lodged with the Registrar,
Apothecaries’ Hall, 40 Mary Street, Dublin, at least
fourteen clear days before the day of examination.

Candidates who desire to obtain the Letters Testi¬
monial of the Apothecaries’ Hall of Ireland, must,
before proceeding to the Final Examination, produce
evidence of having been registered as medical students
for fifty-seven months; also of having attended
courses of instruction as follows:

One course each (winter course of six months) of the
following : Anatomy (lectures), chemistry (theoretical),
midwifery, practice of medicine, physiology and
surgery. Dissections, two courses of six months each.

Courses of three months.—Materia medica, medical
jurisprudence, chemistry (practical), practical physio¬
logy and histology, operative surgery, physics, clinical
ophthalmology, biology, clinical instruction in mental
disease, pathology, and a course in vaccination.

Medico-Chirurgical Hospital, twenty-seven months
to be distributed over the last four years of study.
The candidate may substitute for nine months in
this, hospital attendance six months as a resident pupil.
Three months' study of fever.

Six months’ practical midwifery and diseases of
women.

Three months’ practical pharmacy in a recognised
clinical hospital or a recognised school of pharmacy, or
a year in the compounding department of a licentiate
apothecary or a pharmaceutical chemist.

Each candidate before receiving his diploma must
produce evidence that he has attained the age of 21.

Each candidate must produce evidence of having
before entering on medical studies passed a preliminary
examination in general education recognised by the
General Medical Council, and of having been registered
by that Council as a student in medicine. Certificates
of medical study will not be recognised if the commence¬
ment of the course to which the certificate refers dates
more than fifteen days prior to such registration, except
in the subjects of physics and biology. This registra¬
tion is not undertaken by the Hall.

The details of the course of education required and
syllabus of the examinations will be supplied on appli¬
cation to the Registrar, at 40 Mary Street, Dublin.

THE DIPLOMA IN PUBLIC HEALTH.

This diploma is granted by Dublin University, the
Royal University, and the Conjoint Royal Colleges.
Every candidate must be a registered medical practi¬
tioner. The examination is in :—(1) Chemistry (includ¬
ing chemical physics). (2) Engineering and architec¬
ture. (3) Sanitary law and vital statistics. (4)
Hygiene. (5) Bacteriology. (6) Meteorology. The
General Medical Council recommend that all candidates
shall have studied in a special bacteriological labora¬
tory, also for six months as pupil of a working medical
officer of health, described, for Ireland, as « the medical
officer of health of a county or of one or more sanitary
districts having a population of not less than 30,000 ;
ox a medical officer of health who is a teacher in Public
Health of a recognised medical school.”

In addition t6 taking the prescribed course a candi¬
date for the D.P.H. of the University of Dublin must be
a Doctor in Medicine or a graduate in Medicine, Sur¬
gery, and Midwifery of Dublin, Oxford, or Cambridge,
and his name must have been on the " Medical Register ”
for at least twelve months before the examination. The
Royal University only confers its diploma on its own
graduates.

THE DIPLOMA IN PSYCHOLOGICAL MEDICINE.

The Royal University of Ireland grants a diploma for
proficiency in the treatment of mental diseases under
the following conditions :—

The diploma is conferred only on graduates in medi¬
cine of the University. Candidates must give notice,
in writing, to the secretaries of their intention to present
themselves, and must pay the prescribed fee of £2 at
least one month previous to the examination. Can¬
didates who satisfy the examiners will be required to
pay a further fee of £3 before the diploma is conferred
The subjects for this examination are those required by
the Hutchinson Stewart Scholarship for proficiency in
the treatment of mental diseases.

THE IRISH MEDICAL SCHOOLS.

The Irish Medical Schools are as follows:—

The School of Physic of Duplin University—
This school is formed by an amalgamation of the School
of Trinity College and of the College of Physicians.

Every student of the school must be matriculated by
the Senior Lecturer, for which a fee of 5 s. is payable,
but he need not attend any of the Arts course unless he
desires to obtain a University licence or degree in medi¬
cine, surgery, and midwifery. No student is permitted
to matriculate unless he has passed the Entrance
and a Term examinations of the University, of the
Royal University, of the College of Surgeons, or some
other examination recognised by the General Medical
Council.

Two medical scholarships are given annually at the
School of Physic, value £20 per annum, tenable for two
years, the examinations for which are held each year in
June; one scholarship is given in anatomy and in¬
stitutes of medicine ; the other in zoology, chemistry,
botany, and experimental physics.

A prize of £100 is awarded by the Board to the
successful candidate at a special examination in alter¬
nate years in medicine or in surgery, provided that the
merit be deemed sufficient. The successful candidate
is required to spend three months in the study of medi¬
cine or surgery, as the case may be, in Berlin, Paris, or
Vienna. Before he can obtain the first instalment of
£$o he must satisfy the Senior Lecturer that he possesses
sufficient knowledge of a Continental language to derive
full benefit from the prize. The examination is held in
June, and is open to students who have passed the
Final Examination in Medicine or in Surgery, as the
case may be, within two years of the examination.

In order to obtain the second sum of £50 the prize¬
man must have furnished to the Regius Professor his
formal report on the hospitals attended by him within
two years from the time of obtaining the prize.

The Sir John Banks Medal and Prize, founded
by Sir J. Banks, M.D., formerly Regius Professor
of Physics, are awarded both for best and second best
answers at the Medical Travelling Prize Examination.

The Edward Hallaran Bennett Medal, founded
by pupils of the late Dr. E. H. Bennett, formerly
Professor of Surgery, is awarded to the Surgical Travel¬
ling Prizeman.

Class prizes are given at the end of the session of
between £5 and £10 in value.

The John Mallet Purser Medal, founded by Prof.
Purser’s past pupils, is awarded annually to the student
who, at the ordinary June Intermediate Medical
Examination, Part I., in Anatomy and Institutes of
Medicine, shall obtain highest marks in Physiology
and Histology, provided that he passes the examina¬
tion in full. , ,

Fits-Patrick Scholarship .—This scholarship consists of
the interest on £1,000. It will be awarded annually
to the student who obtains the highest aggregate marks

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IRELAND—EDUCATION.

The Medical Peess. 261

at the five sections of the Final Examinations, provided
that he has completed his medical course in the pre¬
scribed period of five years.

The Royal College of Surgeons in Ireland*
Schools of Surgery. —These schools are attached by
Charter to the Royal College of Surgeons, and have
existed as a department of the College for over a
century. They are carried on within the College
buildings, and are specially subject to the supervision
and control of the Council, who are empowered to
appoint and remove the professors, and to regulate the
methods of teaching pursued. The buildings have
been reconstructed, the capacity of the dissecting room
nearly trebled, and special pathological, bacteriological,
public health, chemical, and pharmaceutical labora->
tones fitted with the most approved appliances, in
order that students may have the advantage of the
most modem methods of instruction. A refreshment
room is now open, where students can have luncheon.
There are special rooms set apArt for lady students.
The entire building is heated by bot-water pipes, and
lighted throughout by the electric' light;

All the lectures and courses of practical instnlction
may be attended by medical students who are otherwise
unconnected with the College.

All the diplomas of the College are open to students
of either sex. Separate rooms have been provided,
and careful provision made for the instruction and
comfort of women students.

Prises .—The Barker Prize, £31 10s. ; the Carmichael
Scholarship, £1$ ; the Mayne Scholarship, £84 The
Gold and Silver Medals in Surgery and the Stoney
Memorial Gold Medal in Anatomy.

Class Prizes’of £2 and £\, accompanied by medals if
sufficient merit is shown, will also be given in each
subject* Prospectus and Student’s Guide can be ob¬
tained on written application to the Registrar, Royal
College of Surgeons, Dublin.

Two short post graduate courses are held in the
vear. Full particulars can be obtained from the
Registrar.

The Catholic University School is situated in
Cecilia Street, Dame Street. It prepares students for
all medical examinations, particularly those of the
Irish Colleges of Physicians and Surgeons, and the
Royal University of Ireland. The school has recently
been rebuilt and refitted, its working space having
thereby been nearly doubled, and several new labora¬
tories, including those for the study of bacteriology and
publie health, have been added. The institution has
also been recently chartered, under the Educational
Endowment (Ireland) Act, and it is now controlled by a
Board of Governors. The total fees for school and hos¬
pital courses is £160, payable as the courses are taken
out.

The following Exhibitions are awarded annually :—
Two first year's, value ^12 10s. each ; two second year’s,
value ^10 each ; one third year’s Royal Exhibition of
£12 ios. ; one final Conjoint Colleges Exhibition of
£12 ios. ; two large gold medals, besides several other
class medals.

A Guide for Medical Students, which gives all the
information required by parents, and by students who
desire to join the medical profession, may be obtained
free on application to the Registrar.

THE QUEEN’S COLLEGES—BELFAST, CORK,
AND GALWAY.

These three important academic institutions educate
students for all colleges and degrees, and are main¬
tained, as hitherto, by a Government grant. The same
curriculum as that formerly adopted is continued,
and the various exhibitions and scholarships are
still available. Each college has the disposal of
about £1,500 per annum in scholarships and prizes.
The colleges are well adapted for high-class technical
education, having lecture rooms provided with every
appliance necessary in the modem training of a medical
student. The colleges are completely equipped with
students’ reading rooms and lending libraries and
refreshment rooms, and with all adjuncts to collegiate
life, guchas literary societies and athletic organisations.

The expense of living in the collegiate towns is quite
moderate. The course of lectures in the winter session
must be diligently attended, no student obtaining A
certificate who has not put in three-fourths of a course.
The scholarship examinations are held in October.

QUEEN’S COLLEGE, BELFAST.

The total cost of the medical curriculum of the Royal
University of Ireland, including examination fees and
perpetual fee for the Royal Hospital, but not including
fees for the special hospitals, is about £95. If the Con¬
joint Examination of the Royal Colleges is taken the
expense is almost the same.

Clinical instruction is given at the Royal Victoria
Hospital. The Union and Fever Hospitals, the
Maternity Hospital, the Ulster Hospital for Women
and Children, the Hospital for Sick Children, the Oph¬
thalmic Hospital, the Ulster Eye, Ear, and Throat
Hospital., and the District Lunatic Asylum are also
open to students.

Prizes. —(1) Ten medical scholarships each year, value
j£2p.each;, (2) two Dunville studentships (one each
year), value £150 each ;' (3) one Andrews student¬
ship each' alternate year,'value £140 ; (4) numerous
sessional prills. A Mackay Wilson Travelling Medi¬
cal Scholarship will be awarded in 1909.

During the summer session special classes are formed
in bacteriology and clinical pathology, and during the
winter facilities are afforded to medical men to Work at
these subjects in the pathological laboratories. From
time to time lectures and demonstrations are given in
the anatomical department on the Advanced Anatomy
of the Nervous System, or some other department of
applied anatomy.

A pamphlet containing full information can be had
on application to the Registrar, Queen’s College,
Belfast.

QUEEN’S COLLEGE. CORK.

The arrangements in the Faculty of Medicine are
made chiefly with reference to the requirements of the
Royal University of Ireland, but students proceeding
for the examinations of the Conjoint Boards of England,
Scotland, or Ireland, the Society of Apothecaries of
London, or the Apothecaries Hall of Ireland, can
arrange the course of lectures which they attend, and
the order in which they attend them, to meet the re¬
quirements of those bodies. Certificates of attendance
in the college are also accepted by the University of
Cambridge. The total fees for the college lectures and
Hospital attendances required by the Royal University
of Ireland is about £85.

Clinical instruction is given at the North and South
Infirmaries. Students can also attend the Mercy Hos¬
pital, the Cork Union Hospital, the County and City of
Cork Lying-in Hospital, the Maternity, the Hospital for
Diseases of Women and Children, the Fever Hospital,
the Ophthalmic and Aural Hospital, and the Eglinton
Lunatic Asylum. The winter session commences on
October 21st, and ends at the end of April. The
courses of the summer session are delivered in the
months of April, May, and June.

Schotttrskips and Prizes .—Eight medical scholarships
two in each of the first four years, of the valne of £25
each, and in the fifth year the Blaney Scholarship of the
value of atxmt ^32, and a Senior Exhibition, value £30,
Three Exhibitions, one in practical medicine, one in
practical surgery, and one in practical midwifery, each
of the value of £15. Book prizes at the sessional
examinations.

Further information can be obtained in the College
Regulations, or on application to the Registrar, Queen’s
College, Cork.

QUEEN’S COLLEGE, GALWAY. 1

Clinical teaching is carried on in the Galway Hospital,
established as a Public General Hospital (in the place of
the County Galway Infirmary) by Act of Parliament
(1892). The Galway Fever Hospital and Galway
Throat Hospital are also open to students. The
medical lectures are recognised by the Royal Uni¬
versity of Ireland and the various Licensing Bodies in
the United Kingdom.

D

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282 The Medical Press.

IRELAND—EDUCATION.

Sept, ii, 1907.

Prises .—There are eight Junior Scholarships in Medi¬
cine of the annual value of £25 each. Two are tenable
by matriculated students of the first, second, third, and
fourth years. The Council has power to award exhibi¬
tions for distinguished answering. Sessional prizes are
offered in each subject. A Senior Scholarship in Ana¬
tomy, value £40, the holder of which is usually appointed
Demonstrator, is offered annually for competition,
tenable for one year by a student who shall have
attended the Medical School of the College for at least
two sessions, and shall have obtained a Degree in Arts
■or Medicine, or a Diploma in Medicine, from a Licensing
Body. Scholarship examinations are held at the com¬
mencement, and those for Sessional Prizes at the close,
of each session.

The PHARMACEUTICAL SOCIETY OF IRELAND.

The Pharmaceutical Society of Ireland issue two
qualifications and a certificate< The qualification of
Registered Druggist; the qualification of Phar¬
maceutical Chemist; and the certificate of competency
as Assistant to a Pharmaceutical Chemist.

Registered Druggist .—This qualification entitles the
holder to keep open shop for the selling, retailing,
and mixing of poisons. In order to obtain it, a person
must now have served an apprenticeship or assistant-
ship of four years to an apothecary, pharmaceutical
chemist, or to a person who was, or would have been
•entitled to become, a registered chemist and druggist
or a registered druggist, and be 21 years of age. He
shall be examined with respect to his knowledge of
English orthography and composition, arithmetic, and
the weights and measures of the British Pharmacopoeia,
the appearance and properties of the various drugs and
chemicals in general use, and as to the provisions of the
Poisons Act. The fee is four guineas.

Examinations in Dublin (also in Belfast and Cork
or other place if 12 candidates offer) on the second
Tuesday of January, April, July, and October.

Pharmaceutical Chemist .—The qualification of a
pharmaceutical chemist in Ireland confers greater
privileges than is the case in England.

The subjects of examination are divided between
the “ Preliminary ” and the " Licence.”

The Preliminary examination is held on the first
Thursday and following day of January, April, July,
and October.

The fee is £2 2s. for the first attempt, and tos. 6d.
for each subsequent examination. Further particulars
with reference to the subjects for examination may
be obtained from the Registrar. The British Society’s
examination is accepted in lieu of this, as well as those
recognised by the General Medical Council as a pre¬
liminary to medical studies.

Pharmaceutical Licence Examination .—This examina¬
tion confers the title of Pharmaceutical Chemist and
thefright to compound medical prescriptions. Candi¬
dates must be 21 years of age, and must have passed
■the Preliminary prior to the service at practical
pharmacy, unless such service was commenced before
1 st January, 1907. They must, unless having
passed the Preliminary previous to 1884, produce
•certificates of having served four years as assistant
or apprentice to an apothecary or pharmaceutical
chemist or four years to a druggist, two years
to an apothecary or pharmaceutical chemist, also a
•certificate of having attended a course of practical
chemistry of not less than three months' duration,
.and of having actually worked at the bench for 100 hours
during the said course at a recognised school; and also
.& course of botany and materia medica. The fee
for examination is five guineas, and for re-examination
two guineas. Examinations are held in Dublin on
the second Wednesday and following day of January,
April, July, and October.

Assistant to a Pharmaceutical Chemist .—The exami¬
nation for the certificate of competency as an assistant
may be described, in brief, as the same as that for the
Licence, minus the examination in chemistry and
botany, with the fee reduced to one guinea (half a
guinea on the second and subsequent attempts). The
Preliminary examination must be passed as for the
Licence, and the usual 14 May s’ notice must be given.

Candidates must have been engaged in practical
pharmacy for four years.

Examinations are held on the Monday following
the pharmaceutical Licence examination or on such
days as the Council may direct.

DEPARTMENT OF AGRICULTURE AND TECH
NICAL INSTRUCTION FOR IRELAND.

Royal College of Science for Ireland.

Session 1907—1908

This College, situate in St. Stephen’s Green, Dublin,
supplies a complete course of instruction in science
applicable to the industrial arts, especially those which
may be cast broadly under the heads of agriculture,
chemical manufactures, engineering, physics, and
natural science. A diploma of Associate of the College
is granted at the end of the three years’ course. Non¬
associate students may join for any course required.
There are several entrance scholarships, (a) in agricul¬
ture, and (b) in science and technology, tenable for three
years, of the value of £50 each yearly, with free
tuition. There are four Royal scholarships of the
value of /50 each yearly, with free education, tenable
for two years. Two are competed for by the first year
associate students at the end of each session. All the
laboratories and drawing schools are open daily for
practical instruction. The Session commences on
Tuesday, October 1st, 1907.

The courses of chemistry, physics, botany, geology,
and mineralogy and zoology are recognised by the
Royal University of Ireland, and certificates of attend¬
ance are granted to medical and other students attend¬
ing these courses, as also the courses of the chemical,
physical, zoological, botanical, and geological labora¬
tories.

The Entrance and Science Scholarship Examinations
are held during the first week in July, and the Examina¬
tions for Agricultural Scholarships in the first week
in September.

THE DUBLIN HOSPITALS.

The clinical hospitals in Dublin are ten in number
exclusive of three lying-in hospitals. There are also
two children’s hospitals, an orthopaedic hospital, a fever
hospital, an ophthalmic hospital with two centres, a
dental hospital, and other special institutions. Some
of the clinical hospitals, though they have no actual or
official connection with any school, are in close affinity
with certain teaching bodies ; while others, again, are
without any special connection with any school. While,
however, such affiliation of a school or hospital may
exist, it should be remembered that the Dublin schools
and hospitals are open to all comers, and the student is
competent to attend any hospital or any school he
wishes, and to change his place of instruction from year
to year as he may see fit.

The Irish Licensing Bodies require attendance on
hospitals for twenty-seven months, i.e., three winter
sessions of six months and three summers of three
months, with the five years of study. The fee at all
general hospitals is £8 8s. in winter, and for the summer
1 £6 6s., or £ 12 12s. for the entire session of nine months if
j taken together.

| GENERAL HOSPITALS.

Richmond, Whitworth, and Hardwicks Hos-
I pitals. —The accommodation at these hospitals is as
; follows :—Hardwicke Hospital, 120 beds ; Whitworth
J Hospital. 64 beds; Richmond Hospital, 86 beds—
1 total, 270 beds. These hospitals are visited each morn-
| ing at nine o’clock by the physicians and surgeons, and.
in addition to the usual bedside instruction, clinical
lectures are delivered on the most important cases.
Instruction is also given on various special branches of
medicine and surgery. The Truss Establishment, for
the distribution of trusses to the ruptured poor of
Ireland, is connected with these hospitals. There are
large ophthalmic, aural, throat, and gynaecological
dispensaries, and instruction in these important sub-
1 jects is given. Twelve resident clinical clerks are ap-
I pointed each quarter, and provided with furnished
apartments, fuel, &c. The appointments are open not
I only to advanced students, but^also to those who ar

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IRELAND—EDUCATION.

The Medical Press. 283

J iualified in medicine and surgery. A house surgeon
or the Richmond Hospital and a house physician for
the Whitworth and Hardwicke Hospitals are elected
every six months, and receive a salary. The Rich¬
mond Lunatic Asylum, containing i,6oobeds, adjoins
these hospitals.

Meath Hospital and Co. Dublin Infirmary.—
This hospital was founded in 1753, and now contains
160 beds available for clinical teaching. A new build¬
ing for the isolated treatment of fevers, containing 40
beds, has recently been added. The certificates of this
hospital are recognised by all the Universities and
licensing bodies of the United Kingdom. Medical and
surgical resident pupils and clinical clerks and dressers
are appointed every three months, and a house surgeon
is elected annually. A prospectus giving the complete
arrangements for medical and surgical classes for the
coming session may be obtained from the Secretary of
the Medical Board, Mr. William Taylor, F.R.C.S.,
47, Fitzwilliam Square, Dublin.

The Adelaide Medical and Surgical Hospitals
occupy a central position within a few minutes’
walk of the College of Surgeons and Trinity College.
From October 1st, the physicians and surgeons visit
the wards and give instruction at the bedside at
the advertised hours. There is a large detached
fever hospital, and also wards for infants and children.
Operations are performed, except in cases of urgency,
at 10 a.m. on Tuesday, Thursday, and Saturday.
Special hours are devoted to clinical instruction in the
diseases peculiar to women, and students are individu¬
ally instructed in the use of the stethoscope, ophthal¬
moscope, laryngoscope, and microscope ; also special
instruction is given on practical pathology and X-ray
photography. Two House Surgeons are elected annually
and three resident pupils half-yearly. Prize exami¬
nations, including examinations for the Hudson Scholar¬
ship, £30 and a gold medal, and a senior prize of £10
and a silver medal, in addition to surgical and medical
prizes, are held at the termination of the session. The
large dispensaries afford facilities for the study of eye,
ear, throat, and cutaneous diseases, as well as of minor
surgery and dentistry. Further particulars from Mr.
Heuston, F.R.C.S.I., 15, St. Stephen’s Green North.

The Royal City of Dublin Hospital. —This hos¬
pital has recently been enlarged and improved to
a very considerable extent. A special course of
instruction is given on ophthalmic and aural disease.
There are special wards for the treatment of diseases of
the eye, of children, and of women, and practical in¬
struction is given on diseases peculiar to women ; there
is also a separate building for infectious diseases.
Clinical clerks to the physicians and dressers to the
surgeons are appointed from the most deserving of the
class. A new operation theatre, sterilising room, and
anaesthetic room have been constructed in accordance
with the most modern surgical requirements. A
Rontgen-ray and light treatment of lupus department
has recently been added. A resident medical officer
is elected annually, and resident medical and surgical
pupils are appointed from among the past and present
students of the hospital. Operations are performed
on Tuesdays, Thursdays, and Saturdays, at 10 a.m.
Special classes for first year students. Full particulars
can be had on application to Mr. G. Jameson Johnston,
M.B., F.R.C.S.I., Hon. Sec. Med. Board.

Sir Patrick Dun’s Hospital is situated on the
south-eastern side of the city, and about half a mile
from the University School of Physic. It is officered
almost exclusively by the professors and examiners in
that school. Formerly all University students were
compelled to attend this hospital, which was purely a
medical institution, but some years ago the obligation
was removed, and the hospital was opened for surgical
cases. It is now free to all students. There is a special
wing devoted to fever cases, and regular clinical instruc¬
tion is given by the members of the medical staff
throughout the winter and summer sessions. Special
classes for students commencing their hospital studies
will be held in the wards during the months of
October, November, and December. They will em- j
brace the elements of medicine and surgery, including |

note-taking. Opportunities are also afforded to
students for e xam ining cases of throat, ear, and eye
diseases, as well as for performing minor surgical
operations and bandaging. In the X-ray Department
opportunities are given the members of the hospital
class of seeing the various applications of the X-rays
to the diagnosis and treatment of injury and disease.

Mater Misericord le Hospital. —This hospital,
containing 345 beds, is open at all hours for the recep¬
tion of accidents and urgent cases. Fifty beds are
specially reserved for the reception of patients suffering
from fever and other contagious diseases. A course of
lectures and instruction on fever will be given during
the winter and summer sessions. A certificate of
attendance upon this course to meet the requirements
of the various licensing bodies may be obtained.
Opportunities are afforded for the study of the diseases
of women in the wards under the care of the obstetric
hysician, and at the dispensary, held on Tuesdays and
aturdays. Lectures on clinical gynaecology will be
delivered on Saturdays at 11 a.m. Ophthalmic surgery
will be taught in the special ward3 and dispensary. A
special course of instruction in pathology and bacterio¬
logy, as applied to medicine, will be given. Connected
with the hospital are extensive dispensaries, which
afford valuable opportunities for the study of general,
medical and surgical diseases, accidents, &c. Leonard
Prizes: One gold and one silver medal will be offered
for competition annually in the subject of medicine, and
one gold and one silver medal in the subject of surgery.
Junior Leonard Prizes : Two prizes of the value of £3
and two prizes of the value of £2 will be offered for com¬
petition m medicine and surgery respectively.

Mercer’s Hospital. —This hospital, founded in
1707, is situated in the centre of Dublin, in the imme¬
diate vicinity of the Schools of Surgery of the Royal
College of Surgeons, the Catholic University School of
Medicine, and Trinity College. It contains 120
beds for medical and surgical cases, and arrange¬
ments have been made with the medical officers
of Cork Street Fever Hospital whereby all students
of this hospital are entitled to attend the clinical
instruction. of that institution and become eligiole
for the posts of resident pupil, &c. There is a large
out-patient department, and a special department
for diseases peculiar to women. There are also special
wards for the treatment and study of children’s diseases.
During the past few years the hospital has undergone
extensive alterations in order to bring it up to modern
requirements. A house surgeon is appointed annually.
Five resident pupils are appointed, each for six months,
and clinical clerks and dressers are appointed monthly
from among the most deserving members of the class.
The certificates of this hospital are recognised by all
the licensing bodies. For further particulars apply to
Mr. R. Charles B. Maunsell, M.B., F.R.C.S.,’32 Lower
Baggot Street, Dublin.

St. Vincent’s Hospital was established in 1834, it
has 160 beds, and in connection with it there is a largely-
attended dispensary, a convalescent home, and a
nurses’ institute. In addition to the ordinary clinical
instruction, systematic courses of lectures are given in
each department of medicine and surgery, and are
illustrated by cases in the hospitals. The resident
officers consist of a house surgeon, a house physician,
and four resident pupils. Three clinical lectures are
delivered daily in the wards, illustrated by selected
cases, and beginning at 9 a.m. Two gold medals
and other valuable prizes and certificates of merit
are awarded at the end of each session. A prospectus
can be had from Dr. Dargan, 45, Stephen’s Green.
East Dublin.

Dr. Stbevens’ Hospital, situated at Kingsbridge,
is the oldest and one of the largest clinical hospitals
in Dublin, and contains over 200 beds. A very fine
Nurses’ Home was recently added to the in¬
stitution, with accommodation for over seventy nurses.
A new and thoroughly equipped dispensary and
out-patient department has been completed and opened
to patients. There is accommodation for twelve
resident pupils—four medical, six surgical, and two in
the special departments, each of whom is supplied with

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284 The Medical Pees*.

IRELAND—EDUCATION.

Sept, ii, 1907.

a separate room. All information with regard to these
appointments can be had from the Resident Medical
Officer at the hospital. Licensing bodies recognise six
months’ residence as equivalent to a year's ordinary
attendance at hospital. The manufactories and rail¬
way works in the neighbourhood supply this hospital
with large numbers of accidents and other cases, while
the special ward for venereal diseases affords excep¬
tional opportunities for the study of this important
subject.

Jervis Street Hospital is the oldest established
in Dublin. The new hospital was completed in
1896, since which time it has been open for the re¬
ception of patients. In addition to large medical
and surgical dispensaries, the out-patient depart¬
ment includes special departments for the treat¬
ment of diseases of the skin, eye, ear, and throat,
and diseases peculiar to women. Two resident
surgeons are appointed annually. Clinical clerks and
surgeons' dressers are selected from among the most
attentive of the advanced students without the payment
of any additional fee. Twelve interns are appointed
annually, and are provided with apartments, <Sx., free
of expense. Special certificates are given to resident
pupils and dressers who have performed their respective
duties to the satisfaction of the physicians and surgeons.

Students of Jervis Street Hospital are entitled to
attend free of charge the Children’s Hospital, Temple
Street, which contains 100 beds, and where special
lectures are given on Diseases of Infancy and Childhood,
and on Orthopaedic Surgery and appliances, and to
obtain special courses in fevers at Cork Street Fever
Hospital.

Students of other Hospitals are admitted as residents
when vacancies occur.

Terms : £2 2s. per month, or £5 5s. for three months,
exclusive of board.

SPECIAL HOSPITALS.

The special hospitals of Dublin are the Rotunda, the
Coombe, and the National Lying-in-Hospitals, Cork
Street Fever Hospital, the Royal Victoria Eye and Ear
Hospital (amalgamation of St. Mark’s Ophthalmic
Hospital and the National Eye and Ear Hospital), the
Dental Hospital, the Throat Hospital, the Orthopaedic
Hospital, the Children’s Hospitals in Harcourt Street
and in Temple Street, and the City Hospital for
Diseases of the Skin.

The Rotunda Hospital. —This institution is the
largest, the longest established, and the most famous
gynaecological as well as maternity hospital in the
British Empire. The work performed by it is about
three times greater than that of any other hospital of
its kind in Ireland. The number of patients admitted
to the hospital, and also attended in the extern
maternity has increased enormously within recent
years. The routine daily work comprises the attend¬
ance of lectures on midwifery and gynaecology ; practice
in abdominal palpation ; personal conduction of
parturition both m the extern and the intern maternities;
cystoscopic examinations, as well as attendance at
the operation work of the hospital. The hospital affords
exceptional advantages to qualified men who take out
a three months’ course during the autumn, winter,
and spring months, for they (if considered competent)
are permitted a certain amount of practical operation
work, viz.—forceps, curettings, perineorrhaphy, Ac.
Students are liable to summary dismissal without
refund of fees for gross misconduct, or serious breach
of the hospital rules. A special afternoon class in
gynaecology is held by the Senior Assistant, £2 2s.
per month. The Pathological laboratory under the
direction of Dr. Rowlette has become an important
feature of the hospital. Students can enter at any
time for periods of one month or longer. Certificates of
attendance are accepted by all the licensing bodies.
The L.M. certificate is obtained by attendance at the
hospital for six months, with the subsequent passing
of an examination. A special certificate in gynecology
is presented to students whose work meets with the
Master’s approval. Paid clinical assistants are selected
(from among those who have obtained the hospital

L.M. certificate) by competitive examination, for
periods of six months. The residents’ quarters have
undergone complete renovation and now afford com¬
fortable accommodation. The grounds of the hospital
contain asphalt and grass courts for lawn tennis and
croquet. There is also a full-size billiard table.

Fees for Pupils.—Intern :—One month, £6 6s. ;
two months, £9 9s. ; three months, £12 12s. ; six
months, £21 ; single months other than the first,
£4 4s ; board and lodging in the house per week, £1 5s.
Night students (not resident in house), £6 6s. for
first three months ; £4 4s. for the second three months.
For further particulars apply to E. Hastings Tweedy,
Master, Rotunda Hospital, Dublin.

Coombe Lying-in Hospital. —This hospital consists
of two divisions, one of which is devoted to lying-in
cases, and the other to th' treatment of diseases
peculiar to women. The practice of this hospital is
one of the largest in Ireland ; nearly 18,000 cases are
treated annually, either as intern or extern patients.
Lectures are delivered, practical instruction is given, and
gynaecological operations are performed in the theatres
daily. There is a general dispensary held daily, at
which instruction is given on the diseases of women
and children. There is a special afternoon dispensary
held by the Master and his assistants, at which prac¬
tical instruction in gynaecology is given. This is the
largest dispensary of its kind in Dublin. There is no
extra charge for attendance at this dispensary. There
is accommodation for a number of qualified and un¬
qualified intern pupils, who enjoy exceptional advan¬
tages of acquiring a thorough knowledge of this branch
of their profession. Lady medical students can reside
in the hospital. Clinical assistants are appointed from
among the pupils as vacancies occur. Certificates of
attendance at this hospital are accepted by all licensing
bodies, and the diploma is recognised by the Local
Government Board as a full legal midwifery qualifica¬
tion. The residents’ quarters have been much en¬
larged. A billiard table has been erected for the use
of students. Extern pupils pay, for full course of six
months, £?> 8s. Intern puuils pay one month, £4 4s.,
six months, £iZ 18s. Board and lodging to the
hospital, 18s. per week. Lady students' intern pay
for one month, £$ 5s. ; each consecutive month, £4 4s.

* National Maternity Hospital. —This institution,
under the mastership of Dr. Barry and Dr. A. Horne,
is situated in Holies Street.

Cork Street Fever Hospital is the only special
fever hospital in Dublin. It is supported mainly by
subscriptions, an annual Government grant, and capi¬
tation grants for patients. Regular clinical instruction
is given during the winter and summer sessions to those
who desire a special course in fevers. There are also
courses for the Diploma in Public Health. All par¬
ticulars may be obtained on application to the Medical
Superintendent.

The National Children's Hospital for the treat¬
ment of all non-infectious diseases peculiar to children,
with which the Pitt Street Children’s Hospital, founded
in 1821, was amalgamated, is capable of containing 50
beds for the reception of cases of deformity and all
other forms of surgical disease. There is a large
general dispensary for extern patients held daily from
10 to 11. Operations are performed on Saturday at
12 o’clock. Practitioners and students can attend on
application to Sir Lambert H. Ormsby, F.R.C.S.I.

°The Children’s Hospital, Dublin (under the care
of the Sisters of Charity).—This institution is one of the
most progressive and up-to-date children’s hospitals in
the Kingdom, besides being the largest in Ireland.
There are 100 beds available for patients ; about 1.000
cases are admitted to the wards annually; and about
7,000 or 8,000 seen in the dispensary. During the last
year a new operating theatre has been opened. It is
fitted and furnished in the best possible fashion for
present-day surgery. Special attention is given to
orthopaedic surgery, and the number of deformities
from all parts of Ireland treated and cured in the
hospital is rapidly increasing. A special masseuse
has been appointed to the hospital to aid in this depart¬
ment.

le

Sept. H. 1907*

IRELAND—EDUCATION.

The Medical Press. 285

The hospital is recognised lor clinical instruction in
the diseases of children by the R.U.I. and licensing
bodies, which require a certificate of instruction in this
important branch of medical education. A nursing
home is in connection with the institution, and trained
nurses are always available for private cases. Senior
students or others requiring a post-graduate course at
the hospital should apply for full particulars to M. C.
Staunton, hon. sec., or to any member of the staff.

The Incorporated Orthopaedic Hospital, Ire¬
land. —This hospital was founded in 1876, and contains
80 beds. It is available for every class of deformity
available for treatment. Particulars may be obtained
from Captain Borthistle, Registrar, at the hospital.

The Royal Victoria Eye and Ear Hospital,
Adelaide Road, Dublin.—This hospital, which was
opened in March, 1904, is an amalgamation of St.
Mark’s Ophthalmic Hospital and the National Eye
and Ear Infirmary. The hospital contains 80 beds.
Clinical instruction in diseases of the eye and ear,
including the use of the ophthalmoscope and operations,
is given daily from 10 till 1. Special classes for
practical instruction in the use of ophthalmoscope,
&c., and for the demonstration of cases, are formed
from time to time.

The Incorporated Dental Hospital, Lincoln
Place.—This hospital, recently erected, is the only
special Dental Hospital in Dublin. It is officered by
a very strong staff of the leading dental surgeons
of Dublin, and has a large clientele and extensive
practice among the Dublin poor. The fees are
£15 15s. for the first year’s study, and £12 12s. for
second, and proportionately smaller fees for shorter
periods.

The City Hospital for Diseases of the Skin and
Cancer, Great Brunswick Street.—The first and only
one of its kind in the city was the first in Ireland to
instal the Finsen treatment. Senior students are
admitted free to the practice of this hospital, which has
a large daily out-patient attendance, with 15 beds
available for the admission of acute cases. Classes of in¬
struction will be given at regular intervals during the
winter and summer sessions in the use of the Finsen
light, X-rays, high frequency currents and radium, with
demonstrations on (1) the production and use of the
Rontgen rays, (2) electric currents, direct and alter¬
nating, with description of resistances, rectifiers and
transformers; (3) accumulators, their construction, use,
and methods in charging; (4) vacuum tube, choice
of tube for particular kinds of work. Fluorescent
screen, and how to localise foreign bodies.

BELFAST HOSPITALS.

* Hospital for Sick Children, Queen Street.—This
institution, erected by voluntary donations, and sup¬
ported by voluntary contributions, was opened for the
reception of patients on April 24th, 1879. The hospital
consists of a medical ward with twenty-eight beds, and
one of a similar size for surgical cases. It is strictly
non-sectarian in its principles, and is open to all de
nominations. Children from birth to the age of 12 years,
and not suffering from contagious disease, are ad¬
missible as in-patients. A very large extern is con¬
ducted in the out-patient department between the
hours of 9 and 10 a.m., where children from birth to
14 years are attended to. The convalescent home,
which, is situated at Newtownbreda, contains thirteen
cots, and its situation and equipment render it an
admirable adjunct to the after-treatment of the cases
admitted to the hospital. During the winter session
systematic courses of lectures and demonstrations in
the medical and surgical diseases of infancy and child¬
hood are delivered in the wards on Wednesday and
Friday of each week at 9 a.m.

* Mater Infirmorum Hospital.— Established 1883.

160 beds. The New Mater Hospital, which was
erected at a cost of over ^50,000, was formally opened
on April 23rd, 1900. During the year the intern
patients numbered 1,525 ; accidents, 3,762, and cases
treated in the Dispensary*, 22,597; 389 surgical

operations were performed with the most satisfactory
results. The total number of patients who received

treatment was 27,884, being an increase of .1,517 as
compared with the year 19041 A notable feature is in
the number of accident cases, as the hospital is con¬
veniently situated in proximity to. a large working-
class population, and within easy reach of most Of the
public works.

The Belfast Maternity Hospital (Incorporated).
—Established 1794- 3° beds.—The practice of the
Maternity Hospital, the certificate of which, is recog¬
nised by the Royal University, See., Sec., is .open to
students. The fee for the session is £2 2s. Resident
nurses are also received for training for a period of six
months, and a diploma given which is recognised by
public bodies. Conditions for such on application to
the Matron. During the year 1906,, 373 patients were
treated in the hospital, and 310 patients at their own
homes. Besides this, 177 patients were dealt with in
the extern gynecological department. . Clinical
lectures and bedside demonstrations are given by
members of the staff during both the winter and summer
sessions. Students wishing to attend should apply
to Dr. H. D. Osborne, 32 Lonsdale Terrace, Belfast,
Hon. Secretary to Medical Staff, on or before November
1st and May 1st.

I Note.—Hospital was rebuilt in 1904 and removed

to splendidly equipped new premises in Townsend
Street. A Resident Surgeon elected periodically.

Ophthalmic Institution and Eye and Ear
Hospital, Great Victoria Street, Belfast.—
Established 1844. New hospital erected, 1867. New
extern department and operation theatre added, 1902.
This hospital is situated on the main road between
Queen’s College and the Royal Victoria Hospital. It
j contains about 30 beds for intern patients, and a large
I extern department. The latter is open on Monday,
Wednesday and Friday at noon for eye cases, and on
Monday and Thursday at noon for ear and throat cases.
Special courses of instruction are given during the
winter and Summer sessions, but students can enter at
any time, and can always obtain plenty of practice in
ophthalmoscopic work. Full particulars may be
had from Dr. Cecil Shaw, 18 College Square East,
Belfast.

Royal Victoria Hospital. — Established 1791 ;
incorporated by Royal Charter, 1875 and 1898. New
hospital opened, September 17th. 1903. 300 beds;
Convalescent hospital, 24 beds; Children’s Hospital,
33 beds; Consumptive Hospital, 10 Deds.

Ulster Eye, Ear, and Throat Hospital,—
Established 1871. New hospital opened 1874* 30

beds.

Ulster Hospital for Children and Women,
Mountpottinger, Belfast, is the only hospital in the
large part of the city situated on the County Down
side of the river. It is placed in a working class
district, and has a great field for its charitable opera-
lions, There are in the hospital about twenty-two
beds for children and eight for women. There is an
extern department for children open every week-day,
except Saturday, from 9 till 10, and for women at
11.30, and a special department for diseases of the eye,
ear, and throat on Tuesdays and Fridays from 9 till ioi
During the summer and winter sessions, clinical instruc¬
tion is given to students daily, operations being chiefly
performed on Wednesday and Saturday, There is a
resident midwife for extern work, and every facility is
afforded students for attending their cases in the
district,

CORK HOSPITALS.

Victoria Hospital for Women and Children.—
Established 1874. 70 beds. An immense amount of

work is done in this hospital to relieve the poor of Cork,
Kerry, and other counties. A large number of
successful operations are done every year. The
hospital contains several very fine private rooms for
paying patients.

* County and City of Cork Lying-in Hospital*—

ftstablished 1798, 17 beds.

* Eye, Ear, and Throat Hospital, Western Road«—

Incorporated 1898, 35 beds, Inpatients treated

during year, 454; outpatients, 4,338. Clinical In-

Sized by GoOgle

286 The Medical Pees*.

IRELAND—EDUCATION.

Sept, ii, 1907.

straction is given during college session. Special
demonstrations in the use of the ophthalmosccpe,
larynogscope, &c., are given from time to time.

•Fever Hospital and House of Recovery,—
Established 1801, no beds.

•Maternity. —Established 1872.

•Mercy Hospital. —Established i 857« 80 beds.

• North Charitable Infirmary.— Established 1774
no beds. Special wards for treatment of diseases cf
women and children. The extern department is largely
availed of, and the number of accidents treated is
very large. Clinical instruction is given daily from
9.30 a.m. to 12 noon. A new and thoroughly up-to-
date operating theatre has recently been added at
enormous expense.

Cork South Infirmary and County Hospital,—
Founded 1773, The hospital contains 100 beds,
available for clinical instruction, 40 medical and 60
surgical* There are also special wards devoted to the
treatment of diseases peculiar to women and children,
and a large medical and surgical extern department*

Clinical instruction is given daily during the session
from 9.30 to 11.30, in both the medical and surgical
wards, and clinical lectures are regularly delivered.

The operation and sterilising rooms are thoroughly
up to date. The X-ray department is fully equipped
with the newest apparatus necessary for such work.
Students are regularly instructed in the methods of
using the rays by practical demonstration on the cases
requiring their use,

The hospital has been largely availed of by students
of the Cork School of Medicine.

GALWAY HOSPITALS.

• County Hospital, —Established 1786, 60 beds,

• No answer to our request for information received from these
hospitals.

IRISH PUBLIC SERVICES.

The Poor-law Medical Service.

For several years past the unsatisfactory nature
of the Irish Poor-law • Medical Service, as a career
for young practitioners, has furnished a theme for
the opening addresses at all the leading medical
schools. In addition to the petty annoyances, the
laborious and harassing duties, and the ever-increasing
amount of clerical work which the new orders of the
Local Government Board impose from time to time, the
unfortunate medical officers are grievously underpa ; d,
their salaries being totally out of proportion to the
duties discharged, and in the majority of rural districts
barely sufficent to cover the out-of-pocket expenses,
such as are incurred in the keep of a horse and man,
and other servants. The Local Government Board
have recently laid it down, moreover, that the dis¬
pensary patients have the first call on the time of the
medical officer, and that, even if he is engaged on an ur¬
gent private case, he must give it up and go off to attend
on a scarlet-runner, as the dispensary visiting tickets
are not inappropriately called. So strictly is he bound
up to the discharge of his duties that unless incapaci¬
tated by sickness or other cause, or with the permission
of the guardians expressly granted, he cannot leave
his district for a single day, even if he makes provision
for the performance of his duties in his absence by a
brother practitioner. The Irish Medical Association,
whose work includes the safeguarding of the interests
and the improvement of the condition of the Poor-
law medical officer, considers it an imperative
duty to point out to young practitioners the
following facts : (1) That the Poor-law Medical Service
is one in which there is no promotion. (2) That
it is a service where few facilities exist for original
research, and still - less for further medical culture,
especially in the rural districts. (3) That, while
medical education has become wider in its require¬
ments, and more costly and difficult to procure,
almost the same rate of payment given to less
educated men forty years ago is still offered, and this,
too, at a time when the rural prosperity of the country
is less, and consequently lucrative private practice more
difficult to obtain. (4) That there is no compulsory

superannuation, and, as a consequence, many old and
infirm doctors are forced to remain on in the service
long after they have become unfit to discharge the
duties, seeing nothing but extreme poverty and perhaps
the workhouse itself staring them in the face.

We need go no further thau to say that the Irish
Poor-law Medical Service is a service to avoid. We
therefore strongly urge on young medical men the
importance of supporting the interest of the profession
by refraining from applying for vacant posts of which
the salary is insufficient, from accepting posts as
locum tenens at a lower rate than £4 4s. per week.

There are 159 workhouses and about 810 dispensary
medical officers, besides apothecaries. The number of
vacancies that occur annually averages 100. The
salary in this service used to average about £1 14, but is
rapidly coming down, and when it is taken into con¬
sideration that in the vast majority of rural districts it
is necessary to keep one or more horses, the average
area being from forty to sixty square miles, it is plain
that there will not be a large margin left from the public
emoluments.

The medical officer is also ipso facto the registrar of
births, marriages, and deaths, and medical officer of
health for the district, under the Public Health Act,
passed in 1873 and amended in 1878. The former office,
in country districts, yields between £5 and £10 a year,
and the emoluments of the latter appointment in very
few cases reach £20, averaging about £12, The medical
officer is also vaccinator for the locality, and is required
to vaccinate everyone who wishes to come. For each
patient a fee of 2s. is paid, along with his salary, by the
guardians, and the sum total of those fees varies, accord¬
ing to the populousness of the district, from £4 to £100,
an average for the provinces being about £io.

Qualifications .—The qualifications required by the
Local Government Board are a licence in surgery, in
medicine, and in midwifery; but registration in the
“ Medical Register," if effected since the passing of the
Medical Act, in 1886, fulfils all requirements. The
candidate must also be 23 years of age.

Duties .—The duty of the dispensary doctor is two¬
fold. He has to attend his dispensary on a given day or
days in the week. Frequently there are two dispen¬
saries in the district, separated from each other by
several miles, and he will have, perhaps, to attend two
days a week. He has also to visit at any hour of the
day or night a sick person for whose relief a visiting
ticket has been issued by a guardian, warden, or
the relieving officer, and to continue his attendance
as often as may be necessary to the termination of the
case. Moreover, he has a great many registry books
to keep and a multitude of returns to make, and in
many districts he has to make up all the medicines for
the poor.

Workhouse Hospitals .—The number of unions in
Ireland is 159, to each of which is attached a medical
officer, who is appointed and controlled by the board of
guardians in the same manner as the dispensary medical
officer. The salary is usually better than that of the
dispensary doctor, and the duties of a more easy and
satisfactory description, inasmuch as they are con¬
fined to daily attendance at the workhouse hospitals,
and no night visits out of doors or long journeys
across the country are involved.

The Irish Lunacy Service.

This service, at present, affords a comfortable liveli¬
hood for 22 Resident Medical Superintendents and 32
Assistants. The Superintendents receive salaries and
allowances ranging, according to the number of inmates
of the asylum, from £500 to £1,000 a year, and the
Assistants receive salaries and emoluments averaging
about £200 a year. There are also Visiting Physicians
receiving about £120 a year, but this class of officer
is being allowed to die out, and no new appointments
will be made. The Superintendents and Assistants
must devote their whole time to their duties.

Heretofore the appointments of Medical Superin¬
tendents have been in the patronage of the Lord
Lieutenant, but, under the Local Government
Act, they are in the hands of the County Councils, with

zed by Google

Sept, i i, 1907.

IRELAN D—EDUCATION. The Medical Press. 2$7

the proviso that no one shall be appointed who is not a
tally registered practitioner with five years’ service as
Assistant. The Assistant is appointed by the Committee
of the County Council to which the management of the
the asylum is entrusted. In addition to these officers,
there are, in certain larger asylums, Clinical Residents,
who receive about ^50 a year and full allowances.
These appointments afford excellent introduction to the
higher places in the service.

Other Appointments.

There are, in addition to those which we have men¬
tioned, certain appointments open to medical practi¬
tioners in special localities. They are :—

(1) Attendance on the Royal Irish Constabulary.
(2) Attendance on the Coastguards. (3) Factory
Surgeoncies. (4) Attendance upon the depot soldiers
who are not otherwise provided for.

The Constabulary are paid for at the rate of 2s. per
month for each member of the force on duty in the
district, including the wives and children of the men, but
not of the officers. This includes the supply of medi¬
cines. The appointment to this position rests with the
Inspector-General of the Royal Irish Constabulary, who
usually acts upon the advice of the local District
Inspectors as to the convenience of the men, and, of
course, the emoluments depend on the number of
Constabulary stations and the number of men in each.

The Coastguard Service.—The duty of the Medical
Officer is to attend the men when sick and to examine
candidates either for admission or for superannuation.
The fees vary from 5s. to 2s. 6d. per visit. The appoint¬
ments rest with the Admiralty, but are usually secured
for the local Poor-law Medical Officer. The emolu¬
ments depend on the number of stations and men.

Factory surgeoncies are in the gift of the Chief
Inspector of Factories in Whitehall. There is a set
scale of payment by the factory owner to the inspector
for this work, but we believe it is not adhered to, and,
in some districts, at all events, the emolument is a
matter of arrangement. The amount depends upon the
size of the factory, the position being, in Dublin or
Belfast, or in other large manufacturing centres, a
lucrative one, but in other places scarcely worth taking.
The attendance on the military depots is not worth
mentioning.

Tot farther particular* see advertisements

Boy-al College of Physicians...

School*.
University of Dublin
Royal College of Science for

Ireland .

Royal College of Surgeons ...
Queen's College, Oorts
Queen’s College, Galway
Oathohc University.

General HotpitaU;

Royal City of Dublin.

8 ir Patrick Dun's .

Mater Misericordite.

8 t| Vincent's.

69 Richmond. Whitworth and

! Hardwicke .

67 Mea-h .

, Adelaide.

67 Jervis Street.

?? ! Special Ho*pi*al» .-

City Hospital for Diseases of

j the 8kln .

Rotunda, Lying-in .

! Royal Victoria Eye and Ear

52 National Children's .

53 | Incorporated Dental..

48,8t. Vincent's Asylum for the
50 ‘ Treatment of Mental Diseases

49

64

68

66

.'6

64

65
61
59

49

Death of Mr. Timothy Holmes.

The death of Mr. Timothy Holmes, F.R.C.S., will
form a matter of regret to all old Cambridge and
St. George’s men, as well as to a large circle of other
members of the profession. Mr. Hclmes, who was
over eighty years of age, graduated as Bachelor of
Arts, at Cambridge, as far back as 1847, and after¬
wards entered as a student at St. George’s. He became
a Fellow of the Royal College of Surgeons in 1853,
and was soon afterwards appointed assistant surgeon
to the hospital. He was for a long period full 9urgeon,
and on retirement he was appointed consulting sur¬
geon and joint-treasurer. For many years he was
chief surgeon to the Metropolitan Police, and he had
been president of the Royal Medical and Chirurgical
and of the Pathological Society, as also vice-president
of the Royal College of Surgeons, and Hunterian Pro¬
fessor of Surgery and Pathology to the College. His
surgical writings have been numerous and valuable,
including, besides many detached papers and articles,
important contributions to a “System of Surgery,”
of which he wis editor.

gartlatti).

Notwithstanding the increased competition which
the recent vigorous growth of the great English pro
vincial medical schools, added to the unsurpassed
attractions of the historic Metropolitan hospitals, with
their staffs of renowned teachers, ensures, the Scottish
medical schools seem fully to retain their popularity,
not only, as is natural, among Scotsmen and their
colonial descendants, but among medical students from
England. Wales, and Ireland, and, indeed, all parts of
our Empire. And undoubtedly the competition of other
centres has had the advantage of making Scottish
teachers bestir themselves, with the result that the
efficiency of the medical schools is now much greater
than a decade ago. The advantages derived from
the second half of the Carnegie Bequest, i.e., the
improved equipment of the teaching schools
j and the encouragement of post-graduate research are
proving potent factors in promoting the well-being
of the Universities and Scottish education
generally. Of the four universities, Edinburgh,
of course, occupies the premier position as a medical
school, but at Glasgow, Aberdeen, and St. Andrew's,
an almost equally good—indeed, in individual details,
better—training can be obtained. Two ordinary
qualifications to practise are granted in Scotland—
the M.B., Ch.B. of the Universities, and the triple
qualification of the Colleges of Physicians and Surgeons
of Edinburgh and the Faculty of Physicians and
Surgeons of Glasgow’. The examinations for the Uni¬
versity degree naturally are more exacting than those
for the triple qualification, and the curriculum wider.
Nevertheless, the standard for the latter is much higher
than formerly, though on account of the large
number of examiners in most subjects it is probably
slightly less uniform than that of the universities,
where the examinations are conducted by the pro¬
fessors with one or more extra-mural assessors in
each subject. Two features of the Scottish system,
deserve mention—first, as regards the co-ordination ot
various separate teaching bodies in each centre ; second,
as regards the conditions under which the students live,.
Around each university there has grown up an extra¬
mural medical school, in which the teachers are hospital
physicians, surgeons, and specialists unconnected with
the university, but whose classes qualify for graduation.
Thus the student has usually ample choice, and can,
within certain limits, attend the teacher from whom,
he thinks he will derive most benefit, while the extra¬
mural lecturers, being unendowed and constantly
recruited by fresh blood, have a permanent incentive-
to keep their courses up to the mark, since any slack¬
ness is at once followed by a diminution in the number
of students’ fees. In late years instead of each extra¬
mural teacher lecturing separately, combinations have
been formed, in which different parts of a course on
medicine are given by different physicians, and these
have proved exceedingly popular and successful. A very
important part of the student’s, clinical work, too, is
done at institutions and under teachers quite uncon¬
nected with the universities ; this is his dispensary
practice, which may be taken at one of several dis¬
pensaries situated in the poorer districts of the towns.
Until recently, practical training in obstetrics was one
of the least satisfactory parts of the teaching in Edin¬
burgh. and many students were in the habit of going
to Glasgow or Dublin for their maternity work.
Recently, however, steps have been taken which
should render this unnecessary, and ought to give
Edinburgh students quite sufficient opportunity of
acquiring as good a practical acquaintance with thin
most important subject as they have of obtaining a
theoretical knowledge of it. From what has been
said it will be seen that university undergraduates
and triple qualification men rub shoulders at every
turn—in the wards, dispensary, and lecture-room.
University students have the privilege of studying
under both intra- and extra-mural teachers, while-
men going up for the triple qualification are limited
to the latter. It is not uncommon, therefore, for

ized by Google

288 The Medical Press. SCOTLAND—EDUCATION. Sept, ii, 1907.

a man to come up intending to take the licence,
and to change his mind and go in ior a degree, or vice
nersdf and this can usually be done without much
added expense or taking out many fresh classes, pro¬
vided the change is not made too late in the curriculum.
The weak spot in the Edinburgh curriculum is the
overcrowding of subjects in certain years, but the
new three-term session, with the increased frequency
of professional examinations, which comes into oper¬
ation on October, 1907, will do much to remedy this,
and make the course more elastic.

For the rest, the student lives as he likes and where
he likes; the authorities only demand that he shall
attend classes with due regularity and diligence, and
exhibit sufficient proficiency to pass his examinations.
Most men live in lodgings, a few board with private
families, and some live in the various halls of residence
which have been established. In these last, too, the
student is his own master, the halls being managed
solely by a committee of the residents for the time
being. It is impossible to make any very definite
statement as to the relative cost of a medical education
in the different schools, as compared with London and
Dublin, as so much depends on the extra classes taken
out, the mode of living, and so on. The minimum
inclusive fees for the licence are ^120, for the M.B.
degree about ^146; but almost every student finds it
practically necessary to attend additional classes. On
the whole, the cost of living is highest in Edinburgh,
lowest in Aberdeen ; in the former, while the rent of
lodgings is lower than in London, maintenance, in
eluding clothing and provisions, is somewhat more
expensive. Incidental expenses, amusements, &c., are,
however, considerably less in the Northern capital.
In Aberdeen, money goes much further than in the
south, and the student ought to keep himself on about
two-thirds of the funds required in Edinburgh.

THE CARNEGIE TRUST.

Through the munificence of Mr. Andrew Carnegie,
LL.D., payment is now made " of the whole or part of
the ordinary class fees exigible by the Universities from
students of Scottish birth or extraction, and of sixteen
years of age or upwards, or scholars who have given two
ears’ attendance, after the age of fourteen years, at
tate-aided schools in Scotland, or at such other schools
and institutions in Scotland as are under the inspection
of the Scottish Education Department.”

The Trust provides for the payment of the class fees
of the above students proceeding to graduation in medi¬
cine or science. Application for payment of class fees
under the conditions of the Trust should be made to the
Secretary, Mr. W. S. McCormick, Merchants’ Hall,
Hanover Street, Edinburgh.

UNIVERSITY OF EDINBURGH.

Four degrees in medicine are granted • Bachelor of
Medicine (M.B.), Bachelor of Surgery (Ch.E.), Doctor
of Medicine (M.D.), and Master of Surgery (Ch.M.).
The first two must be taken together, the last two may
be taken separately.

No one is admitted to the degrees of Bachelor of
Medicine and Bachelor of Surgery who has not been
engaged in medical and surgical study for five years,
after passing a preliminary examination in general
knowledge in accordance with the medical ordinances.
A degree in Arts or Science of a British or other recog¬
nised Universitv is held to supersede such preliminary
examination. The subjects included in this general
examination are English grammar and composition,
English history and geography, Latin, arithmetic, and
the elements of mathematics, and Greek, or French,
or German.

The annus medicus of each year is constituted by
at least two courses of not less than one hundred
lectures each, or by one of such courses, and two
courses of not less than fifty lectures each, exclusive of
the clinical courses. Two years of the five must be
spent at the University, the remaining three years at
any other Medical School recognised by the University
Court.

During the first four years the student must attend
botany, zoology, physics, practical chemistry, practical

physiology, practical pathology, and medical juris¬
prudence during courses of not less than 2$ months
each ; public health, not less than forty lectures;
practical anatomy, during two courses of not less than
five months each ; chemistry, anatomy, physiology,
pathology, surgery, materia medica, medicine and
midwifery during courses of not less than five months
each. He must attend a course of twenty-five lectures on
practical pharmacy, or have dispensed drugs for a period
of three months in a recognised hospital or dispensary.
He must attend a nine months’ course in clinical
medicine and in clinical surgery. During the fifth or
final year he must be engaged in clinical studv for at
least nine months. In all, before graduation, he must
have done hospital work for at least three years, and
have acted as clerk in the medical and surgical wards
and attended for six months the practice of a dis-
ensarv, or o f a physician and surgeon. He must also
ave studied (1) operative surgery; (2) mental
diseases ; (3) post-mortems, fevers, and diseases of the
eye, and (4) one of the following. Diseases of children,
of the ear, nose and throat, or of the skin ; (5) vacci¬
nation.

He must attend at least twelve cases of labour
under the superintendence of a registered medical
practitioner or six such cases, and, for at least three
months, the practice of a midwifery hospital. •

Each candidate is examined both in writing and
viva voce —

1. On zoology, botany, physics and chemistry.

2. On anatomy and physiology.

3. On pathology, and materia medica and thera¬
peutics.

4. On medicine, surgery, midwifery, forensic medi¬
cine , and public health.

On October 1st, 1907, a new division of the medical
curriculum will be inaugurated, the year being divided
into three sessions, a 1st winter, a 2nd winter, and a
summer session. At the end of each of these profes¬
sional examinations will be held, instead of twice yearly
as at present. This will admit of some re-arrangement
of classes, pathology being taken before materia medica,
instead of concurrently or subsequently, as at present,

The new order of examination will be as follows -
Physics, end of first half of first winter session ; Chemis¬
try, end of second half of first winter session ; Zoology
and botany, end of first summer session ; Physiology,
end of second summer session ; Anatomy, end of first
half of third winter session ; Practical materia medica,
end of second half of third winter session ; Pathology,
end of third summer session; Materia medica, end of
second half of fourth winter session ; Medical juris¬
prudence and public health, end of fourth summer
session ; Midwifery, end of first half of second winter
session ; Medicine and surgery, end of second half
of second winter session ; Clinical medicine, surgery
and gynaecology, end of fifth summer session.

The degree of Doctor of Medicine may be con¬
ferred on any Bachelor of Medicine and Bachelor
of Surgery, and who is of the age of twenty-four years,
and who produces a certificate of having been engaged,
subsequently to his having received the degrees of
M.B. and Ch.B., for at least one year in attendance
on a hospital, or in scientific work bearing directly
on his profession, or in the military or naval medical
services, or for two years m practice other than purely
surgical. The candidate shall submit to the Faculty
of Medicine a thesis on any branch of knowledge com¬
prised in the professional examinations for the degrees
ot Bachelor of Medicine and Bachelor in Surgery. The
candidate will also be examined in clinical medicine
and must show practical acquaintance with advanced
methods of diagnosis ; he may take, at option, gyne¬
cology, mental diseases, or diseases of children for one
of his three cases. The degree of M.D. is conferred
on holders of the degrees of M.B., C M. (Old Regulations)
on the submission of a thesis approved by the Medical
Faculty, provided that the candidate shall have
passed the preliminary examination in the subjects of
Greek and logic or moral philosophy. Should the can¬
didate elect to do so, he may, how e ver, take the M.D,
degree under the new regulations, substituting an

Sept. n , 1907.

SCOTLAND—EDUCATION.

The Medical Press. 289

examination in clinical medicine for that in Greek and
logic. This course is usually pursued by those who did
not pass in these subjects with the rest ot their pre¬
liminary examinations.

The regulations for the degree of Ch.M. are very
similar.

Fees :—The fee to be paid for the degrees of Bachelor
of Medicine and Bachelor of Surgery is twenty-two
guineas. The fee for the degree of Doctor of Medicine
or of Master of Surgery is ten guineas (Old Regula¬
tions. £5 5s.).

The total expense of the curriculum, including
examination ana matriculation fee, is £146.

Among scholarships, &c., open for competition during
the session 1907-8 are the following :—Vans Dunlop
scholarship, value £100, in chemistry, anatomy and
physics, in botany and zoology, and in physiology
and surgery. Stark scholarship in clinical medicine,
value £110; Buchanan scholarship in midwifery,
value £40 ; Mouat scholarship in practice of physic,
£$7. Mackay Smith scholarship in chemistry, value
£2 5. A Creighton research scholarship (anatomy and
physiology) £100. Houldsworth scholarship, re-search
in pharmacology,£49; McCunn medical research scholar
ship, £100. There are also a great many other bursaries
Fellowships, and prizes open during the session 1907-8,
and for the detaiis governing entry for these the
University Calendar (James Thinn, South Bridge,
Edinburgh) should be referred to.

Graduation in Public Health: Degrees (B.Sc. Sc
D.Sc.) are also conferred in Public Health. Candidates
must be graduates in medicine and must matriculate
for the year in which they proceed for examination.
They must (1) have worked at least twenty hours a
week during a period of not less than eight months
in a recognised Public Health laboratory—five of these
months must be spent consecutively in the Public
Health Laboratory of the University of Edinburgh ;
and (2) have attended a course of lectures on physics
in addition to that qualifying for graduation in
medicine, and one on geology.

Candidates for the second examination are not
admitted until at least eighteen months have elapsed
after having passed M.B , Ch.B , or sooner than six
months after the first examination. They must have
attended two courses of Public Health, one dealing
with medicine, the other with engineering, in relation
to public health. They must also have studied practical
sanitary work under a Medical Officer of Health for
six months, have had three months’ clinical instruction
in a fever hospital, and three months’ instruction in
mensuration and drawing.

Fees for Science Degrees: B.Sc., first examination,
£3 3s. ; B.Sc., second examination, £3 3s.

Diploma of Tropical Medicine .—Every year an
increasing number of candidates avail themselves of
the University Diploma of Tropical Medicine and
Hygiene, which is conferred only on those possessing
a degree in medicine. The course includes practical
bacteriolo gy, diseases of tropical climates, tropical
hygiene, the zoological character and life history of
disease-carrying insects and venomous animals, clinical
instruction at an hospital for tropical diseases. The
examination is held in January and July, the fee
being £4 4s.

University Hall. Edlabargh. —In an educational
number it is worth while to call attention to the
advantages now offered to students coming to Edin¬
burgh to study, in the shape of social residences,
in which students can live in a self-governing com¬
munity. In each house there are private studies
with or without bedrooms, and common sitting and
dining rooms. The charges vary from 7s. 6d. to 22s. 6d.
per week. The residents elect a treasurer from among
their number who acts as intermediary between them
and the housekeeper or servants. It is a satisfactory
indication of the comfort of the Hall that many
graduates live in it and are willing to help or coach
the undergraduates for moderate fees. To gain
admission two references must be produced from past
or present residents, or other suitable person. These
are considered and voted on at a house meeting.

The Hall is an admirable place for parents to send
their sons to. Any unruly member may be expelled
by a meeting of the residents similar to that held
for elective purposes.

Medical School for Women. —The medical teach¬
ing of women in Edinburgh is carried on by the
Scottish Association for the Medical Education of
Women (the Secretary, Minto House, Chambers Street).
The classes are conducted by the lecturers of the Medical
School of the Royal Colleges, and qualify both for the
Edinburgh University degree and for the Licence of the
Triple Board. The classes are for women alone. The
University of Edinburgh does not recognise certificates
presented by female candidates for mixed classes
without special cause shown. Women students are
eligible for the benefits of the Carnegie Bequest,

UNIVERSITY OF GLASGOW.

The University of Glasgow is both a teaching and an
examining body, but admits to examination only those
candidates whose course conforms to its own regula¬
tions. Within certain limits provision is made for
accepting instruction given by recognised medical
schools and teachers ; but eight of the subjects other
than clinical must be taken in this or some other
recognised University entitled to confer the degree of
M.D., and at least two years of the course must be taken
in Glasgow University. Under the new regulations,
laid down in Ordinance No 14, Glasgow No. 1, of the
Commissioners under the Universities (Scotland) Act,
1889, four degrees, open both to men and to women, are
conferred—M.B. and Ch.B. (always conjointly), M.D.
and Ch.M. A preliminary examination must be passed
in (x) English, (2) Latin, (3) Elementary mathematics,
and (4) Greek, French, or German, with possible option
to students whose native tongue is not English in the
case of the fourth subject, and, on passing, students
must register in the books of the General Medical
Council. By a regulation recently enacted, it is no
longer compulsory to pass in all the four preliminary
subjects at once, and they may now be passed at two
stages. For M.B. and Ch.B. a curriculum of five years
is required. A syllabus with full details of the curri¬
culum and of the preliminary examination may be
had, post free, on application to the assistant clerk,
Matriculation Office.

The fees for M.B. and Ch.B. are £23 2s. ; for M.D.
£10 ios., and for Ch.M. £10 10s. For hospital attend¬
ance there is an initial fee of £10 ios., with a further
fee of £3 3s., for each winter session, and £2 2s. for
each summer session of clinical instruction. There are
three very extensive general hospitals in the city,
which afford exceptional opportunities for clinical
work, while the Royal and other asylums, the City
Fever Hospitals, the Maternity Hospital, the Sick
Children’s Hospital, the Eye Infirmary, See.., give
facilities for the study of special branches.

The degrees of B.Sc. and D.Sc. in Public Health
and of B.Sc. in Pharmacy, are also now con¬
ferred. Of late the University has made consider¬
able efforts to extend its laboratory accom¬
modation and equipment, to augment its teaching staff,
and to encourage post-graduate and research work.
Within the last few years there have been provided
new laboratories in the departments of pathology,
anatomy (costing £13,000), chemistry, and surgery
(costing £9,900); while new laboratories, to cost, with
equipment, upwards of £60,000, are now approaching
completion, for the departments of physiology, materia
medica, and medical jurisprudence and public health.

Bursaries and prizes to the annual amount of about
£1,000 are appropriated to medical students, including
an Arthur bursary for women, £20 for three years.

Several bursaries open to students in any faculty are
not infrequently held by medical students, and Scholar¬
ships and Fellowships to the annual amount of £:,6oo
may be held by medical students who have gone
through the Arts course.

Qaeeo Margaret College for Woaen. — Founded
in 1883 (by the Glasgow Association for the Higher
Education of Women, which was formed in 1877 with
the object of bringing University instruction, or its

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SCOTLAND—EDUCATION'

Sept. ii. 1907.

equivalent, within the reach of women), Queen Margaret i
College in 1890 added to its faculty of Arts a School
of Medicine for Women* This was organised entirely !
on University lines, and with the view of preparing
for University degrees ; and when, in 1892, in con¬
sequence of the Ordinance of the University Com- 1
•uissioners authorising the Scottish Universities to j
admit women to instruction and graduation, Queen \
Margaret College became the Women's Department of
the University of Glasgow, its classes in medicine taken
previously to its incorporation with the University were j
recognised as preparing for the degree. A full course
of study for M.B. and Ch.B. is given by University pro¬
lessors and lecturers, with excellent facilities for
hospital and dispensary work in the Royal Infirmary
and other hospitals. A Hall of Residence for the '
students was founded in 1894. Fees for the classes 1
at Queen Margaret College may be paid by the Carnegie ,
Trustees; and several bursaries are open to women |
students of medicine,

The Winter Session begins on 17th October. The

S r os pectus can be obtained from the hon. sec.. Miss
alloway, Queen Margaret’s College, Glasgow.

UNIVERSITY OF ABERDEEN.

The University of Aberdeen possesses under its
charters the amplest privileges claimed or enjoyed by
any academical institution. It confers degrees in the '
five faculties of Arts, Science, Divinity, Law, and ,
Medicine. It also grants diplomas in Public Health, |
Agriculture, and in Education. It is, moreover, a teach¬
ing body equipped with twelve distinct chairs in the
various branches of medicine and surgery. The majority
of the professors devote their whole time to the work of
the chairs. There are fully-equipped laboratories, the |
accommodation for which has recently undergone con- 1
siderable extension. The degrees of M.B. and Ch.B. !
are conferred together; they cannot be obtained 1
separately. The curriculum of study is nearly the same
as in the University of Edinburgh ; the regulations in j
the preceding columns will therefore applv here. Two j
years must be passed at Aberdeen. With regard to
fees, each candidate for the degrees of M.B. and Ch.B.
must pay a fee of £5 5s. in respect of each of the first
three professional examinations, and £7 7s. for the final
examination. Total cost, exclusive of the fees for
degrees, is about £120. Besides the Royal Infirmary,
students have the opportunity of attending several
other local institutions where special courses of in¬
struction are given. Perpetual fee for hospital practice
is only £6. The professional examinations are held
twice in each year, namely, in March and July, directly
after the close of the winter and summer sessions.

Bursaries. —Bursaries, Scholarships, and Fellow¬
ships to the number of fifty, and of the annual value of
over £1,180, may be held by students of medicine. (See
" University Calendar.”)

The Degree of M.D.—The degree of Doctor of
Medicine may be conferred on any candidate who has j
obtained the degrees of M.B. and C.M. (Old Regula- 1
tions). is of the age of twenty-four years, and has been !
engaged subsequently to his having received the degree 1
of flLB. for two years in attendance in a hospital, or in
military or naval medical service, or in medical or 1
surgical practice, and has presented a thesis which has
been approved of by the Medical Faculty. Candidates
for the degree of M.D. (New Regulations) are required ;
to pass an examination in clinical medicine in addition 1
to presenting a thesis. Similar regulations apply to a I
degree of Ch.M. (Master ol Surgery).

A Diploma in Public Health is conferred after exami¬
nation on graduates in medicine in any University in j
the United Kingdom. Regulations may be seen in the
" Calendar.” or obtained on application to the Secretary j
the Medical Faculty. i

Aberdeen Royal Infirmary. —This is a well-equip- :
ped institution, containing 250 beds, and affords |
excellent opportunities for clinical study to students at 1
the Aberdeen University. The city, moreover, offers i
inducement in the way of cheaper living and compara* ;
tive quiet to that obtained in Edinburgh and Glasgow,
and will doubtless be preferred by some on this account* *

ST. ANDREWS UNIVERSITY.

United College St. Andrews and University
College, Dundee.

This University (session opens October 15 th) grants
the degrees of M.B., Ch.B., M.D., and Ch.M, The
degrees of the University are open to either sex. For
the degree of M.B., Ch.B., two of the five years of
medical study must be spent in the University of
St. Andrews ; the remaining three may be spent in any
University of the United Kingdom, or in any foreign,
Indian, or Colonial University recognised for the
purpose by the University Court, or in such medical
schools or under such teachers as may be recognised for
the purpose by the University Court. The preliminary
examination and the professional examinations are of
the same character as in the other Scottish Universities.
A Diploma in Public Health is also granted by the
University of St. Andrews to graduates in medicine of
any University in the United Kingdom. Twelve
months must elapse between the date of graduating in
medicine and entering for the examinations for the
diploma. The course of study required consists of (1) a
six months’ course of practical chemistry, bacteriology,
and the pathology of diseases transmissible from
animals to man in a laboratory of the University of
St. Andrews ; (2) six months’ work with a medical
officer of health ; (3) three months’ clinical instruction in
infectious diseases. Subjects for first examination :—
Chemistry, physics, bacteriology, and meteorology.
Second examination :—Sanitation, sanitary law, vital
statistics, medicine in relation to public health.

University College, Dundee, was affiliated and made
to form part of the University of St. Andrews on
January 15th, 1897, and the whole medical curriculum
may be taken in the College. The United College,
St. Andrews, offers classes for the first two years of
professional study.

Bursaries and Scholarships.

United College, St. Andrews. — Malcolm bursary,
/25 a year, tenable for five years. Fourteen Taylour
Thomson bursaries, £30 to £20, five tenable for one
year, nine for two, open to women only proceeding to
graduate in medicine.

University College, Dnodee: — Eleven entrance
bursaries of £15, open to women for arts, science, or
medicine, tenable for one year. Four £20 and three
£15 second year bursaries for men or women in arts,
science, or medicine, tenable for one year. Four £20
and two £1 5 third year bursaries for men or women in
arts, science, or medicine, tenable for one year. Two
Educational Trust bursaries of £2 5, tenable for three
years. Applicants must have attended a public or
State-aided school ih Dundee for at least one year before
examination. Bute bursary, annual income from
£1,000 (men only).

Preliminary Examinations .—The dates of the next
two|examinations are September 27th, 1907, and March
27th, 1908. Schedules (obtainable from the Secretary
of the University) to be returned filled up. and fees
paid by September 14th, 1907, or March nth, 1908.

Fees for Degrees .—Total fees for M.B., Ch.B., are the
same as at other Scottish Universities, ».<?., 22 guineas
(payable in instalments). Fee for the degree of M.D..
and also for that of Ch.M., is 10 guineas in each case.
For the Diploma of Public Health examinations the
fee is £5 5s. for each of the two examinations.

Class Fees .—The fee payable in each of the following
classes is 4 guineas, viz.:— -Chemistry, physics, zoology,
botany, physiology, anatomy, materia medica.
pathology, forensic medicine, and public health,
medicine, surgery, and midwifery. The fee for the
practical classes in these subjects is 3 guineas each. In
clinical surgery-, clinical medicine, ophthalmology,
diseases of the throat, nose, and ear and mental
diseases, the class fees are 2 guineas each. The fee for
Public Health chemistry required for the D.P.H., is
7 guineas. A special class in Bacteriology is also held
for the D.P.H. for which the fee is 3 guineas.

Dundee District Asylum.. —The appointments include
a qualified resident assistant and two resident clinical
clerks. Clinical instruction is given.

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y O

Sept. ii. 1907.

SCOTLAND—EDUCATION.

he Med ical P ress. 2 QI

Further information will be found in the Calendar of
the university published by Messrs. Blackwood and
Sons. Edinburgh, or can be had of the Dean of the j
Medical Faculty, Professor C. R. Marshall. (See
advertisement page).

Dnodee Royal Infirmary —The Infirmary con- !
tains 360 beds, with a special ward for the treatment of
children. Three resident qualified assistants are
appointed annually. Clinical clerks and dressers are
attached to the physicians and surgeons, and students |
are appointed to assist in the post-mortem room. Out- \
patients are seen daily at 9 a.m. The instruction given
at the Infirmary is recognsed for purposes of graduation j
by the Scotch Universities, the University of London,
the University of Cambridge, the Royal University of
Ireland, and by the Royal Colleges of England and
Scotland. Hospital Ticket for the Infirmary, £2 2s.
each session, or £3 3s. a year. Further information on
application to the Medical Superintendent.

THE COLLEGES.

The Poyal College of Physicians of Edinburgh, the |
Royal College of Surgeons of Edinburgh, and the
faculty of Physicians and Surgeons of Glasgow have
made arrangements by which, after a series of examina¬
tions, the student may obtain the diploma of the
co-operating bodies, and can register three diplomas
under the Medical Acts, viz., Licentiate of the Royal
College of Physicians of Edinburgh, Licentiate of
the Royal College of Surgeons of Edinburgh, and
Licentiate of the Faculty of Physicians and Surgeons
of Glasgow.

The three bodies grant their single qualifications
only to candidates who are already registered as
possessing another and opposite qualification in medi¬
cine and surgery as the case may be.

Regulations of the Conjoint Board of the
Royal College of Physicians of Edinburgh and
the Royal College of Surgeons of Edinburgh and
the Faculty of Physicians and Surgeons, Glas¬
gow.— The candidate must produce certificates of
having attended the following course of lectures, the !
certificate distinguishing the sessions and the schools
in which the courses were attended. Anatomy, six
months; practical anatomy, twelve months; chem¬
istry, six months ; practical chemistry, three months ;
materia medica, three months; physiology, six
months; medicine, six months; clinical medicine,
nine months; surgery, six months ; clinical surgery,
nine months; midwifery, three months; medical
jurisprudence, three months; pathology, three months.
The candidates must also produce the following certi¬
ficates :—(a) Of having attended six cases of labour
under the superintendence of a registered practitioner.

(b) Of having attended for three months^ instruction
in practical pharmacy. The teacher must be a member
of the Pharmaceutical Society of Great Britain, or
the Superintendent of a laboratory of a public hospital
or dispensary, or a registered practitioner, or a teacher
to a class of practical pharmacy. (c) Of having at¬
tended for twenty-four months the medical and surgical
practice of a hospital, containing eighty patients,
and possessing distinct staffs of physicians and surgeons.

(d) Of having attended for six months the practice of
a public dispensary, or of having assisted for six months
a registered practitioner, (e) Of having been instructed
in vaccination.

First Examination, Fee £§. —The first examination
shall embrace chemistry, physics, and elementary
biology, and shall take place not sooner than the end
of the first year, including a winter and summer
session. Candidates who desire to enter for the first
professional examination must produce certificates of
attendance on chemistry, practical, chemistry, ana¬
tomy, and six months’ practical anatomy.

Second Examination, Fee £$. —The Second exami¬
nation embraces anatomy and physiology and shall
not take place before the termination of the summer
session of the second year of study. Candidates must
produce certificates of attendance on anatomy, prac¬
tical anatomy, and physiology.

Third Examination, Fee £s ,—Comprises the subjects

of pathology, materia medica, and pharmacology and
advanced anatomy.

Final Examination, Fee /15.—The Final examination
embraces medicine (including therapeutics and medi¬
cal anatomy, clinical medicine); surgery (includ¬
ing surgical anatomy and surgical pathology); clinical
surgery ; midwifery and gym-ecology, medical juris¬
prudence and hygiene ; and shall not take place before
the termination of the full period of study.

Subjects of Preliminary Education: (1) English
grammar and composition; ^2) Latin, grammar,

translation from specific authors and easy unseen
translation ; ( 1) (a) arithmetic, to vulgar and decimal
fractions ; ( b) algebra, to simple equations ; (c) geom¬
etry, to the first two books of Euclid ; (4) elementary
mechanics of solids and fluids, comprising the elements
of statics, dynamics, and hydrostatics ; (5) one of the
following :—(a) Greek ; (6) French ; (c) German ; (d)
Italian ; (e) any other modern language; (/) logic-
(g) botany ; (h) zoology ; (i) elementary chemistry. '

Qualification in Public Health: The College of
Physicians, in association with the Royal College of
Surgeons of Edinburgh and the Faculty of Physicians
and Surgeons of Glasgow, confers a certificate of com¬
petency in public health. The examinations are held
in April and October. Fee, £10 10s.

For the special regulations of the Royal College of
Surgeons of Edinburgh, intending candidates should
apply to Mr. James Robertson, 48, George Square,
Edinburgh; and for those of the Royal College of
Physicians, to Dr. H. Rainy, 16, Great Stuart Street,
Edinburgh.

The Fellowship of the Royal College of Physicians of
Edinburgh is conferred only by election, and the candi¬
date must have been a member of the college for at
least three years, and have attained the age of twenty-
seven years.

The Membership is conferred only on a licentiate of a
college of physicians or graduate in medicine of a
British or Irish University, provided he shall have at¬
tained the age of twenty-four years and shall have passed
an examination on : (1) medicine, including therapeutics
(2) on one of the following optional subjects, in which
a high standard of proficiency ts expee'ed — (a) a depart¬
ment of medicine specially professed ; ( b) psychological
medicine ; (c) pathology ; (<f) medical jurisprudence ;
[e) public health ; (/) midwifery ; (g) gynaecology.
The examination is of a searching character extending
over three days, the first of which is devoted to clinical
and side room work, and written commentary on a
case examined. The second day is taken up by written
papers, and the third by practical examination on
special subject and orals.

The fee for membership is 35 guineas, for fellowship
38 guineas, with a stamp duty of £25—^101 13s. in all.

The licence, or single qualification in medicine, is con¬
ferred on candidates who already possess a recognised
qualification in surgery. The examinations for this
licence are held on the first Wednesday of each month,
save those of September and October, in medicine,
materia medica, midwifery, and medical jurisprudence.
The lee is £15 153., and intending candidates should
communicate with the Secretary of the College at least
eight days before the date of examination.

The Fellowship of the Royal College of Surgeons of
Edinburgh is conferred (except under certain conditions
as to age and professional standing) only on candidates
who have passed a special examination, and have pre¬
viously obtained a diploma from the college, or from
either of the Colleges of Surgeons of England or Ireland,
or the Faculty of Physicians and Surgeons Of Glasgow,
or the surgical degrees of the Universities of Great
Britain, and who are twenty-five years of age. The
subjects for examination for those who are already
Licentiates of the College are on the principles and
practice of surgery, clinical and operative surgery, and
one optional subject.

Those who are not Licentiates of this College ‘ on
principles and practice of surgery, clinical and operative
surgery, surgical anatomy, and one optional subject ;
and in such supplementary subjects as have not, in an
adequate manner, been included in the examination for

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292 The Medical Press.

SCOTLAND—EDUCATION.

Sept, ii, 1907.

the registrable surgical qualification possessed by such
candidates, and which are required in the examination
for Licentiates of this College.

The optional subjects shall embrace: (a) Surgery,
special branches; (b) advanced anatomy and physio¬
logy ; (e) surgical pathology and morbid anatomy;

( d) midwifery and gynaecological medicine and sur¬
gery; (e) medical jurisprudence and hygiene; (/)

practice of medicine and therapeutics. The examina.-
tions are written, oral, and practical. Three weeks’
notice must be given to Mr, James Robertson, from
whom full particulars as to certificates required may be
obtained. The fee is £30 for those who hold the di¬
ploma of Licentiate of the College,and^45 toothers (no
stamp duty is payable on the diploma). Registered
practitioners, aged not less than 40, who have been in
practice for not less than ten years, and who have highly
distinguished themselves by original investigations,
may under special circumstances be elected without
Examination, Women are not admitted to the Fellow
ship of either college.

Licence. —The examination embraces the principles
and practice of surgery (including operative surgery and
surgical pathology), clinical surgery, and surgical
anatomy, and shall not take place before the termina¬
tion of the full period of study. Fee, ^15 15s.

Dental Diploma. —Every candidate for the dental
diploma must have attended the general lectures and
courses of instruction required at a University or an
established medical or dental school recognised by the
College as qualifying for the diploma in surgery. The
fee is £10 10s,

Edinburgh Royal Infirmary. —Clinical instruction
is afforded at this institution, .which contains 800 beds
under the supervision of professors of the University
and the ordinary physicians and surgeons of the Infir¬
mary, Special instruction is given on diseases of
women, physical diagnosis, diseases of the skin, eye, ear,
throat and teeth, and anaesthetics. Separate wards are
devoted to venereal diseases, diseases of women, diseases
of the eye, also to cases of incidental delirium or insanity,
and three wards are specially set apart for clinical in¬
struction to women students. Post-mortem examina¬
tions are conducted in the anatomical theatre by the
pathologists. The perpetual fee, on one payment, £12;
the annual fee, £6 6s.; half-yearly, £4 4s.; quarterly,
£2 2S.; monthly, ^1 is. Separate tickets amounting to
£12 12s, entitle the student to a perpetual ticket. No
fees are payable for any surgical or medical appoint¬
ment.

The appointments are as follow :—

1. Resident physicians and surgeons are appointed
and live in the house free of charge. There is no
salary. The appointment is for six months.

2. Non-resident physicians and surgeons (in the
special subjects and for out-patient work) are appointed
for six months. These appointments may be renewed.

3. Clerks and dressers are appointed by the surgeons
and physicians. These are open to all students and
junior physicians holding hospital tickets.

4. Assistants in the pathological department are
appointed by the pathologists to conduct post-mortem
examinations in tlie anatomical theatre.

Royal Hospital for Sick Children. —During the
year three courses of clinical instruction are given by
the staff of the hospital, who are recognised as Uni¬
versity Lecturers on the subject. The course consists
of clinical lectures, ward cliniques. attendance at post
mortem and out-patient cliniques. Hospital tickets,
£\ is.

SCHOOL OF MEDICINE OF THE ROYAL
COLLEGES, EDINBURGH.

The government of this school, established in 1505, is
now vested in a board which is equally representative
of the two Royal Colleges and the Lecturers, the school
being styled !! The School of Medicine of the Royal
Colleges, Edinburgh.” The present number of lec¬
turers is about sixty, of whom the greater number
deliver qualifying courses of instruction of the same
duration and scope as those delivered within the
University, while a large number of non-qualifying

courses on special subjects of interest to medical science*
but which are not required for graduation, are delivered
both in the winter and summer sessions. The students
who attend the classes of the School of Medicine are
largely students proceeding to the University degree, as
well as those who are intending to take other qualifica¬
tions, such as the triple qualification of the Royal
College of Physicians of Edinburgh, the Royal College
of Surgeons of Edinburgh, and the Faculty of Physi¬
cians and Surgeons of Glasgow ; that of the Royal
College of Physicians of London, and' the Royal College
of Surgeons of England, and the degrees of the different
Universities. The number of students attending the
school averages 1,300 annually.

The minimum cost of the education in the School of
Medicine for the triple qualification of physician and
surgeon from the Royal Colleges of Physicians and Sur¬
geons of Edinburgh and the Faculty of Physicians and
Surgeons of Glasgow, including the fees for the joint
examinations, is about £1 20, which is payable by yearly
instalments during the period of study.

The Winter Session opens October 2nd.

GLASGOW EXTRA-MURAL SCHOOL.

St. Maago’s College aad Glasgow Royal Inflr-
aisry. —This college was incorporated in 1889 under its
new title, being formerly known as the Glasgow Royal
Infirmary School of Medicine. The Medical Faculty
occupies" buildings erected for the purpose of the
medical school in the grounds of the hospital, and the
laboratories, museums, and lecture rooms are of the
most approved description. The college has been
recently equipped with a complete electric light in¬
stallation, and a powerful electric educational lantern.
Attendance on the classes in St. Mungo’s College
qualifies for the medical degrees of the Universities
and the medical and surgical colleges in accordance
with their regulations.

The Royal Infirmary, which is at the service of the
College for teaching purposes, is one of the largest
general hospitals in the kingdom. It has over 600 beds
available for clinical instruction, including an ophthal¬
mic department, and it has special wards for diseases
peculiar to women, for venereal diseases, burns,
and diseases of the throat, nose, and ear. At the
dispensary special advice and treatment are given
in aiseases of the eye, ear, teeth, and skin, in
addition to the large and varied number of ordinary
medical and surgical cases which in a great industrial
centre daily require attention. Students at the college
and hospital get the benefit of dispensary experience
free of charge, and no better or wider field for seeing
hospital practice and receiving clinical experience can
be found than in the Glasgow Royal Infirmary.

Appointments .—All appointments are open. There
are five physicians’ and eight surgeons’ assistants,
who obtain free board and residence in the hospital
and act in the capacity of house physicians and
house surgeons. There is also a house surgeon for
the ophthalmic department. These appointments
are made for six months, and are open to gentle¬
men who have a legal qualification in medicine and
surgery. Clerks and dressers are appointed by the
visiting physicians and surgeons. From the large
number of cases of acute diseases and accidents of
varied character received, these appointments are
valuable to students. In the pathological department
assistants are also appointed by the pathologist.

Fees .—The fees for Lectures, including hospital
attendance necessary for candidates for the Diplomas
of the English, Scotch, and Irish Colleges of Physicians
and Surgeons, amount to about £70.

Anderson’s College Medical School, (Hug**—-
New and excellently equipped buildings were opened
in October, 1887, in Dumbarton Road, immediately to
the west of the entrance to the Western Infirmary, and
within four minutes’ walk of the University. Extensive
laboratory accommodation is provided for practical
anatomy, practical chemistry, practical botany, practi¬
cal zoology, practical physiplogy, practical pharmacy,
operative surgery and public health. There are also
provided a library, reading room, and students’ re¬
creation room. The buildings are constructed upon the

CORRESP O NDENCE ._ The Medical Press. 293

Sept, it, 1907.

most approved modern principles. The dissecting room
is open in winter from 9 a.m. to 6 p.m., and in summer
from 6 a.m. to 6 p.m. These students are assisted in
their dissections by the professor and demonstrators, by
whom daily examinations and demonstrations on the
parts dissected are conducted. The supply of subjects
is ample, and students are consequently provided with
parts as soon as they may be ready for them. Tne
dissecting room is provided with a complete series of
dissecting specimens mounted in plaster of Paris
illustrating the anatomy of the human body. There is
also a large Bone Room, furnished with complete sets of
painted and unpainted bones.

The various 'courses of instruction qualify for all
the Licensing Boards in the United Kingdom, and for
the Universities of London, Durham, Ireland, Edin¬
burgh, and Glasgow, under certain conditions. The
courses in public health (laboratory and lectures) are
also recognised by the University of Cambridge.

The Carnegie Trust pays the fees of students at
Anderson’s College on conditions regarding which
particulars may be obtained from W. S. McCormick,
Esq., LL.D., Carnegie Trust Offices, Edinburgh.

Class Fees. —For each course of lectures (anatomy,
ophthalmic medicine and surgery, aural surgery, dis¬
eases of throat and nose, and mental diseases excepted),
first session, £2 2s. ; second session (in Anderson’s
College), /1 is. : afterwards free. For the following
practical classes, viz. : Chemistry, botany, zoology,
physiology, pharmacy, first session, £2 2s. ; second
session, £2 23. ; in botany and zoology, practical and
systematic course together, £3 3s. Operative sur¬
gery, £2 12s. 6d. ; second course. £2 2s. Joint fee for
classes of systematic and operative surgery, £3 13s. 6d.
Public health laboratory, £\\ us.; with lecture
£\2 12s. Ophthalmic, medicine and surgery, aural
surgery, diseases of throat and nose, mental diseases—
each, £1 is.

Anatomy Class Fees. —Winter : First session (in¬
cluding practical anatomy), £4 4s. ; second session
(including practical anatomy), £4 4s. ; third session,
£2 2s. To those who have had the necessary courses of
practical anatomy, the fee will be £1 is. Summer:
Lectures and practical anatomy, £2 12s. 6d ; separately,
£1 iis. 6 d. each.

Royal Infirmary. —Fees: Hospital practice and
clinical instruction, first year, £10 10s.; second year,
£10 10s. ■, afterwards free. Six months, £6 6s .; three
months, £4 4s. ; pathology, both courses, £4 4s. ;
vaccination fee, is.

Dental Carrlcalnm. —Students studying with a
view to the dental diploma can obtain instruction in
the following subjects : Physics, chemistry, anatomy,
physiology, surgery, practice of medicine, and materia
medica. The special dental courses may be obtained
in the Dental School, 15, Dalhousie Street, Glasgow.
Particulars may be had from D. M. Alexander, Esq.,
97. West Regent Street. _

The International Congress on the Protection of
Infant Life will open in Brussels on September 12th,
and will go on till the beginning of next week. It
is the second international congress on the subject,
the first having been held in Paris two years ago. It
was instituted for the prevention of infant mortality,
and the work of the congiess falls under three head¬
ings, namely, those dealing with: (i) Giving advice
to mothers; (2) Encouraging breast-feeding; and
(3) The distribution of milk to those infants for whom
breast-feeding is either impossible or insufficient. The
Organising Committee of the Brussels Congress, how¬
ever, consider the extension of this programme is
necessary, and it i.. proposed to consider the question
of widening the scope of the Congress so as to include
all questions relating to the welfare of infants. The
matter will be brought before the Congress this week,
and there is little doubt that it will meet with a hearty
welcome from the delegates.

There is a serious outbreak of small-pox in Vienna,
and on Saturday 24,632 persons were vaccinated by
public officials, making 106,000 in the last few days.
The police have forbidden public meetings and pro¬
cessions.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Paris, Sept. 8th, 1907.

Obesity.

] Obesity develops frequently after an acute infec-
| tion, or in the course of a chronic infection. Such
; cases have been observed so constantly that Bouchard
affirmed in his statistics that in one-fifth of the cases
an acute affection might be found at the origin of
obesity.

Experimentally, a notable increase in weight can
: be provoked by a toxic infection. It is thus that
Professor Carnot obtained, in more than one instance,
a considerable development by injecting cultures of

■ the bacilli of Eberth into rabbits; their weight more
| than doubled.

Clinically, an embonpoint consecutive to an in-
! fection has been remarked long since, and one of the
j most frequently noted in this respect is typhoid fever •
! post-typhoid obesity is frequently observed during the
convalescence ; a remarkable reaction takes place in
j the tissues, glands, and the different systems; the
' appetite is, on the other hand, almost insatiable.

Obesity is observed also in the course of chronic
suppurations and recently M. Carnot had seen a case
j where the obesity followed chronic renal suppuration.

Even in the course of cancer, where cachexia is the
! rule, the mesentery and the epiploon have been fre-
j quently found loaded w'ith fat.

Among the cases of obesity due to infectious mala
dies, tuberculous and syphilitic obesity take the first
rank.

The relations between obesity and tuberculosis are

■ more frequent than is generally believed; stout
j tuberculous patients are not very rare.

I It is thus that Laennec speaks of cases of tuberculosis
I where the patients maintained their embonpoint; and
j Milcent says that frequently a considerable local
lesion coincides with an otherwise healthy condition,
and even with embonpoint.

Ferrand and Quinquand remarked the facility with
which certain scrofulous patients increased in weight
under treatment. 6

Sarda and Vires speak of tuberculous patients in
whom nothing reveals the pulmonary lesions with which
they are affected. " It is certainly not on their face
that the diagnosis can be read ; they are generally
more or less developed and some really stout.” *

1 Lemoine, in his lectures on fat phthisical patients
I insisted on certain cases of torpid tuberculosis pre-
| senting externally all the appearance of health and
even of embonpoint, and showed how such an aspect
| could lead to an error in prognosis.

These forms were, he said, frequently curable, the
patients belonging more or less to the chlorotic type

Daremberg, on the contrary, says that the embon¬
point is deceptive ; such patients prolong their life
it is true, but hardly ever get well; they are incapable
of consuming an excess of food which poisons them if
overfed.

M. Carnot has seen several cases of obesity provoked
by the infection a few months after an attack of haemop¬
tysis ; frequently, also, under the influence qf over-
feeding and rest, tuberculous patients have been known
to increase more rapidly in weight than normal sub¬
jects.

It would similarly seem that in many agricultural
shows, the fattest animals have been discovered to be
affected with tuberculous ganglions.

Syphilitic obesity sometimes appears at the outset
of the infection, and in a certain number of cases
overfeeding has had some influence in predisposed
subjects, but in the majority of cases the automatic
regulation of nutrition does not act normally on
account of the insufficient functions of the different
glands of secretion genital glands, thyroid body, &c.)

Digitized by GoOgle

CORRESPONDENCE.

Sept, ii, 1907.

294 The Med ical Press

Thus considered, and no matter how their intimate
mechanism acts, obesity on the one hand, emaciation
on the other, should be considered as morbid syndroma,
indicating a trouble in nutrition, derived frequently
from the same causes.

(GERMANY.

Berlin. Sept. 8m. 1907 .

At the Otological Society, Hr. Sonntag showed
Two Cases of Otitic Py.emia.

A man, a:t. 36, who had suffered from pain in the
ear for a fortnight and a rigor twenty-four hours
before. There were granulations and a fistula in
the upper and posterior part of the wall of the auditory
meatus. Temperature 41 C. The opened-up sinus
looked velvety and pulsated. A fortnight later a
secondary plastic operation was performed. Con¬
trary to Voss, of Riga, he did not look upon puncture
of the sinus as free from danger. He had seen the
punctured spot become purulent. ( b ) A man, aet.
24, who had had suppuration of the left ear for a
fortnight and two days ago a rigor with mental dulness
and a yellow tinge of the skin. The meatus was
swollen. No nystagmus. The part was completely
chiselled out. Cholesteatoma. Fistula of the hori¬
zontal semi-circular canal. The sinus, when opened
up, appeared to be collapsed. Opening of the
sinus, which contained a little fluid. The sinus
was bordered on both sides by solid thrombus.
The temperature from that time remained normal,
and a month later a plastic operation was performed.

Neuronal.

(c) Dr. George Dreyfuss, of the University Irrenan-
stalt, Heidelberg, reports his experiences with neuronal
in the Therap. Monatsh. May, 1906. The drug was
given to seventeen patients in 1905, sometimes as a
calmative, when there was great excitement, and
sometimes as a hypnotic, when all other means of
overcoming the sleeplessness failed. The sleep pro¬
duced lasted variously, according to the degree of
excitement or agrypma. Calm and only sleepless
patients generally went to sleep in a quarter to half an
hour after taking the medicine. The sleep was deep
and mostly uninterrupted. Excited patients took a
longer time, one to three hours or even longer before
sleeping, but they frequently quieted down in an
hour. The doses, according to the object aimed at,
varied in amount; 0.5 gm. sufficed in simple cases
of sleeplessness, but 1 gm. was required in obstinate
cases. In cases of excitement, especially those of a
catatonic kind, larger doses had always to be given ;
1.5 gm. as a minimum, 2 gm. as an average, and some¬
times as much as 2.5 gm. These doses were never
exceeded in the twenty-four hours. There were
disagreeable effects in two cases. In one, violent
headache came on the second day ; in another, an
arterio-sclerotic patient, who had been given 2 gm.
of the medicine, it had to be stopped as it caused
headache, mental disturbance and a very marked
rapid and dicrotic pulse. It did not appear to have
any cumulative properties, nor was it observed to
lose its effect. In many patients high doses were
given for three or four weeks together, and the like
effect was produced, whether given in the form of
powder or tablet. In certain control experiments
veronal alone appeared in general to be superior to
neuronal. Chloral was not so certain, whilst trional
was less powerful and the like effect was only obtained
by larger doses (neuronal, 1 to 1.5 gm.; trional, 2 gm.).
Paraldehyde failed completely even in large doses,
in one case in which neuronal was quite successful.

AUSTRIA.

vlMaa, Sept. 8th, 1907 .

Pleiochromic Icterus.

Soucbk in a long article on the origin of urobilin
relates several cases of pleiochromic icterus, which he
recognises as a transformation of the bilirubin into
urobilin. This is an old controversy. Whence comes
the urobilin ? In this case Soucek is in favour of

' the transformation theory from biliverdin and bili-
! rubin.andit may or may not be a normal constituent
j of the urine. Urobilin has the chemical formula of
hjematoidin, but differs in spectroscopical analysis.
1 Others have it that urobilin is only a hydroxid of
bilirubin and can be obtained from the latter by de¬
oxidation, according to Jaffe’s experiments. MacMun,
on the other hand, affirms that there is no identity
existing between urobilin and hydrobilirubin, and
further assures us that there are two urobilins to be
found in the urine, while some authors aver that
frequently no urobilin can be found in perfectly healthy
urine. Here we have a wide divergence of opinion
all based on experiments. MacMun has a febrile
urobilin and a normal urobilin, both bodies having a
similar chemical composition, but differing in their
spectroscopical analysis; in normal urobilin the
absorption line disappears, while in the febrile does it not.
The aether solution of the febrile has two faint lines
near D, while the normal has nothing. From this he
reasons that the product is an aqueous peroxide of a
sulphuric alcoholic haematin solution, which is
identical with normal urobilin. Other experiments
have got yellow, red and brown lines on both sides
of D, which weaken the last theory. Stokvis affirms
that the urobilin is obtained from the bilirubin. Hoppe-
Seyler has it from the haemaglobin. and haematin,
while Nobel believes it is a form of hacmatoporphyrin
Whatever the body may be Soucek found an entire
absence of bilirubin throughout a febrile illness,
while the urobilin reaction was constantly present.
The blood was analysed at the same time and found
to contain bilirubin. This, he thinks, settles the
question that urobilin is nothing more than a trans¬
formation of bilirubin which takes place in the kidneys.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME*

BELFAST.

PuBLi Health. —The report of the Medical Officer
of Health at the last monthly meeting of the Corpora¬
tion showed the lowest death-rate that has been known
in the city for many years, 15.4. That from zymotic
diseases was 1.0, and from chest affections, 5.2. During
the preceding four weeks the cases of cerebro-spinal
meningitis which had been notified, numbered 13, so
that a steady decline in the epidemic goes on. Ery¬
sipelas, which had been rather prevalent lately, was
also declining One case of anthrax occurred. There
are n.w only seven cases of cerebro-spinal meningitis
under treatment at the Purdysburn Fever Hospital.
It appears that the public has got over its dread of
the disease, which was at first fostered by the alarmist
paragraphs in the daily Press, and as case to case in¬
fection is, to say the least, not very obvious, cases are
now kept at home instead of being sent to hospital.

Queen’s College : President’s Annual Report.
—President Hamilton’s annual report, just issued,
shows the College to be in a most flourishing and
sati-factory state. The number of students is high
in all faculties, and the facilities for study, thanks to
the Better Equipment Fund, are greater than they ever
were. Seven assistants have been appointed in various
departments, including Dr. Howard Stevenson, as
assistant to the professor of surgery, and Dr. C. G.
Lowry to the professor of midwifery. Six of the seven
new appointments are filled by old students of the
College, and the President points out that these
appointments confer a double benefit, helping brilliant
young graduates of the school, and encouraging re¬
search and higher education. Twenty years ago the
entire teaching staff of the College numbered just
twenty, and now that number is doubled. The new
laboratories, which are to be opened by Lord Kelvin
at the end of this month, will also add to the teaching
facilities of the College. These have been provided
out of a Treasury grant of ^5,400, with an equal sum
contributed by the Better Equipment Fund, and
bring the number of laboratories in the College up to

Digitized by GoOgle

Se:-t. ii, 1907. CORRESPONDENCE. The M epical Press. 395

eight, all well fitted and convenient for work. A new
scholarship, established by the munificence of Mr.
Robert Mackay Wilson, Fitzwilliam Square, Dublin,
will be much appreciated by medical students, as it
takes the form of a travelling medical scholarship of
the value of £100 per annum.

LETTERS TO THE EDITOR.

THE MEDICAL ASPECT OF DENTAL CARIES
IN CHILDHOOD.

To the Editor of The Medical Press and Circular.

Sir, — I imagine that most physicians have long been
familiar with the fact mentioned by your correspon¬
dent in The Medical Press and Circular of August
28th. that enamel when its development is complete
is incapable of physiological activity. He makes an
assertion, however, which I venture to question,
when he says that the temporary teeth “ can be
influenced only through the mother.” As a matter
of clinical experience I make bold to say that there
is no proof that this is so. on the contrary, there is
much to suggest that the development of the enamel
of the temporary teeth can be influenced very dis¬
tinctly by disease after birth ; and if it were necessary
to quote a dental authority to show that this is possible,
I would refer your correspondent to Tomes, who
says in his “ System of Dental Surgery,” 4th edition,
p. 98. “ The calcification of the temporary teeth
is not so far advanced at the time of birth but that
we might expect them to be influenced by the occur¬
rence of disturbing causes during the first month or
two after birth ”; and on p. 3, ” The temporary
teeth in a nine months’ foetus are partly formed.
The central incisors are calcified through most of the
length of the crown, but the lateral teeth are less
advanced. The terminal points only of the canines
are calcified while the masticating surfaces of the
first temporary molars are completed except the
enamel, which at this stage has not attained to more
than half its thickness, a condition which is common
also to the more anterior teeth.”

Your correspondent seems even to doubt this
possibility of influencing the development of the enamel
of the permanent teeth after birth. It hardly seems
necessary to quote dental authorities to show that
for some years after birth the development of the
enamel of the permanent teeth remains uncompleted,
and is, therefore, capable of being influenced by
disease and safeguarded by' treatment which arrests
the disease. It must be remembered that the mere
fact that there is an outer surface of enamel does not
show that the development of enamel is complete;
the point which I wish [to insist upon is that the
thickness of enamel, upon which largely depends
its effectiveness as a barrier to decay', can be influenced
bv nutritional disease in infancy and, although I
did not say so in the remarks to which your corre¬
spondent refers, I think it is quite possible and likely
that this applies in some degree to the temporary as
well as to the permanent teeth. In conclusion let
me say that none can be more conscious than I am
that an adequate knowledge of dental pathology
can only be obtained by r special study and special
experience such as a physician can hardly hope to
attain ; and if it seems presumptuous in a physician
to criticise the remarks of a dental expert, I do so only
in the hope that clinical medicine may gain fuller
knowledge from the excellent scientific investigations
which so many dental surgeons are making nowadays
on obscure points such as the influence of disease in
early life upon the development of the teeth.

I am, Sir, yours truly',

Geo. F. Still.

114 Harley Street, W., Sept., 2nd, 1907.

THE INEBRIATES’ ACT.

To the Editor of The Medical Press and Circular.

Sir,— All those who are working to combat the evils
which the Inebriates'Act was designed to deal with
will be glad to hear of the announcement made by

1 Canon Horsley in the Times of September 2nd. The
Council of the Church of England Temperance Society
I is asking for a departmental enquiry into tbe working
of the Act, and the value of the various “ cures ” for
the reclamation of alcoholics and “ narcomaniacs,” and
I the Home Secretary has promised to receive a deputa-
| tion on this subject early in the autumn. A depart¬
mental enquiry could easily' be made to expose the
true character of the numerous bogus and fraudulent
drink cures now so extensively advertised. Some of
I these impostures are under the patronage of parsons
and soft-headed philanthropists who ought to know
better. Canon Horsley could, no doubt, easily put
his finger upon some of the former class. An elemen-
! tary knowledge of the psychology and pathology of the
inebriate which any educated man can acquire, is
sufficient to guard one against acceptance of the claims
which the bogus drink-cures put forth ; and the
educated men who support these cures can be only such
as are, in spite of their general culture, ignorant of
science or perhaps scomers of science and of scientific
methods. Inebriety is not always due to one and the
same cause. On the contrary' its causation is always
extremely complex, being made up of many widely
varying physical, mental, and moral factors. To
claim for any drug or combination of drugs the power
to attack and destroy these factors, is to claim to
work miracles ; and when the procedures and remedies
of the miracle-monger are kept secret, and worked
for commercial considerations, no sensible man of the
world, and least of all a medical man of the world,
will have anything whatever to do with them. A
discoverer of a cure for drunkenness by drugs or any
other simple means would rank among the greatest
benefactors of mankind, with Jenner, Pasteur, and
Lister. Wealth would surely be his, and honour—a
monument in every civilised land. It is not con¬
ceivable that any real man of science would for gam
withhold such a boon from suffering humanity, or
would hesitate to place his discovery with full dis¬
closure of its nature in the hands of men of science who
alone are competent to tests its merits. The bogus
drink-cure proprietor forms in truth one class of the
army of medical impostors whose methods call for
investigation by a Royal Commission as advocated
so persistently in the Medical Press. If the trade of
these men did no more than plunder the simple and
suffering it would be bad enough; but the trade is mostLy
pursued with cynical and callous disregard of the
injury to health and the misery it inflicts upon its
victims. It is impossible to believe that if the story
were once publicly told and established by evidence
laws would not be speedily devised to put an end to
this nefarious traffic.

I am, Sir, yours truly.

Sept. 2nd, 1907. " H. S.

THE ANNUAL CATHEDRAL SERVICE OF THE

_ GUILD OF ST. LUKE.

To the Editor of The Medical Press and Circular.

Sir, —May I draw attention to the advertisement
appearing in the present issue of The Medical Press
and Circular respecting the Annual Festival Service
of the Guild of St. Luke, to be held at St. Paul’s
Cathedral on October 22nd, and request that those
who desire to attend will communicate with me as
soon as possible. As we are expecting a large attendance
from the City Companies and others, we are anxious
to allot space as soon as possible.

Claude St. Aubyn-Farrer,
Westboume Park Road, Registrar.

London, VV., Sept. 7th, 1907.

Dr. W. H. Ai.lchin, consulting physician to West¬
minster Hospital, will deliver an introductory address
on the present state of medical education in London
at the opening of the Medical School on October 1st.
On October 4th Sir Samuel Wilks will occupy the
chair at the first meeting of the Guy's Hospital
Physical Society, when Dr. G. A. Gibson is to read
a paper, entitled “ Past and Present. ”

Digitized by GoOgk

_2g6 The Medical Press. NOTICES TO

NOTICES TO
CORRESPONDENTS, ffc-

W* Correspondents requiring a reply in this oolumn are par¬
ticularly requested to make use of a Distinctive Signature or
Initial, and to avoid the practice of signing themselves
“ Reader,” “ Subscriber,” ' Old Subscriber,” etc. Much con¬
fusion will be spared by attention to this rule.

SUBSCRIPTION!.

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C. W.—The extracts you are good enough to send are not the
sort of thing we care for in this journal. They may seem amus¬
ing to a certain class of render, and we should recommend you
to try our contemporary the Winning Pott.

CLINICAL LECTURES.

The following lectures have been received, and are hereby
acknowledged. They will appear in our columns week by week
in the ordinary course: —

Corner. Edwd. M. t B.Se.Lond., M.B.Cantab, F.R.C.S., “ De¬
formities of the Foor Associated with Abduction.”
Heilbronner, M.D., Professor of Medieine in the University of
Utrecht, on “ The Early Diagnosis and Treatment of Pro¬
gressive Paralysis."

Lepine, R. M., Professor of Medicine in the University of
Lyons, on “Uraemic Meningitis."

Morrison, James, M.D.Lond., "Lingering Labour: its Causes
and Treatment.”

Nicholson, H. Oliphnnt, M.D., F.H.C.P., "The Prevention of
Fever in the Puerperium."

Haundby, Robert, M.D.. LL.D. 'Hon.), F.R.C.P.Lond., " The
Sphygnomanometer in Medicine.”

Sinclair, Thomas, M.D., F.R.C.S., "Traumatic Epilepsy Treated
by Operation.”

Stephenson, Sydney, M.B, F.R.C.S., "Congenital Anomalies of
the Eye."

Stqney, R. Atkinson. M.B., B.Ch., F.R.C.8., "Cancer of the
Rectum” (illustrated).

Swan, R. L., F.R.C.S., " Tubercular Diseases of the Knee-
Joint and the Treatment of Kinoval Cavities.”

Tcarsley, Maeleod, F.R.C.S., "Osteosclerosis."

Optic.—W e must say that in our opinion it is hardly con¬
sistent with what is due to your colleagues, to sny nothing of
encouraging unqualified practice, to continue to send prescrip¬
tions for spectacles to opticians who prescribe themselves. Op¬
ticians have shown themselves extremely obstinate and we
believe foolish in asserting their independence in this matter,
and while medical men can get. but cold comfort out of the
law, they can easily and safely combine, and send their patients
for spectacles only to such ethically-practising spectacle-makers
as they can rely on. If the shoemaker sticks to his last, he is
all the more likely to make better shoes.

NOTICE TO HOSPITALS AND COLLEGE DEANS.

The Editor desire* to thank those gentlemen attached to the
various Schools and Hospitals for supplying him with the
information from which the foregoing pages have been composed.
NOTICE TO OUR READERS.

Ab this number is mainly devoted to information necessary for
student* intending to join one or other of the various medical
colleges, and for those who. having passed their curriculum, are
about to enter the ranks of the nrofession, much of the ordinary-
matter which usually fill* our columns is necessarily deferred till
next week.

GRATUITOUS COPIES.

A vert large number of copies of this issue are being sent
gratuitously to all the educational establishments, hospitals,
reading-rooms, club*, and large hotels. In the United Kingdom,
and to a large number in America, India, the Colonies, and on
the Continent; should any of our readers desire to present a
copy to a patient or friend who contemplates sending his son to
a medical school, our publisher will be happy to supply him with
a duplicate free of cost on receipt of address.

Dr. L.—The treatment of multiple warts of the fingers is ns
varied ns most treatments for Omple ailments. Have you tried
lime water? The patient to drink a wineglassful of lime water
with each meal. At any rate it can do no harm, and we
should be interested to hear if you get nnv good results.

R. D. M.—Radium is -till being used medicinally, nnd the
demnnd for its use as a therapeutic agent has led the manage¬
ment of tho Imperial Uranium Works, in St. Joachimsthal,
Bohemia, to construct a special laboratory for the industrial
production of radium compounds. The uranium ores of this
locality contain higher percentages of the clement than any
otl(;'r known deposits. The ores nnd the residues from the
uri^pium extraction have hitherto been treated chiefly at Pnris,
where the method for isolating the minute traces of radium
was perfected by Madame Curie and her husband. There will
b' manifest advantage, in carrying out the extraction at the

CORRESPONDENTS. _ Sept, i i, 1907.

place of origin, in view of the enormous amounts of rock
required for the production of a tiny fragment of a radium salt.
Interesting likewise is the fact that an extensive sanatorium
is being erected in the same locality, where patients can take
baths in the water pumped from the uranium mines. This
water seems to be sufficiently charged with radium compounds
in solution to exert a distinct therapeutio action, and physicians
have already begun to prescribe its use.

Old L. 8 .' A.—The subject of Acropancsfheaia was dealt with
at length in the Medical Press and Circular of April 10th,
1907, in a clinical lecture by Dr. A. T. Whiting. If you refer
to that number you will find all the points on which you
require information discussed.

Devonian.—W ebbed fingers nre always oongenital, and in a
simple case can be easily dealt with, i.e., when the phalanges
nre not united. Simple incision of the web is often followed
by reunion of the web, but a careful plastic opera’ion, under an
ansesthetio, the divided parts being sutured, will generally be
successful.

Bacanntfi.

Durham University College of Medicine.—Demonstrator of Physio¬
logy. Salary, C20U per annum. Application to ProfesMjr
Howden, Durham College of Medicine, Newc.'is’le-upon-Tyne.
(See advt.)

Cambridgeshire, etc.. Asylum —Second Assistant Medical Officer.
Salary, £120 per annum, with board, lodging, and attend¬
ance in the Asylum. Applications to T. Ming rave Francis,
Clerk to the Visitors.

Torbay Hospital, Torquay.—House Surgeon. Salary, £100 per
annum, with residence, board, and washing. Applications
to H. J. Pncke, Secretary.

London Temperance Hospital, Hampstead Road, N.W.—Resident
Medical Officer. Salary, £120 per annum, board, lodging,
nnd washing. Applications to A. W. Bodger. -eoretary.
Gravesend Hospital.—House Surgeon. Salary, £100 per annum,
with board and residence. Applications to A. E. Thomas,
Secretary.

West Herts Infirmary, Hemel Hempstead, Herts.—House Surgeon.
Salary, £100 per annum, with rooms, board, and washing
found. Applications to the Rev. W. T. T. Drake, Boro'
Gate, St. Albans.

Newcastle-upon-Tyne City Hospital for Infectious Diaeases.—
Resident Medical Assistant. Salary, £104 per annum, with
board, lodging, ete. Applications to the Medical Officer of
Health, Health Department, Town Hall, N< vrcastle-upo'n-
Tyne.

Jlppointmemt

Dewar, J., M.B., B.S.Aberd.. Certifying Surgeon under the
Factory nnd Workshop Act for the St. Margaret's Hope
District of the county of Orkney.

Fi.itcroft, T. E-, L.R.C.P.Edin.. L.F.P.S.Glasg., Certifying
Surgeon under the Factory and Workshop Act for the North
Bolton District of the county of Lancaster.

Glabsinoton, Charles W., ■ M.R.C.S.Eng., L.D.S.. Dental Sur¬
geon to the Duke of York's Koval Military School. Chelsea.
Gunn. A. B. M.. M.B.. M.S.Aberd., Certifying Surgeon under
the Factory and Workshop Act for the West ray District of
the county of Orkney.

Lawrt, Richard Cooer. L.R.C.P.Lond., M.R.C.S.Eng , Medical
Officer to the No. 1 District and Workhouse, IVnxancc.
Lawson, Thomas Cornei.ii'b, M.R.C.S.Eng., 1. S.A., District
Medical Officer by the Stratton Union, Cornwull.

Scott, Frederick R., M.B., B.S.Durh., Medical officer of Tyne¬
mouth Workhouse.

Smith, G. McCall. M.B.. B.S.Edin., Certifying Surgeon under
the Factory and Workshop Act for the Strathmiglo District
of the county of Fife.

births.

Carr.—O n Sept. 3rd., at Mowmacre, Chesterton, Cambridge, to
Dr. nnd Mrs. Frank Carr, a son.

CorfiE i,i>.—On Sept. 4th. at Field View, Upper Tooting, the
wife of Edward Carrnthers Corfleld, M.R.C.S.Eng., L.R.C.P.
Hnd L.S.A.Lond.. of a »on.

Drew.—O n Sept. 3rd. the wife of Douglas Drew, B.S., F.R.C.S..
of a dnughtcr.

Furmvai.e.—O n Sept, tith, the wife of Captain C. H. Furnivale,
R.A.M.C.. of a Mm.

WarriaciCB.

Bruce—Bowden.— On Sept. 3rd, nt St. John’s Church, Dum¬
fries, Lewis Campbell Bruce, M.D.. F.R.C.P.K., second sou
of Major-General A. A. Bruce, retired Bengal Staff Corps,
to Caroline Desborough. elder daughter of the I*te Major
H. G. Bowden, of the 22ml Foot.

Daniel—Baptv. —On Sept, tith, at Epsom Parish Church. Alfred
Wilson Daniel. M.D., son of the late Dr. W. C. Daniel, of
The Silver Birches, Epsom, to Lent Gertrude Lucie Lee
Bap'y, daughter of Samuel Lee Baptv, of Birp>.ughum.

Scathe.

Chaplin. —On Sept. 3rd, nt St. Leonards-on-Sea, Sophia Caroline,
widow of the late Thomas Chaplin. M.D., of -'erusalem.
Clark. —On Sept. 4th. at Rose Hill. Dorking. Chari-6 Mackinnon
Clark, M.D., L.R.C.P., M.R.C.S., aged forty-two.

Digitized by Google

The Medical Press and Circular.

"SALUS POPULI SUFREMA LEX.*

Vol. CXXXV. WEDNESDAY, SEPT. 18, 1907. No. 12

Notes and Comments.

The Board of Education have
fi«ard>f Edaca- certainly got to work,with a celerity
tloa aad Its unprecedented in the annals
Medical Staff, of Government departments, in
their preparations for adminis¬
tering the Education (Administrative Provisions)
Act. Indeed, there can be no doubt that they
had their plans and arrangements well in hand
before the Bill passed. In selecting Dr. George
Newman for the post of Chief Medical Adviser to
the Board, Mr. McKenna has made a wise selec¬
tion. His field of choice was extremely wide, but
we fancy it will be generally agreed that Dr.
Newman’s attainments, experience, and industry
in public health and bacteriological work combine
to fit him admirably for his new duties. Dr.
Eicholz, who has been in the office for many
years, will, of course, form one of Dr. Newman’s
staff, and the Board, it is understood, are anxious
to get to work as quickly as possible with what
material they have. In advising local authorities
how best to proceed with the new task, which it is
hoped they will all undertake in earnest, it is ex¬
ceedingly important, if the medical inspection of
school-children is not to disappoint lay ad¬
ministrators, that the more practical side of the
work should be brought forward at first, leaving
the more academic phases for subsequent con¬
sideration. It is difficult to raise popular en¬
thusiasm over minute anthropometric measure¬
ments, whereas most people can appreciate
the value of ridding children of adenoids or pro¬
viding them with glasses. To such more tangible
aspects of the problem it would be better to pay
attention at first.

If the old saying de minimis non
Deceased curat lex embalms a salutary
Wife’* Sister. principle of law, a still more
obvious if less salutary one which
shows itself at times, is that people
care a great deal more for little laws than they
do for great ones. Out of the mass of important
legislation passed last session the only Act which
has touched the public imagination or fired the
pens of the autumn correspondents of the news¬
papers is the Deceased Wife’s Sister Act. Now
the question dealt with in that measure is trifling
in the extreme. To begin with, women being
longer-lived than men, the number of widowers
comparatively speaking is small, and of those the
number who re-marry is even less, and out of the
remainder the ones who were so happy with their
first wife as to wish to embrace another of the
same family might be counted as single spies

rather than in battalions. As the whole number
of such in the country must have been waiting
some time to have their marriages legalised,
and as up to date only two couples have
given notice of their intention to avail them¬
selves of the privilege it really is a case of
de minimis. However, an ecclesiastical point
being touched, the whole country is divided
into two camps waging religious war with all
the fervour of Turks and Crusaders, and any
stick being good enough to beat an infidel
with, the anti-aunt champions have not
failed even to invoke the physiological argu¬
ment. This seems to run as follows : That on
the una caro principle, if a man marries his sister-
in-law and has children they will be liable to all
sorts of degenerations and abnormalities.

If the argument is to be pleaded
Her seriously, we should demand

Physiological some sort of evidential basis,
Iflunsalty. but, needless to say, none is forth¬
coming. As in all " anti ” cam¬
paigns, assertion and asseveration are more
important that fact. Now presumably the
greatest blessing about the Deceased Wife’s
Sister Act is that it will save an amount of valu¬
able time every session, and that it has transferred
the cock-pit of the dispute from the floor of the
House to the lean columns of the autumn Press.
But as to physiological argument, the “ one flesh ”
principle will not hold water for a moment, what¬
ever religious or even moral support it may have.
Most practitioners have seen the children of first
cousins presenting some of the minor if not the
major stigmata of degeneration, and these no
doubt are the result of consanguinity, although
marriage in that degree has always been allowed
by both Church and State. The prohibition of
cousin-marriages is a matter which, if it came to
the point, would derive an appreciable amount
of physiological support. The suggestion, how¬
ever, that a husband and wife in course of time
acquire some of each other’s characteristics, and
that a husband, by marrying a sister-in-law, can
reproduce those characteristics with added force
in the offspring, is the most fantastic nonsense
that good people in want of an argument ever
strained out of books they do not understand.
Medical men, as such, having no interest in the
question but a physiological one, can nevertheless,
assure the disputants that they had better confine
their polemics within the bounds of Statute and
Canon law, and leave alone the science of heredity
against which there is such a multitude of real

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Google

LEADING ARTICLE.

Sept. i 8,* 1907-

298 The Medical Press.

offences in civilised society that there is no need
to import fanciful ones.

Strange things happen in the
Dentistry calling of medicine, but if the
■ la Daily Mail is to be believed, still

“ Daily Mall.” stranger ones happen in the
practice of dentistry. It is as¬
serted by the New York correspondent of that
journal that one George Davis, aged thirty-eight,
who died recently in the County Hospital of
Chicago, was diagnosed to have suffered from a
broken neck. The symptoms complained of
during life were pain in the neck and paralysis of
the right arm, and they apparently came on after
a visit to the dentist’s. Davis had called on that
practitioner with a view to having a painful tooth
removed, and the molar being firmly set, the
dentist had used a series of jerks to loosen it.
The physicians who saw the patient subsequently
believed that the neck had been dislocated by this
treatment, and death occurred in due course.
The account adds : “ The name of the dentist is
not known,” and one is quite prepared to believe
this modern Hercules will remain incognito.
Indeed, it would be a pity if he did not, for he
would be sure to dispute the impeachment, and
if he was believed, the beautiful story with its
pregnant suggestiveness would be spoiled. Let
us take the innominate dentist on trust, and add
this catastrophe to the list of surgical dangers
attending minor operations, for its like we shall
never look on again. What greater lesson could
we have of the pitfalls that attend apparently
simple operations or of the frailty of cervical
vertebrae ?

There are so many hidden dan-
Hyfieoic gers to health in this world we
Sheets. have the misfortune to live in,
that it is really questionable if
some penal restriction should not
be applied to scaremongers. These gentlemen go
about trying to find some new horror wherewith
to make our flesh creep, and the amount of in¬
genuity they expend in the pursuit of their avoca¬
tion is astonishing. The last, and we imagine
the silliest, of these menaces to health has been
discovered by one Mr. Shuttleworth-Brown,
inventor of the new hygienic bed-sheet. We all
know Mark Twain’s calculation showing the
tremendous risk run by people who sleep in beds,
but, apparently, the hygienic sheet would reduce
this danger to the comparative security enjoyed
by people who travel in submarines or dirigible
balloons. The real danger of sleeping in bed
consists in the erroneous notion possessed by
servants that sheets should be turned. Of
course, nothing of the sort should be done. If
the sheet is turned, the particles of epithelium and
so on that are rubbed off the skin get into the
bedding, whereas if the sheet is never turned the
epthelium remains where it was. Consequently,
Mr. Shuttleworth-Brown has presented to the,
world his new sheets, which have a tuck in them
so that people may tell whether they have been
turned or not. So that any servant who here¬
after turns a sheet will have short shrift and no
benefit of clergy. How the new hygienic sheet
will catch on amongst those who prefer extravagant
idiocy, we cannot say, but we should imagine that
a sheet that would not wash would have an even
better chance of popularity among them. The

drivelling folly that is perpetrated under the name
of hygiene is enough to make angels weep and
all sensible people shudder at the very mention
of the word.

Wisdom is justified of her children,
Manifestations but since the inauguration of the
of era of manifestoes, many of the

Wisdom. children of light seem to have

lost touch with their notion of the
eternal fitness of things. Or is it perhaps that
they have only lost touch with their sense of
humour ? Drink having been manifestoed from
two points of view, it is the turn of food. The
week before last we published a strange and naif
document of a pro-vegetarian tint, and this week
it is our privilege to give publicity to another
ingenuous expression of opinion on a similar
subject. The signatories of the latter draw atten¬
tion to the interesting fact that “ insufficient and
improper food is a prominent factor in the causes
to which degenerative tendencies might be as¬
cribed.” Surely these gentlemen might be a
little bolder and omit the subjunctive. We
fancy there would be found few to quarrel with
them if they took their courage in both their
hands and asserted point blank that insufficient
and improper food does actually produce degenera¬
tive tendencies. Sam Weller, when he realised
Mr. Pickwick’s soft-heartedness, exclaimed in
admiration that his master’s heart had been bom
later than his body, and when we read this latest
of manifestoes we begin to wonder if signatories’
hearts are not similarly afflicted with an excess of
juvenility. Is it really worth while to appeal to
the ” Lord Mayors and Mayors of London and of
other cities and towns, all municipal authorities,
and other good folk, to direct attention to this
important subject ? ” In a word, might it not be
taken for granted that if the people sin in eating
insufficient and improper food, they probably do
so not so much through ignorance as that either
they have not enough money to buy sufficient
food, or that they have too much money and
so can afford improper food ? At any rate, we
would venture to throw out the suggestion for
what it is worth.

LEADING ARTICLE.

A MEDICAL DEPARTMENT IN THE BOARD
OF EDUCATION.

The gradual extension of the scientific method
in the working of national administration is a
process which, though at times slow and halting,
may be regarded nevertheless as inevitable. So
far as State education is concerned it is oaly
within the last few years that the greatness-
and complexity of the health problems involved
in that system have been recognised. At the
present moment these questions are engaging
the attention of “ experts,” medical, sociological,
educational and political, in all the nations. Clearly,
the subject is so far only partly explored, and
investigators are faced with years of patient
labour before facts can be properly ascertained, and
the kaleidoscope of school life reduced to a
plain presentation of cause and effect capable
of statement in the form of a general law. In
our own country it is reassuring to find that
we'are taking steps to bring ourselves up to the

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Sept. 18, 1907.

CURRENT TOPICS.

The Medical Press. 299

level of the sanitary standards enforced in the
schools of other civilised nations. Of all the
social measures passed by the Government
during the Parliamentary Session that has recently
come to a close, there is probably not one of
greater and further-reaching importance than the
Education (Administrative Provisions) Act,
whereby provision is made for the compulsory
medical inspection of children in elementary
schools, and power is given to local authorities
to make arrangements for medical treatment, as
well as to establish what are known as play
centres and vacation schools. It is now officially
announced that the Board of Education have
decided to establish a Medical Department for
the purpose of giving them advice and assistance
in the discharge of the new duties imposed by the
above-mentioned Act. The chief duties of the
Board in this direction will consist in advising
and supervising local education authorities as to
the manner and degree in which those authorities
carry out this medical inspection; in giving
such directions as may be necessary regarding
the frequency and method of such inspection in
particular areas, and in considering and sanction¬
ing such arrangements as may be proposed under
the Act by individual authorities for attending
to the health and physical condition of the
children. The Board will also collect and collate
the records and reports made by the authorities
in the process of carrying out the new duties
imposed by the Act, and will issue an official
annual report on the subject.

The national importance of this new departure
it is hard to over-estimate. It provides in some
sort a guarantee that in future the State will
discharge the duty of safeguarding the health
of the individual child. At length the voice of
the reformer has carried conviction to the legis¬
lature, and in future the halt and the maimed,
the crippled and the defectives of all kinds will
be carefully tended from the first day of their
entrance into the elementary schools. It follows
infallibly that such a work carried out system¬
atically and scientifically in the schools must
go far in stemming the unnecessary waste of health
and life that is steadily exhausting the vitality
of the nation. It is obvious that a great task
lies before such a Medical Department as that
now added to the Board of Education. The
special science it is called upon to administer
is still in its infancy, and a suitable administrative
machinery will have to be created. We under¬
stand that the precise details of the organisation
and personnel of the new Department have not
yet been determined. At the same time we are
glad to hear, on good authority, that the work
will be mainly that of a central controlling
body, leaving wide powers of individual action
to local authorities. Meanwhile, the President
of the Board of Education has appointed Dr.
George Newman, the well-known Medical Officer
of Health of the Metropolitan Borough of Finsbury,
to be Chief Medical Officer of the Board. He
has an able lieutenant in the person of Dr. Alfred
Eicholz, who has for nine years been on the

Board’s staff as Medical Inspector of Schools.
It is further understood that the Board of Educa¬
tion will issue shortly to the local education
authorities a circular setting forth their new
duties in the matter of the medical inspection
of school children. In conclusion we may re¬
iterate our opinion that the creation of the new
Medical Department marks one of the most
important departures in public health that have
been adopted by the British Government.

CURRENT TOPICS.

An Imperial Vaccinationist.

The news that an extensive smallpox epidemic
has broken out at Vienna naturally raises some
sort of wonder that in the twentieth century
it is possible for such a thing to occur in a civilised
country. It is a simple scientific proposition
which asserts that any community protected by
vaccination and re-vaccination has no need to
fear the inroads of smallpox. Nor is it less
self-evident that the terribly fatal infection of
that malady runs riot when introduced into a
population partially or wholly unprotected
by vaccination. From these premises it follows
that the Viennese, being seriously invaded by small¬
pox, must be inefficiently protected by vaccination.
Precisely the same inference might have been
made upon equally infallible grounds when London
was ravaged by smallpox some years ago, when the
disease picked out and decimated the un¬
vaccinated population. Yet it is this vulnerable
material that the anti-vaccinationist, in his blind
fatuousness seeks to multiply, regardless of the
deadly peril to which he is thereby exposing
his countrymen. Were anti-vaccinationists
to have their way the population of the United
Kingdom would soon be reduced to the
helpless state of a tribe of South Sea
Islanders in face of an outbreak of smallpox.
So far as orthodox medicine is concerned
in Vienna, it has found a staunch supporter
in the person of the Emperor Francis Joseph,
At the advanced age of 77 years his Majesty was,
naturally, at first somewhat loth to follow the
advice of his medical advisers, but later
allowed himself to be vaccinated. This act,
simple in itself, is worthy of being recorded as
characteristic of a king, who by a life of self-
sacrifice and resolution, has raised his kingdom to
a first rank among the nations of the world. Nor
do we doubt that under similar circumstances
our own countrymen would find themselves
stimulated in no less a degree by kingly example.

An Echo of a Famous Manifesto.

Some months ago the wonder of the community
was excited by an extraordinary manifesto in
favour of alcohol, signed by a number of prominent
medical men and published in the form of a letter
by a prominent medical journal. That document
was followed by a counter-manifesto from The
Medical Press and Circular, signed also by
various distinguished men in the profession, and
stating that alcohol was unnecessary to mankind

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300 The Medical Press.

CURRENT TOPICS.

Sept. 18, 190 7 -

under ordinary conditions, while at the same
time it had a restricted field of usefulness as a
medicine. The points thus raised were taken up
widely by the general Press, and have since been
followed up with unremitting energy by the
advocates of total abstinence. While there can
be no question as to the absolute bona fides of
those who signed the original manifesto, there is
some reason to suspect that they have been made
in some obscure way the catspawsfor those interests
on the commercial side of alcohol. At any rate,
it has been often reported that their manifesto
has been circulated by societies devoted to the
brewing and distilling trades. The unwisdom_of
signing any public declaration of the kind is shown
by the latest attack upon its character. Last
week a lecturer in Birmingham is reported to have
said that he had obtained the shareholders’ lists
of a number of companies and from a perusal of
them he had discovered that three of the medical
signatories of the original company held brewery
shares. Although the gentleman in question, Mr.
Tennyson Smith, made his statment to a public
audience, we cannot but think he is labouring
under a misconception of some kind. The in¬
cident, however, shows the extreme caution that
should be exercised by any member of the medical
profession who is invited to sign declarations of
faith that may possibly be appropriated by un¬
scrupulous persons for private ends.

Economical Poor-Law Dentistry.

The boarding-out system applied to Poor Law
children, excellent in itself, nevertheless requires
constant supervision to prevent abuses. At
Bristol, the hemes in connection with boarded-out
children have been reported upon by Dr. Fuller,
the Local Government Board Inspector. The
portion of his report dealing with dental matters
deserves careful attention. He found that the
teeth of many children were in a neglected con¬
dition, that carious teeth were left unheeded,
that extractions were unnecessarily frequent,
and that no provision was made for scaling the
teeth. This state of affairs, the Inspector re¬
marks, is hardly to be wondered at when the
contract with the dentist is examined; for it
can hardly be possible to ensure proper stopping
at one shilling per tooth, especially when it is
noted that the stopping is to be done with gold
amalgam. In view of this report the Bristol
Guardians have arranged for a routine examination
of the children’s teeth once every three months.
The necessity of reporting adversely upon con¬
tracts of this nature could possibly be avoided
were a more rigorous examination of the terms
of such agreements carefully made by the
Local Government Board in the first instance.
Bristol has a good record as regards Poor-Law
administration, and in this instance has shown
a commendable desire to carry out its duties
conscientiously. u

Proposed Fublic Health Parliament.

The activity shown nowadays in the various
departments of public health science is no less con¬

spicuous than it is unflagging. Hardly have we
settled down after the recent Public Health and
School Hygiene Congresses than we are faced
with another excellent enterprise of a similar
complexion. The proposal came in the first
place from Dr. Armstrong, the well-known medical
officer of health for Newcastle-upon-Tyne. His
original idea was to summon a national congress
to frame legislative suggestions for the con¬
sideration of Parliament with regard to the
scourge of tuberculosis. From that nucleus
the scheme has grown so as to include other urgent
problems, for instance, infant mortality, milk,
and meat supplies, the housing of the masses,
the drink problem, the disposal of sewage, and so
on. Dr. Armstrong suggests that delegates
should be elected by constituted authorities
on a basis of population, that they should meet
in London as a representative Parliament, and
frame measures for the guidance of the national
Parliament at Westminster. The suggestion is
altogether admirable and should the financial
and other difficulties of organisation be satis¬
factorily surmounted, there is every prospect
of its adding greatly to the establishment of
public health as one of the chief factors in the

world’s progress. -

The Emotional Theory of Infection.

Lady Carlisle is an Englishwoman of whose
kind-heartedness and fine philanthropy we may as
a nation well be proud. Her attitude as regards
infectious diseases, however, is one which, although
inspired by motives of the highest and purest
nature, are nevertheless, in our opinion, so pre¬
judicial to the public interest that we venture to
offer some sort of gentle remonstrance. Recently
the Malton Rural District Council complained that
infection was carried by poor children brought into
their district by charitable agencies from Leeds and
Bradford. Lady Carlisle has written to the Leeds
Mercury a letter in which she practically declares
her belief that there is no truth in the u infection
scare.” She draws a vivid picture of the joy of “ the
little ones as they ramble to and fro during the
sunny summer days, gathering up stores of health
and good spirits, and measuring in their quick little
town brains visions of beauty,” and so on. That is
all very well, but the mere expression of Lady
Carlisle’s disbelief in infection does not lessen the
virulence of the germs of diphtheria, measles,
whooping-cough, tuberculosis, and so on, that are
conveyed into “ the cottage homes of this beautiful
district" (Malton), by little infected town bodies.
Surely the modern doctrine of the responsibility
which forbids the individual to injure others by
the spread of personal contagion justifies the atti¬
tude of the Malton Council. If poor children are to
be imported thither from Leeds and Bradford, then
it is imperative on those who send them to ascertain
that they are free from infectious disease. The
fatalism of the poor is a great obstacle in the way
of preventing the spread of infectious diseases, but,
happily, educated persons, as a rule, are alive to
the scientific aspects of prevention.

Chicago in England.

There were many people who, at the time or
the revelation of the Chicago horrors a year of
two ago, had more than a suspicion that, if all

Google

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Sept. 18. 1907.

PERSONAL.

The Medical Press. 3 01

were known, the conditions in many London
factories were not such as to allow of our adopting
a very superior air toward our American cousins.
It is always much easier, however, to express
indignation at atrocities far away than to search
out injustices in the next street. A report
recently issued by the Industrial Law Committee,
though it does not make any sensational revela¬
tions such as came from Chicago, nevertheless
shows plainly to what tyranny women and girls
employed in the smaller factories of London
are liable to be subjected. It is true that the
Factory Acts have done much for their protection,
but the great difficulty is to bring the law to bear
on a particular injustice. Inspectors are not
ubiquitous, and employers are often adept in
evading the law. A girl who draws the attention
of the inspector to a breach of the law is almost
certain, directly or indirectly, to lose her employ¬
ment. Several cases of this sort are quoted.
Particulars, too, of a shocking nature are giveu
as to the conditions under which many of these
girls in the East End have to labour. In a box
factory, seventy girls work in a varnishing room
whose windows are never opened for fear of dust.
In ^dressmakers’ shops the hands may have to
work from early morning till late in the afternoon
in rooms unventilated and unheated, without,
for seven or eight hours at a stretch, any break
for meals. These are the kind of cases which
the Industrial Law Committee investigate, and
from their report it is evident that they are at no
loss for material on which to exercise themselves.

Mr. Haffkine and India.

We are very glad to see from a leading article
in The Times of September 7 th that that
journal definitely espouses the cause of Mr.
Haffkine. In The Medical Press and
Circular, ammg other journals, the injustice
done to that eminent scientist has been the subject
of strong protest, and we warmly welcome the
strong influence of The Times on the same side.
We agree with our contemporary that the Indian
Government had a difficult decision to make and
that they were bound to attach great weight
to the advice of the experts, but now that it has
been shown by the clearest evidence available
that Mr. Haffkine was in no way responsible for
the unhappy Mulkowal incident, the least that
can be expected is that Mr. Haffkine shall be
reinstated in his old post. It is less than justice
to offer him, as Mr. Morley has told us the Govern¬
ment have done, an indefinite engagement carrying
no specified status, for Mr. Haffkine might find
himself in some invidious position from which
he could not easily extricate himself if he accepted
it. If a mistake has been made—and even the
most official mind must admit that such has
been the case—surely only complete reparation
can repair the harm that has been done. We
can hardly believe that the Government of India
intend indefinitely to stiffen their backs, but if
they do, other means must be employed to show
that instructed public opinion in this country
cannot be denied its right of seeing that justice
is done in the public services.

PERSONAL.

The King has been pleased to give and grant unto
Bryden Glendining, Esq., M.B., Physician in
attendance on her Majesty the Queen of Spain, his
Majesty’s Royal licence and authority that he may
accept and wear the Insignia of Caballero of the Order
of Carlos III., conferred upon him by his Majesty the
King of Spain, in recognition of valuable services

rendered by him. -

It is expected that the new buildings of the Royal
Army Medical College in London, now nearly arrived
at completion, will shortly be opened by H.M. The

King. -

Dr. J. T. Wilson was president of the Congress of
the Sanitary Association held in Aberdeen, and de¬
livered the opening address.

Mr. Alfred H. Tubby takes the chair at the dinner
of the Westminster Hospital Medical School on

October 3rd. -

Dr. Alfred Eicholz has been appointed to the
staff of the new medical department of the Board of
Education.

Captain W. H. S. Nickerson, V.C., M.B., R.A.M.C..
has been appointed Sanitary Officer of the Northern
Command.

Sir Herbert M. Ellis, Director-General of the
Medical Department of the Royal Navy, will preside
at the St. George’s Hospital dinner on October 1st.

Major Ronald Ross, F.R.S., Professor of Tropical
Medicine at Liverpool University, will distribute the
prizes at the Opening of the Leeds Medical School
on October 1st.

Sir Almroth Wright delivered the inaugural
lecture of the post-graduate medical classes at the
Royal Infirmary, Glasgow, his subject being ‘‘The
Principles of Vaccine-Therapy.”

Mr. J. C. McWalter, M.A., F.F.P. & S.Glas., M.D.
Brux., D.P.H., Barrister-at-law, has been appointed
Examiner in Medical Jurisprudence to the Apothe¬
caries’ Hall.

Dr. George Newman, F.R.S.E., D.P.H., Medical
Officer of Health for Finsbury, has been appointed
Chief Medical Officer to the Board of Education.

The long-service medal has been awarded to Surgeon-
Major Ernest W. Barnes, of Liverpool; a well-earned
recognition of his long and energetic connection with
the volunteer force.

The Royal Commission on Mines have appointed
Dr. A. E. Boycott, M.D., of the Lister Institute of
Preventive Medicine and Guy’s Hospital, to make an
investigation with a view to determining whether
there are any indications of the disease known as
ankylostomiasis (miner’s worm) in coal mines in
Great Britain.

On October 4th, Sir Samuel Wilks will occupy the
chair at the first meeting of the Guy’s Hospital Physical
Society, at the opening of the session, when Dr. G. A.
Gibson is to read a paper, entitled “ Past and Present.”

It is notified in the Gazette that the King has
nominated Mr. David Caldwell McVail, M B., to be,
for a further period of five years from October 28th,
1907, a member of the General Council of Medical
Education and Registration of the United Kingdom,

for Scotland. -

Mr. James Burdett Moxon, of Brigg, Lincolnshire,
surgeon, one of the oldest medical practitioners in
England, who died at the great age of 95, left estate
of the gross value of £1,113 ns. 9d., of which
£1,095 ns. 8d. is net personalty.

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302 The Medical Press.

CLINICAL LECTURE.

Sept. 18, 1907.

A Clinical Lecture

ON

CANCER OF THE RECTUM, (a)

By R. fATKINSON STONEY, M.R, B.Ch., F.R.G&,

Surgeon to the Royal City cf Dublin Hospital; Lecturer on Surgery at the Royal Medical Services

School, &c.

I have chosen this subject for lecture this these wards within the last few months and as
morning for two reasons: first, the rectum is they all show some points of special interest I

one of the commonest positions in the body to be shall commence by briefly recalling to your re-

attacked by cancer ; secondly, this is one of the membrance the main facts of these cases,
forms of cancer which frequently remains un- Case I.—R. R. ; male, jet. 75, was admitted to
recognised till late, and this in spite of the fact this hospital on November 8t’h, 1905, suffering

that probably at least ninety per cent, of these from a tumour of the rectum. He gave a history

growths are palpable by the finger examining | of pain in the back, increased by defecation and

Specimen (actual size) frcm Case III. The rectum with the anal end uppermost has
been opened to show the large cauliflower-like growth on the posterior wall.

the rectum, even at an early stage. I hope before
I have finished this morning to explain why this
disease is so often overlooked for a long time,
and to put you on your guard, so that you may
make an early diagnosis in these cases.

We have had three cases of rectal cancer in

(a) Delivered at the 1 oyal City of Dublin Hospital on Thursday,
December I3tb, 1906.

difficulty in getting his bowels to move, with
occasional traces of blood in his motions for some
months. On rectal examination a large, irregular
ulcer with thickened, hard, everted edges was
felt on the posterior wall of the rectum, within
about two inches of the anus. It was just possible
to pass the finger to the upper limit of this ulcer.
An operation was performed on November 25th,

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Sept. 18, 1907.

CLINICAL LECTURE.

The Medical Peess. 303

and the rectum with the growth was removed.
It was found impossible to bring the upper end
of the rectum to the anus, so a sacral anus was
made, and the whole of the lower part of the
bowel removed. The patient was discharged
from the hospital a month later with the wound
completely healed.

Case II.—D. B., act. 48, male, was admitted
on March 18th, 1906, complaining of piles,
alternating constipation and diarrhoea and pain
in the region of the sacrum. On rectal examin¬
ation a large mass was felt filling the upper part
of the pelvis but no growth could be felt in the
rectum. The following day the patient was
examined under an anaesthetic with the electric
sigmoidoscope; after it had been passed for
about 6 inches without any growth coming into
view, the patient coughed and the instrument
appeared to move suddenly upwards, but no
growth was visible ; he was then returned to bed.
Late that night the patient developed symptoms
of commencing general peritonitis, and on open¬
ing the abdomen early the next morning diffuse
peritonitis was found, evidently starting from a
large foul-smelling pelvic abscess which had
burst, probably during the examination on the
previous morning ; the adhesions in the pelvis
were so numerous and complicated that it was
difficult to make out where the abscess came
from, but it was evidently in direct connection
with the bowel, and there appeared to be a
growth of the upper part of the rectum. The
whole length of the colon was packed with scybalae,
so a colostomy was performed and the abdomen
washed out, and the pelvic abscess drained.
The patient recovered from the peritonitis, but
though he lingered for a month, the pelvic abscess
continued discharging, and he died on April 20th.
At the autopsy the whole pelvis was full of
stinking pus, there was a large malignant growth
of the upper part of the rectum, and a communi¬
cation between the lumen of the bowel above the
growth and the abscess cavity.

The third case you see before you, the patient,
A. R., male, set. 58, was sent up to the medical
wards of this hospital from the country on
October 3rd, 1906, supposed to be suffering from
piles and some liver trouble. On examination
after admission he was found to have a growth
in his rectum, and was at once transferred to the
surgical wards. On rectal examination a very
large cauliflower-like growth was felt on the
posterior wall of the rectum within three quarters
of an inch of the anus, the finger could not reach
its upper border, and the growth appeared fixed.
On October 6th a colostomy was performed, and
the rectum and pelvis examined at the same
time. Xo enlarged glands could be felt, and
the growth did not appear to have extended
beyond the rectum. The intestine was opened
on the 10th, and on the 27th the rectum was
removed. The wound is now practically healed,
and those of you who saw the patient on ad¬
mission will notice the great improvement in
his appearance, he has put on over a stone since
the last operation, and is almost ready to return
home, (a)

These three cases illustrate in a very beautiful

(a) The patient returned to tbe country on January 3rd, 1907, with
Itae wound completely healed, only a very small quantity of mucous
coming daily from the lower end of the rectum which opens In the
sacral region, and an artificial anus In the Inguinal region over which
he has some control.

j manner the three types of cancer of the rectum
; proper which may occur.

| (i) The ulcerous variety—this commences as a

! nodular growth or plaque involving part only
of the circumference of the intestine. Sooner or
later this breaks down and forms a typical,
malignant ulcer with everted, thickened and
hard edges, it usually grows slowly, and may
not produce marked symptoms of obstruction.
The first case was a very good example of this
form.

(2) The cauliflower variety—this also starts
as a nodular growth, but it extends fairly rapidly
and finally forms a large, rough, irregular, cauli¬
flower-like growth projecting into the lumen of
the rectum, but it does not tend to ulcerate to
any great extent; it may produce marked
symptoms of obstruction. The third case was a
very good example of this form, and here you
see the actual specimen. (See illustration). Both
of these two types usually grow from the posterior
wall of the rectum.

(3) The annular variety tends early to involve
the whole circumference of the gut, and as a
rule ulcerates early, and by its contraction causes
a well-marked constriction of the canal, giving
rise to distinct obstructive symptoms, and some¬
times leading to a perforation of the dilated
bowel above. The second case more nearly
approached this variety than either of the other
two.

The symptoms of cancer of the rectum are
often extremely vague, and are frequently put
down to piles in the earlier stages. Pain is usually
one of the first symptoms; at first it may be felt
only during and after defecation, or there may
be merely a feeling of weight and dragging in the
lower part of the back, and after defecation the
patient may feel that there is still something
more to be passed. Later, when the growth
ulcerates, there may be some blood with the
motions; this is very rarely copious, but is, as a
rule, only a streaking or staining of the motion
with blood. When the tumour commences to
cause obstruction, a very definite train of symp¬
toms arises—there is tenesmus and straining and
alternating constipation and diarrhoea. The latter
is a spurious diarrhoea, and consists of fecal-
stained mucus ; it is brought about as follows :—
the growth causing obstruction leads to a reten¬
tion of the feces above the stricture, this leads to
irritation of the mucous membrane with an
outpouring of mucus, which collects and dissolves
some of the hard feces, and then this fecal-
stained mucus trickles through the stricture.
Haemorrhoids may be caused by the pressure of
the tumour and the straining it leads to. In
fact the onset of haemorrhoids after the age of
40 or 50, with the passage of small quantities of
blood, with alternating constipation and diarrhoea,
may be looked upon as pathognomonic of cancer
of the rectum, and should always lead to im¬
mediate digital examination of the rectum. This
digital examination is the final test to which all
suspected cases must be submitted, and as I
mentioned before in a very large proportion of
the cases the growth can be felt. It may also
be seen by the proctoscope or sigmoidoscope. If
the growth attacks the anterior wall of the rectum
it may spread to the bladder and give rise to
further symptoms, pain on micturition, discharge
from the rectum whenever the bladder is emptied,
or finally to a recto-vesical fistula. In the second

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304 The Medical Press.

CLINICAL LECTURE.

Sept. x8 , 1907

case the patient met me one day in the street
and said he must get something done, as he was
suffering from piles. I advised him to come into
hospital at once ; but I did not see or hear of him
again for over six months, when he told me the
piles were worse, and on questioning him he told
me he suffered from alternating attacks of consti¬
pation and diarrhoea, the latter being in the form
of very frequent motions, when only a very small
quantity was passed. This made me suspect
cancer, and I insisted on his coming into hospital
the next day for examination. In the third case
the patient was treated in the country for several
months for piles and liver trouble, the symptoms
in reality being caused all the time by the growth
in the rectum. These two cases should emphasise
the fact that one must never be satisfied with
making a diagnosis of haemorrhoids in an elderly
patient without a digital examination, or precious
time may be lost

Unfortunately, cancer of the rectum still gives
very bad results after operation, and this in spite
of the fact that the disease occurs in an organ
which is easily removed completely, and that it
tends to remain limited within the muscular
coats of the rectum for a considerable period.
These bad results can only be explained by the
fact that most of the cases are operated on too late.

Considering now the question of what the
surgeon can do for a case of cancer of the rectum,
the ideal treatment is, of course, complete removal
of the disease with restoration of the continuity
of the alimentary canal and a preservation of the
sphincteric apparatus of the rectum. For this
to be possible the following points must be ful¬
filled :—removal of the growth must not involve
removal of the anal canal, or at least the external
sphincter must be preserved. After removal it
must be possible to free the upper end of the
bowel sufficiently to bring it, without tension, to
the lower part. Frequently this ideal form of
operation is not possible, and then one must be
satisfied with a sacral anus, over which the
patient has little or no voluntary control. This
is more liable to occur in the case of males than
females, as in the former the rectum is usually
shorter and has not so long a mesentery.

The operations described for the removal of
cancer of the rectum are generally divided into
three types, according to the point from which
the growth is attached :—(a) Perineal; (6) sacral ;
(c) and combined abdominal and sacral.

The perineal operation is rarely done, as it is
only suitable to cases where the growth is situated
very low down, involving really the margin of the
anus or the anal canal.

The sacral is the form of operation applicable
to the majority of cases. Here the rectum is
attacked from behind, after removal of the
coccyx and the lower one or two pieces of the
sacrum. The removal of the sacrum must never
extend above the level of the third sacral foramina,
or the third sacral nerves will be cut, and as they
supply both the rectum and the bladder, incon¬
tinence of both urine and fasces will result from
their destruction. In some cases, especially
where the growth is situated high up, it may
be better to start the operation by an abdominal
incision, through which the bowel is divided
above the growth, the rectum freed and the
superior hemorrhoidal vessels tied, and the
operation may be completed by an incision in
the sacral region.

The advisability of performing a preliminary
I colostomy in the left inguinal region is a disputed
j question. The following are its disadvantages :—

(а) it necessitates two operations instead of one ;

(б) it is difficult or troublesome to close this
artificial anus if at the second operation it is

i found possible to unite the two ends of the rectum
j and preserve the normal anus ; (c) it may prevent
' the upper end of the rectum being sufficiently
freed to bring it down to the lower end ; (d) there
is a more or less sentimental objection to the
presence of an artificial anus in the inguinal region.
On the other hand the advantages are as follows :
—(a) it relieves any obstruction that may be
present, and may allow of the general health of
the patient being greatly improved by good
feeding before the more severe operation of
removal is undertaken. This point was well ex¬
emplified in the last case, where it was not thought
safe to embark on an extensive operation owing
to the very weak condition of the patient on
admission into hospital; ( b ) it allows a thorough
examination to be made of the tumour and its
connections, and shows the presence or absence
of enlarged glands or secondary growths in the
liver ; (c) it allows of careful cleansing of the
rectum by washing out the lower bowel before
the second operation, and therefore diminishes
the risks of sepsis during the operation ; (<0 it
prevents the passage of faeces through the operation
area, and therefore diminishes the risk of the
occurrence of sepsis after the operation; and
this is one of the most important causes of the
operative mortality ; ( e ) lastly, if at the second
operation it is found impossible to unite the two
ends of the bowel, an inguinal anus is more con¬
venient for the patient than a sacral one, and
after a time the patient may gain some, if not
complete, voluntary control over it, if the bowel
has been brought through the separated (not cut)
fibres of the abdominal muscles.

As regards cases where the growth has extended
beyond the limits of removal, by the performance
of a timely inguinal colostomy, not only may the
patient’s life be prolonged but in addition his
pain and discomfort may be greatly reduced by
diverting the flow of faeces from the ulcerated
surface, and by the topical application of soothing
or antiseptic lotions. Again, the possible onset
of acute obstruction, a common fatal complication,
is prevented. If this operation is decided on,
it should be done as soon as possible, and the
surgeon should not wait for the onset of symptoms
j of acute obstruction, as colostomy, which normally
is a comparatively trifling operation, is under
I these circumstances attended with a considerable
[ mortality.

The last point we have to consider this morning
is that of prognosis. As I have already told you
this is unfortunately not as good as one could
wish, either as regards immediate or remote
prospects. There is not only a considerable
mortality from the operation but there is also a
large number of recurrences, not usually in the
form of local growths, but more often as secondary-
deposits in distant fiscera, especially the liver.

The main dangers of the operation are:—

! (a) Shock from the severity of the operation in a
j patient who is worn out from pain, loss of sleep,

I septic absorption from the ulcerated bowel and
! inability to take sufficient nourishment, or possibly
I the complication of acute obstruction. This
I danger can be largely overcome by careful treat-

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Sept 18. 1907.

ORIGINAL PAPERS.

The Medical Press. 305

ment of the patient before operation, and in
some cases by the performance of a preliminary
colostomy ; (6) the onset of peritonitis due to
infection of the peritoneal cavity, either at the
operation or immediately afterwards, as in the
sacral operation the peritoneal cavity is practically
always opened. This danger may be almost
entirely eliminated by care during the operation,
and by stitching the peritoneum around the upper
end of the bowel, so as to shut off the general
peritoneal cavity; (c) sepsis from infection of
the large wound resulting from the operation or
sloughing of the bowel; this may be largely, if not
altogether, avoided by the technique of the
operation, by careful drainage and packing of the
wound, and by the prevention of tension on the
upper end of the bowel and careful preservation
of its blood supply, also, as I mentioned above,
by the performance of a previous colostomy.

The dangers of recurrence can only be lessened
by careful and complete removal not only of the
rectum, but also of the tissues between it and
the hollow of the sacrum, and by the earlier
recognition of the disease, which will allow of
operation being performed before infection of
the glands and liver has occurred.

Note. —A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture
for next week will be by Sydney Stephenson, M.B.Edin.,
F.R.C.S., Ophthalmic Surgeon Evelina and North-
Eastern Hospitals for Children, Kensington General
Hospital, &c. Subject ; “ Congenital Anomalies of the
Eye.”

ORIGINAL PAPERS.

THE JUSTIFICATION FOR

ARTIFICIAL DILATATION OF THE
CERVIX

TO HASTEN DELIVERY AT FULL TERM, WITH A
DISCUSSION ON THE MOST APPROPRIATE
METHOD OF PROCURING THIS DILATATION, (a)

By ROBERT JARDINE., M.D., Edin.,

Professor of Midwifery. St. Mungo's College, Glasgow, Stc.

In opening the discussion Prof. Jardine said
that the first part of the subject, viz., the justi¬
fication of the operation, need not occupy much
time. The operation had been in use for such a
long time that it might be maintained that it
was justified by use and want. No justification
was necessary for an operation which enabled one
to save life. Undoubtedly conditions occasion¬
ally arose where, in the interest either of the
mother or the child, or of both, a quick delivery
was necessary, and, if that delivery was to be carried
out through the natural passages, artificial
dilatation of the cervix was necessary. A case
of unavoidable haemorrhage might be taken
as an instance where the operation was called
for in the interest of the mother. In the
interest of the child the operation was justi¬
fiable in a case of prolapse of the cord early
in labour when it was impossible to replace
•and keep the cord up. While the operation was
perfectly justifiable under certain conditions
it was occasionally done when there were no just
reasons for its use. He strongly protested
against this.

The most appropriate method of procuring

(a) Abstract of Opening Address for discussion. Section of Gynseco-
ogy, Exeter Meeting, British Medieal Association, 1907.

dilatation. —He first described the methods which
approach nature’s way by means of hydrostatic
bags or the vaginal plug. These methods were
slow, and uterine action was called into play
by them. Of the bags he considered the firm
ones, like Champetier de Ribes, to be more useful
than the rubber ones of Barnes. He had found
the vaginal plug most useful in placenta praevia,
but the plug required to be properly inserted
or it would do more harm than good.

Manual and bi-manual methods were next
described. Manual dilatation was the one most
frequently employed, and was most useful when
the cervix was soft and partly dilated.

Dilatation by expanding instruments. —These
instruments, like Bossi’s, acted much like the
hand, but the arms were not sensitive and therefore
gave no indication when the parts were being
torn. These screw instruments required to be
used with great care, and at least half an hour
ought to be occupied in the operation. If the
cervix was not taken up very great caution was
necessary.

Cutting methods. —Multiple incision of the
cervix, as recommended by Duhrssen. The
cervix should be obliterated. The number of
incisions varied from two to seven. There was
risk of the lateral incision extending so as to cause
injury to the uterine arteries, and in making the
incisions one should avoid the lateral position
and especially when making four incisions. The
child should be delivered at once, preferably by
forceps, and after the placenta was away the cervix
should be drawn down for careful inspection.
If there was bleeding the incisions should be
stitched, but if there was no bleeding stitching
was not absolutely necessary.

Vaginal Ccesarean Section. —Diihrssen’s name
was also associated with this operation, but he
had not been the first to perform it, although
he had been the first to suggest it.

Effacement of the cervix was not necessary
and it was preferable that the presenting part
should not have been engaged, as version was the
method of delivery usually adopted. One very
essential condition was that the uterus should be
mobile, so that the cervix and lower uterine
segment could be pulled well down.

He described the operation, and also Duhrs¬
sen’s perineo-vaginal incision to enlarge the
vagina. He did not think this incision necessary,
as the vagina could be dilated manually. It had
been maintained that the operation was a very
easy one and quite free from risks. Occasion¬
ally even an expert would find it a difficult opera¬
tion to perform, and the not inconsiderable
number of cases published amply proved that it
was not by any means free of risk. The risks
were (1) infection, which was common to
all operations, but less in vaginal than abdo¬
minal ones; to guard against it the strictest
asepsis was necessary. (2) Injuries to mother
or child ; the uterus might be ruptured by exten¬
sion of the incision, and the bladder had been
injured. In regard to the child it had been bom
dead, and men had even found craniotomy
necessary. (3) Haemorrhage; this was fairly
common as the uterus was usually atonic; in
all cases it was necessary to be prepared to tampon.
He considered that vaginal Caesarean section was
an operation for experts in vaginal surgery, and
not one which an ordinary general practitioner
could undertake.

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306 The Medical Press.

ORIGINAL PAPERS.

Sept. 18, 1907.

In conclusion, Prof. Jardine said that in deciding
on the proper method to adopt the attendant
had to consider the condition of the cervix, and
also the amount of his experience. If he were an
adept in vaginal surgery he would probably
prefer vaginal Caesarean section in all cases in
which there was likely to be difficulty in dilating
the cervix, but if he had had no experience in that
form of surgery, in the interest of his patient,
he should adopt one of the other methods, or else
call in the assistance of an experienced colleague
who could undertake the major operation of
vaginal Caesarean section. In reference to this
operation in cases of placenta praevia he was of
opinion that, like ordinary Caesarean section, it
was quite uncalled for, as better results could be
got by other methods.

CONTAGIOUS DISEASES AND
SCHOOL ATTENDANCE.'(o)

By Sir SHIRLEY MURPHY, M.R.C.S.,

. Medical Officer of Health.

That attendance at school should be compulsory is
inevitable under the conditions of our civilisation,
that this attendance involves increased risk of exposure
to infection is undoubted, hence the duty of the State
to protect the child from risks incidental to an act of
enforced obedience is a moral obligation. Our object
in meeting in this room is to endeavour to learn how
this protection may be best afforded with the least
interference with the primary intention of the child’s
attendance at school, or how this primary intention
may be best effected under conditions which reduce to
a minimum the risk to which the school-attending
child is exposed. In our study of this subject we are at
once confronted with the fact that the risk of infection
to the school child in the school is only part of the whole.
In endeavours to control the spread of infectious disease
in the school it is impossible to ignore the conditions
which prevail in the home. In efforts to limit the
occurrence of infectious disease in the home we must
have regard to the opportunities of infection which
occur in the school. In England, until recently, the
Education Authority has been separate from the
Health Authority, and difficulties which have stood
in the way of organised administrative effort have
been great. Probably nowhere were the results more
manifest than in London during the epidemic of diph¬
theria which prevailed, especially in the six years
1892-7, during which some 15,000 children lost their
lives. In such matters division of administration
involves the weakening of the machine. Two separate
bodies, even with the best intention, do not accom¬
plish that which would be effected by one body en¬
dowed with the powers of both.

In England the difficulty is being met by the con¬
stitution of the Health Authority as the Education
Authority, and this has in it the basis of an effective
machine. The Health Authority has, however, not
always been provided with the necessary machinery
to effect the object in view, and this machinery must
be developed and adapted for the new work which it
is required to undertake. Changes are slow, and some
mistakes are made, but in the end the true issues are
usually seen, and progress in the right direction is
made. The guiding principle must be that the ad¬
ministration which is designed to protect the health
of the population at “ all ages ” is that which must be
concerned with the health of the child at school age,
whether in the school or in the home.

The question may well be asked. To what extent
does attendance at school contribute to the number
of cases of infectious disease in the population ? The
information required to answer this question is scanty,
but some indication of the extent of this contribution

is afforded by a comparison of the number of^cases
occurring in holiday periods with the number occur¬
ring in periods when children are attending school,[and
in this connection I might cite the figures arrived at
by comparing the number of cases of scarlet fever
and diphtheria which actually occurred in the month
of August during the ten years 1895-1904, with the
number of cases of scarlet fever and diphtheria which
would have occurred in London in that month had,
the schools remained open instead of being closed,
this latter figure being arrived at by estimating the
cases for the month of August from the actual noti¬
fications in the two preceding months of June and July
and the two succeeding months of September and
October. The difference between the actual and the
estimated cases is in respect of scarlet fever 3,974,
or 27.6 per cent., and in respect of diphtheria 2,002,
or 2 3-3 P er cent.

A legitimate criticism of these figures would be that
they may be due not to actual decrease in opportunity
of infection during the school holidays, but to— (a)
diminished population in London, owing to the exodus,
of young persons at the time of the August holiday, or
(6) the system of notification being less operative
during the summer holiday, owing to the children being
less under observation than during the period they are
attending the schools, or (c) to a combination of both
circumstances.

On these points I may observe that with regard to
(a) much the same decrease is observed in the August
holiday among the child population of those places in
the country to which the London population resorts
at the time of the holiday. On turning now to (b) it
must be admitted that the notified cases of infectious-
disease in these places would experience somewhat
similar diminution if the decrease were due to the
cessation during the holiday of observation of children
in school.

Concerning this point of criticism I may, however,
point out that the decrease of notified cases of infectious
disease in children of school age is often followed a week
later by decrease of notified cases of infectious disease
among children of a younger age than the school age.
suggesting very strongly that there has been diminished
opportunity for these younger children to acquire
infection from other persons, and this finds its most
ready explanation in actual decrease of infectious
disease among children of school age.

My own view is that there is decrease of infectious
disease among children of school age as the result of
closure of the schools during the summer holiday, and
that the figures given above represent substantially
what that decrease has been, or, in other words, the
proportion of cases of infectious disease which at that
period of the year was due to the opportunities of
infection from person to person as the result of aggreg¬
ation of children in school. In any attempt to estimate
the proportion of cases of infectious disease which
during the whole year may be due to this circumstance,
it is necessary to recollect that in the autumn months
both scarlatina and diphtheria show a marked increase
of prevalence, and it may be that there is an ability
of the disease to spread in school at that time which
is greater than its ability at other times. If this be
the case, the actual proportions of cases in the whole
year due to school attendance would be less than is
suggested by the figures given above.

The facts, however, go to support the view that
prevalence of disease is maintained by inconspicuous
cases, whether mild and unrecognised cases, or by
cases of persons who, having no symptoms of their
own, are merely “ carriers,” with an ability to infect
susceptible persons.

Hence arise our difficulties in dealing with infectious
disease in schools, the difficulty of detecting exceedingly
slight cases of disease, the still greater difficulty of
detecting " carrier ” cases.

Obviously, any child who is suffering from an ailment
that raises question of infectious disease should be at
once excluded from the school, and inquiry should be
made as to the nature of the malady. In this matter
the teachers can and do render invaluable service.

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<«) Introduction to Discussion at International Congress on School
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Sept. 18. 1907.

ORIGINAL PAPERS.

The Medical Press. 3 °7

and the extent to which they exercise watchfulness
over the children under their charge will often determine
whether disease is limited to a single child or whether
it spreads to other children. Again, the exclusion of
children coming from infected homes is a principle
which is generally accepted, although certain modifi¬
cations in the applications of this principle are possible
in practice, owing to differences in the behaviour of
the various infectious diseases which commonly affect
school children.

In deeding with outbreaks of infectious disease in
schools, the question will always arise whether depend¬
ence should be placed on the exclusion of particular
scholars, or whether the closing of classes or schools
should be resorted to. This is a subject which will
engage the serious attention of this Section, and it
may be hoped that the papers which will be read will
contribute to the knowledge required for determining
under what circumstances " exclusion ” or “ closure ”
should be adopted. Where bacteriology can be em¬
ployed, as in the case of diphtheria, the first of these
methods is largely adopted, and hopes are held out
that the complete examination of material from the
throats of the children attending an invaded school,
and the exclusion of all children harbouring the Klebs
Loeffler bacillus may suffice without the more extreme
step of closing the class or the school. To determine
whether this will prove to be sufficiently effective at all
times, at the height of an epidemic, as well as at times
of smaller prevalence, further experience is needed.
Results which are obtained during the decline of an
epidemic cannot always be relied upon as affording
sufficient ground for inference that the same method
will be equally effective at a time when diphtheria in
a community is rapidly increasing in proportion ; but,
however this may be, there is no question that ample
provision should be made both in respect of bacterio¬
logical laboratories and in staff for complete enquiry
into the condition of the children attending the
invaded school. The more thoroughly this work can be
done the greater is the hope that the exclusion of par¬
ticular scholars wall suffice. Other considerations have
to be held in view to determine whether the school
shall be closed, especially when other diseases are con¬
cerned which cannot thus be dealt with. Beyond the
question of the extent to which the school is invaded
there remains the further question of the proportion
of children attending the school who are susceptible to
attack. As the result of previous recognised or unrecog¬
nised attack, and as a result of natural immunity, there
must be a considerable balance of children who are
saf; from further risk of infection. If we were to judge
from the number of cases of scarlet fever which are
notified we do not find evidence that any large propor¬
tion of London children suffer from this disease. Thus,
taking the experience of London during the ten years
1897-1906, we may learn approximately that of chil¬
dren under ten years of age living in 1906 only 63.8
per 1,000 had been attacked ; among those at the
other ages being under nine years, 57.5 ; under eight
years, 50.4 ; under seven years, 42.2 ; under six years,
33.9; under five years, 25.2 ; under four years.
17.2 ; under three years, 10.4 ; under two years 5.2 ;
under one year, 1.7 per 1,000. Notified cases, however,
provide an incomplete basis for estimating the propor¬
tion of children who have passed through an attack
of the infectious diseases, and we can in no way assume
that the balance represents the number of susceptible
children remaining. In some degree the number of
modified cases is swollen by cases notified in error,
but, on the other hand, not all the cases of recognised
infectious diseases are notified, and still more certainly,
only a proportion of the actual cases which occur are
recognised. Further, it is common experience that only
a proportion of the persons exposed to infection are
attacked, even when, so far as can be known, they
have never before suffered from the malady ; hence
nothing but actual experience can show what infectious
disease will do if left unchecked in a class cr school of
children of any particular age. On these points interest¬
ing material will be placed before the Section.

In view of the special incidence of infectious disease

upon children in the first few years of life, the question
of the age at which these children should be required to
attend school is a subject well deserving of study, and
will be before this Section. In England the age of com¬
pulsory attendance is five years, in Germany it is one
year later. An examination of the statistics of infec¬
tious disease of communities having a different age for
attendance should throw some light on this subject.
If the age of attendance be deferred, protection from
attack of school-derived mealses would obviously not
be extended to every child under that age. If older
brothers or sisters contracted measles in school, they
would bring the disease home to younger brothers
and sisters, although these younger brothers and sisters,
if they themselves attended school, would have the
additional risk of exposure to measles in the school
itself. It is, of course, the family of a single child
which would derive the most benefit. How would
deferred school attendance show itself in the statistics
of infectious disease ? It is quite likely it might be
manifest ii the case of scarlet fever and diphtheria,
and but little, if at all, in the case of measles. The
subject is well worth inquiry, which, of course, should
relate to each of the diseases with which we are con¬
cerned, inasmuch as they do not manifest the same
degree of infectivity. Unfortunately, it is the usual
practice to group for the purposes of publication all
cases occurring from five to ten years of age, and here
I may make an appeal to those who have the tabulation
of these figures that, whether published or not, the
number of attacks and the number of deaths should
be separated for each year of life so as to be available
to determine statistically a question of this sort.
However, “ the lower age limit of school attendance ”
will be before us from the pen of an especialy able
writer, and the need for the proposal I have made
may be better determined after we know the contents
of this paper. Under all circumstances we may bear
in mind that if the age of attack is deferred it results
in a lessening of the fatality of the disease and that,
if postponement of age of attendance at school leads
to postponement of age of attack, the result will be a
saving of child life.

I have made no mention of prophylactic inoculations
but I may say that the value of vaccination as a pre¬
ventive of small-pox needs no mention here. Experience
of the use of antitoxic serum as a prophylactic in schools
is much more limited, but good results have been
claimed for it.

One of the advantages of school attendance is the
opportunity which is afforded for dealing with all
conditions of health of that part of the population
which is of school age. whether they affect life or only
cause inconvenience. Hence, the parasitic diseases of
the skin, trachoma, &c., are included in our programme.
Of these I need say nothing more than to insist on the
great advantage to the population which would result
from a systematic treatment of all children who suffer
from contagious maladies of this sort. There should
be no difficulty in the practical eradication from the
population of all such conditions if the work is seriously
undertaken in connection with the children who are
brought under observation in the schools and if the
work be followed to the home where the younger
children are found. In the same way it may be
pointed out how much may be done for the cure of
pediculosis. A condition of this sort ought not to be
tolerated in a civilised community, and school attend¬
ance gives a claim for interference with this condition
in the child population.

A BIRD’S-EYE VIEW OF
NEURASTHENIA

By M. MARC., M.D.,

Prof«*»or of the Faculty of Medicine, Paris.

[SPEC I ALL v REPORTED FOR THIS JOURNAL.]

If the term neurasthenia had not been distorted
from its original meaning, if under this title there
were no tendency to describe a definite disease of the
nervous system, no term could be more appropriate
as applied to certain nervous states.

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308 The Medic al Press.

ORIGINAL PAPERS.

Sept. 18, 1907.

Unfortunately, and especially in neuropathology,
physicians cannot resist the temptation to systematise,
to create morbid entities whicn, once promulgated,
are erected into absolute dogmas. Neurasthenia
is a curious example of this regrettable tendency of
the human intellect.

Formerly authors used to describe under the name
nervousness all nervous states not dependent upon
lesions of the nerve centres, and manifested by very
diverse features, the only characteristic feature
whereof was indeed their abnormality. Hysteria,
for instance, was a form of nervousness. Some very
suggestive contributions, cleverly handled by Beard
and, later, by Charcot, rendered it necessary to dis¬
tinguish between hysteria and neurasthenia, and by
artificially grouping the symptoms of nervousness
they succeeded in building up two special diseases
of the nervous system, two neuroses capable of identifi¬
cation by their respective stigmata. The morbid
picture was so admirably drawn that it was universally
accepted, and forthwith everybody was on the look¬
out for neurasthenic subjects, with a large measure
of success, for plenty of persons presented the typical
stigmata evoked by the interrogative suggestion of
the examiner.

Beard, in order to explain how it was that such a
striking disease could previously have escaped recogni¬
tion, admitted that neurasthenia was a new disease
caused by the complexity and overstrain of modem
society. It is odd to notice that the same explanation
has been given of the prevalence of appendicitis,
which we learned from the works of Sir Frederick
Treves, and of the tabetic arthropathy which was
unknown before Charcot called attention thereto.

But observers soon found themselves hampered by
the narrow limits assigned by Beard. They were, to
begin with, obliged to admit that hysteria, this other
" one and indivisible ” disease, was sometimes associated
with the other neuroses and Charcot conceded the
existence of hystero-neurasthenia, just as, since his
time, we speak of hystero-epilepsy. The distinguishing
features of neurasthenia were so commonplace that
they cropped up everywhere. Neurasthenia was
for the nervous system what influenza was for the
respiratory tract, the disease responsible for every¬
thing, which would explain everything. Then special¬
ists took to describing special forms of neurasthenia,
and we were treated to dyspeptic neurasthenia,
cardiac neurasthenia, syphilitic neurasthenia, gonor¬
rhoeal neurasthenia, and so on.

In short, the unduly narrow limits of neurasthenia

?ave way on all hands, and after having been the
ashionable disease, neurasthenia has comparatively
fallen into abeyance and is less frequently invoked.
Professional opinion has gradually undergone an
evolution, and neurasthenia is no longer regarded
as a special disease, but rather as an abnormal state
of the nervous system, characterised more particularly
by inadequate reactions and a tendency to depression.
Like the hypochondriacs of former times neurasthenics
are usually depressed, tiresome and tired, complaining
of everything, and more alive than their normal fellows
to all kinds of disagreeable sensations and impressions,
so much so as to make mountains out of mole-hills.
The loss of will-power renders them unable to resist
these auto-suggestions or to throw them off: in short,
their nervous system is inadequate, lacks spring,
and is asthenic. As suggested above, no term better
describes their plight than the word neurasthenia,
provided no very exact meaning be attached thereto.

Neurasthenic patients only present one feature in
common, viz., nervous asthenia, but no one symptom
or stigma is always present. No two patients differ
more than two neurasthenics, and nothing equals
the variability in course and duration of the neur¬
asthenic condition.

The gravity of neurasthenia depends upon its cause,
and we may divide these patients into two principal
classes :

(1) Constitutional neurasthenics who have Deen so
from their infancy and will continue so till they die.
They have inherited a sort of functional malformation

of the nervous system due to parental strains, they,
are usually the offspring of neurasthenic, epileptic
alcoholic or morphinomaniacal parents. Everything
tends to aggravate the neurasthenic state in these
subjects, and no sooner is one manifestation cured
than another takes its place.

(2) Accidental neurasthenics. A violent moral
or physical shock, a painful emotion, a traumatism,
an attack of disease, an intoxication, or mere over¬
work may determine neurasthenia in any individual
previously in good health. These, however, do not
long remain in a state of neurasthenia, but soon recover
under treatment. The nervous system, depressed
for the time being, reasserts itself under the influence
of rest, hygiene, etc., or after the disappearance of
the disease to which it was secondary.

This is the origin of the neurasthenia that attacks
young people who have worked too hard for examina¬
tions, or business men whose occupations have been
too much for them, or persons who have been smitten
in their affections or have been bereaved, or who have
been subjected to intense disappointment or who
have been in a railway accident. The same remark
applies to the victim of poisoning—tobacco, lead,
syphlilis, tuberculosis, dyspepsia, etc. The depression
is fully explained by the cause, though in some in¬
stances the result may be altogether out of proportion
to the apparent cause and may, moreover, have
disagreeably persistent effects. This, however, is
only the case in persons predisposed thereto, so that
the neurasthenia in such persons is more constitutional
than accidental, and the cure is consequently relative
and not absolute.

Neurasthenia hardly lends itself to a general symp¬
tomatic description. Each individual has a neuras¬
thenia of his own. The common character of impotence,
inadequacy and depression is present in all, but the
nervous disturbance bears on this or that part of the
body, according to the local predisposition or lessened
resistence. Every morbid symptom, every painful
sensation, is enhanced and rendered more persistent
by the neurasthenic state.

In neurasthenia we only get subjective symptoms
which do not admit of verification. The disease consists
in the patient being acutely conscious of a number
of minor ills to which the healthy individual would
not condescend to pay attention. When we examine
a neurasthenic subject everything lies in his narrative,
nothing abnormal can be detected, yet he takes
immense pains not to overlook the most insignificant
detail. One patient insists on his headache, his
neuralgia or his tremors which no one else can detect,
while another emphasises his constipation and his
multiple abdominal sensations. They will not willingly
spare the physician a single detail, we have to take
cognisance of all the analyses of urine and, if of some
standing, the patient will produce a sample of urine
ready for examination along with a sample of faecal
matter.

As a general rule neurasthenics complain of per¬
sistent headache which sets in on rising, compresses
the forehead and skull like a helmet, spreads down the
occiput and neck, is exasperated by work, noise and
light, is accompanied by giddiness, noises in the
ears, disturbances of vision and, in some instances,
by hyperesthesia of the scalp. He constantly
feels weary and rest does not bring any relief. They
feel so limp that they would prefer not to get up or
walk or go out. They get attacks of fatigue quite
suddenly, following an emotion or a worry or even
without any obvious cause. They complain of
aching in the back, or dorsal pain. The rachialgia.
which is characterised by a sensation of pressure or
compression, is generally increased by pressure on
the spinous processes ; the skin may even be hyper-
aesthetic, and they declare themselves unable to bear
the weight of the clothes. The back pain is most
marked at the lower part of the spinal column and
the “ sacral patch ” is one of the classical signs.

The digestive disturbances have been specially
investigated by Bouveret and Mathieu. Usually
the condition is one of gastro-intestinal atony, the

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ORIGINAL PAPERS.

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appetite is capricious and poor, the patient feels
hungry and cannot resist the sensation without feeling
faint, so that he eats at all times. At table, however,
after the first few mouthfuls he has had enough.
He feels better after a meal, but this does not last long
f r he soon complains of a feeling of weight in the
epigastrium, of swelling of the stomach, of eructations,
flatulence and palpitation, and he feels drowsy. Con¬
stipation and muco-membranous entero-colitis often
accompany this morbid condition. The state of the
gastric juice is variable, sometimes the secretion is
insufficient and poor in hydrochloric acid, in others,
on the contrary, there is hyper acidity.

The gastric troubles are most pronounced in the
grave cases in which the patient becomes emaciated
and loses strength, and we are tempted to think of
cancer.

Insomnia is of frequent occurrence. The patients
are a long time in getting to sleep and awaken in a
mental state of excitability or even anxiety. They
get to sleep again with difficulty and often have
disagreeable dreams.

The principal psychical trouble consists in a diminu¬
tion of the personality with enfeeblement of the mental
faculties, inability to concentrate the attention, and
a tendency to sad thoughts. The emotions are not
under control, and the memory is impaired. The will¬
power is almost completely lost, so that the patient
is incapable of arriving at the most trifling decision,
even in regard to his ordinary occupations or habits
of life. Every act is a burden to him, he hides himself
from everybody and everything. Unable as he is
to fix his attention he cannot read or work, and his
conversation is incoherent. He often experiences
unnecessary apprehensions, he thinks he is suffering
from some dreadful disease, and it is very difficult
to get these ideas out of his head.

In addition to these general symptoms we get
certain secondary manifestations, such as continuous
or intermittent giddiness. This is relieved by rest
in bed and by taking food, but not always. It
may be accompanied by a dazed feeling with dis¬
turbances of vision and noises in the ears, in fact,
the syndrome of Menidre. The patient complains
of cramps, of fibrillary contractions of the muscles,
twitching of the eyelids and trembling of the hands.
Th? hypersethesia may be limited to some part of the
body, but is most frequently localised in the scalp
or over the sacrum. Such patients may complain
of every conceivable painful sensation. Sight might
appear to be disturbed, the eye quickly tires, the
image becomes blurred and the patient experiences
painful distension of the globes as soon as he attempts
continuous work, yet ophthalmoscopic examination
of the eyes shows them to be normal.

The genital organs are frequently incriminated,
such patients suffer from nocturnal emissions which
disturb and alarm them, and they are devoured by
the terror of becoming impotent.

Attacks of palpitation supervene under the influence
of some trifling emotion or fatigue, the patient thinks
he has heart disease, and is dissuaded from that
belief with the greatest difficulty. His apprehensions
are sometimes intensified by persistent tachycardia,
irregularities of the pulse or attacks of pseudo-angina.
Urinary symptoms may be present. There may be
pollakiuria or urethral smarting. Phosphaturia has
often been mentioned among the symptoms of neur¬
asthenia, but that is a mere error of diagnosis. The
presence of a phosphatic deposit in the chamber is
not due to excessive elimination but to precipitation
consequent upon the reaction of the urine or to an
insufficiency of the aqueous vehicle. Deminerali¬
sation and leakage of phosphates have never really
been met with except in presence of emaciation.

The diagnosis is easy; too ea9y indeed. The
physician must be careful not to label as neurasthenic
dist rbances due to disease of the heart, stomach or
lungs. We must never proceed on the strength of a !
mere statement, but must examine the patient
thoroughly in order to make sure that the apparent
neurasthenia does not mask some organic trouble.

Certain persistent headaches, with loss of memory,
change of temper and mental depression may usher
in general paralysis, but if these symptoms are asso¬
ciated with inequality of the pupils and impaired
reflexes lumbar puncture will enable us to make the
distinction. Headache and vertigo may be due to
cerebral tumour or to syphilis, as can be ascertained
by careful examination and close observation of the
exact symptoms. Pain in the limbs with persistent
weakness and dulled reflexes may be indicative of
tabes, but the Argyll Robertson pupil, the abolition
of the reflexes and Romberg’s sign will put us on the
right track.

The diagnosis may sometimes be rendered difficult
by the fact that the symptoms of the organic affection
are at times very ill-defined and that such affections
often give rise to neurasthenic manifestations: in
short, we must learn to detect the organic lesions
behind the neurasthenic mask.

We must likewise display a judicious scepticism
in respect of all elderly soi disant neurasthenics who
complain of inability to work, dyspeptic troubles,
vertigo, headache, palpitation and feeling of numbness,
because the examination of the urine, the heart and
the large vessels will in some cases enable us to identify
Bright’s disease or arterio-sclerosis.

Lastly, we must be careful not to diagnose as cases
of neurasthenia certain states characterised by languor
with anxmia and loss of appetite and strength super¬
vening in young subjects, for these signs may be merely
the manifestations of latent tuberculosis.

In short, we must not be in a hurry to formulate a
diagnosis of neurasthenia; this should always be
very guarded indeed ; it should be considered rather
as a refuge for the destitute, that is to say, merely
the result of our inability to discover any organic
lesion capable of determining neurasthenic symptoms
and even in constitutional neurasthenics we must
always make careful research for affections likely
to give rise to the neurosis.

Neurasthenia is always very difficult to cure when
it is not purely accidental. The first indication in
the treatment is to attack the underlying affection :
treat the syphilis, stop the overwork, calm the emotions
and so on; that is the real way to overcome certain
types of neurasthenia.

Hygienic measures constitute the basis of the
treatment. The patients should avoid undue fatigue,
they should be incited to take regular, graduated,
physical exercise in the open air, and in most instances
a period of rest treatment at a certain altitude is
indicated. Hydrotherapy in the form of douches and
baths is of service, hot for excitable subjects, cold
for the depressed. Wet packs, rubbing with alcohol
and cold salt water baths, general massage and local
massage in certain painful manifestations, statistical
or faradic electricity, are all valuable in their way.

Medicinal treatment plays a secondary part, but
nervous sedatives and soporifics are useful to subdue
the nervous excitement, ensure sleep and allow of
rest. Stimulants, such as strychnine, arsenic and
phosphates are useful adjuvants, whether they act as
tonics or by suggestion.

Every prescription must be ac ompanied by cheerful
encour igement, for the moral influence of the physician
is of the highest importance, though truly it entails
much patience, tact and persuasion.

In obstinate cases the treatment of neurasthenia
cannot be carried out at home ; the patient must be
withdrawn from his usual environment in order to
disassociate him from his preoccupations, and he must
be isolated in a nursing home or he may be sent to a
health resort in the mountains with rest, massage,
electricity and a special dietary. These are the main
features of the W T eir Mitchell treatment now adopted
by all specialists in this department.

The Committee of the National Association for the
Establishment and Maintenance of Sanatoria for
Workers Suffering from Tuberculosis are about to
open the second half of their main building at Benen-
den, Kent, which will accommodate 68 patients.

by Google

3 IQ The Medical Press.

THE OUT-PATIENTS’ ROOM.

Sept. 18, 1907.

THE OUT-PATIENTS’ ROOM.

METROPOLITAN HOSPITAL.

Chlorosis and Early Tuberculosis.

By Leonard Williams, M.D., M.R.C.P.,

Assistant Physician to the Hospital; Physician to the Frenoh
Hospital in London.

This girl, whose age is 17, has been to see us three
times. On the first occasion she was obviously and
grossly anasmic, with that peculiar tinge about the
face which has given rise to the name of “the green
sickness.” We examined her heart, and found that
it was substantially normal, there was no albumen in
her urine, and we were therefore justified in pro¬
visionally labelling her case one of chlorosis. There
was, of course, a history of scanty and irregular
menstruation. That is so common in these cases that
it may almost be regarded as a symptom. In this
case the scantiness had proceeded to the point of com¬
plete suppression for the last two months. Another
almost invariable accompaniment of the condition is
constipation, and another very common association is
carious teeth. This girl’s teeth were not carious, but
she was constipated. She was given a medicine con¬
taining ferri aramon. cit., 15 grs. ; liq. arsenicalis,

minims; tine, nucis vom., 4 minims; and water to

alf an ounce, three times a day, together with an
aloes pill to be taken in the course of the afternoon.
Aloes is always the best form of aperient to exhibit in
these cases, because in some obscure way it seems to
heighten the effect of the iron.

On the occasion of her second visit she was im¬
proved, but not markedly so. The constipation was
better, but her anaemia, though less, was still very
pronounced. The dose of the iron was therefore in¬
creased to 20 grs., and that of the arsenic to 5 minims.

She comes to-day still slightly improved, but the
result is disappointing. Iron and arsenic in cases of
pure chlorosis may be regarded as specific, and if they
do not cure a case of this kind, then either we have
combined our drugs badly, or there is something else
the matter with the patient.

In this girl’s history there is one factor of rather
sinister significance. I have said that in chlorosis
menstruation is liable to be irregular and scanty, but
it is not very often totally suppressed. Total sup¬
pression of the menses has been described as one of
the earliest signs of tuberculosis, and I need hardly
remind you of Trousseau’s saying that an anaemia
which resists iron is probably due to tubercle. These
two factors being present in this case were sufficient
to arouse the suspicion that the “something ” which
was preventing this girl from reacting to iron was a
tuberculous invasion. We therefore searched for
other signs.

A very early sign of tuberculosis is tachycardia,
which, as I have often previously explained, is due
to vaso-dilation, which may be regarded as one of
the physiological effects of the tuberculous toxin.
Now this girl’s pulse is no less than 120 per minute
in the upright position. It falls to 90 when she is
recumbent—that means that the vessels are unduly
dilated. We have therefore three facts to go upon—
a chlorosis which resists iron, suppressed menstrua¬
tion, and tachycardia. These three in themselves,
though not serious, are distinctly disquieting.

The girl, you will observe, has very little pigment in
her hair. That in itself is sufficient to excite a certain
amount of suspicion, and some of you may have
noticed, when I was examining her chest, that she
had a line of fine down passing from the hair of her
head to between the scapulas behind. That, according
to some people, is another sign to be viewed with
apprehension.

The examination of the chest revealed nothing very
definite. There were the differences between the right
and left apices which are so often found in perfectly
normal people—that is to say. the right side was Tather
less resonant than the left, and the voice conduction
was rather better. The breathing on the right side
did, however, present an abnormality which it is diffi¬
cult to describe, but which has been called “harsh
breathing.” It is not that such breathing is necessarily
high-pitched, or that it has any of the characters of

what we call bronchial breathing, but it is harsh. It
offends the ear, so to speak, and is in very marked
contrast with the weak breathing which is to be found
on the other side. Though I listened carefully I could
not find anything in the nature of cog-wheel breath¬
ing. The examination of the chest, therefore, has
given us no very strong confirmatory evidence.

How are we going to set our suspicions at rest?
Well, if we take the girl into the wards and record her
evening temperatures, we shall probably find some¬
thing very definite to go upon. We shall probably
find, that is, that she has a slight evening rise—a rise
not sufficient to cause her any discomfort, but one of
which the thermometer will tell us in unmistakable
terms. The chart may be expected to show us that,
though her temperature is possibly sub-normal in the
morning, it rises to a degree, or a degree and a half,
above normal in the evening. This is a very important
point, and in suspicious cases it is one which should
always be carefully investigated.

Another confirmatory sign is to be found in the ulnar
reflex. When we made this girl stand at the table
with her fore-arms resting thereon, and the arras flexed
at the elbow, you saw that when I drew a pin smartly
along the ulnar surface from elbow to wrist, there
ensued a wrinkling of the hypo-thenar eminence, due
to a contraction of the abductor minimi digiti, and
that this phenomenon was present on both sides. Now
this ulnar reflex is not pathognomonic of tuberculosis,
but its presence affords very strong confirmatory evi¬
dence of suspicions otherwise aroused. Like so many
other of these reflexes, its absence means nothing.
It is often absent in advanced cases of phthisis,
especially in men who have worked with their coarser
muscles rather than with their finer. It is more easily
elicited in women on account of the better develop¬
ment of the abductor minimi digiti which constant
use of the finer muscles of the hand naturally gives
rise to. This ulnar reflex is occasionally present in
some other conditions, but it is on the whole very rare
except in tuberculosis. In a person of the age of
this patient its presence affords evidence which it is
very difficult to gainsay. .

Further confirmation could, of course, be obtained
by examining the sputum for tubercle bacilli, but
inasmuch as the patient has no cough, it would be
very difficult to obtain sputa coming from the lungs
themselves. Any sputa that she produced would pro¬
bably be salivary only. Nevertheless it is our duty
to see if such an examination will help us.

Another laboratory method which is now deservedly
attracting a very considerable amount of attention is
the estimation of the opsonic index. That, fortu¬
nately, is a comparatively easy matter, and before she
leaves the hospital this girl will go to the laboratory
for the purpose of allowing us to ascertain what her
opsonic index is.

You may be inclined to say that the foregoing con¬
stitute a very flimsy basis whereon to construct a
diagnosis of so grave a condition as pulmonary' tuber¬
culosis ; but the time has now gone by when, before
commencing treatment, we used to wait until there was
an involvement of the pulmonary area so definite that
it was accessible to ordinary percussion and ausculta¬
tion. If we wait for the classical physical signs
before commencing treatment, then we have waited
too long. Phthisis is, no doubt, under entirely favour¬
able circumstances, a very curable disease, but the
condition precedent to its curability is its detection
in the very earliest stages.

It is now our business, therefore, to look for signs
of tuberculous invasion which were formerly Telegated
to positions of minor importance. The laboratory
methods to which I have just referred happily afford
us an amount of assistance which in the large majority
of cases reduce suspicion to a certainty. This patient
I believe to be suffering from commencing phthisis.
Her opsonic index, when we know it, will set the
matter at rest, and it is even possible that the exam¬
ination of the sputum may also confirm the suspicions
which her general condition has aroused.

Now, if we are to cure this girl, how are we to set
| about it? If I were to ask this question of you indi-
! vidually, each one would certainly say “send her to
' a sanatorium.” Unfortunately it is not very easy to

litized by G00gle

Sept. 18, 1907.

CORRESPONDENCE.

The Medical Press. 311

get girls from the out-patient room of the hospitals
into sanatoria ; and even when we succeed we are not
able to select the sanatorium into which they shall go.
Assuming that the methods of treatment are sub¬
stantially the same in all sanatoria—and I think that
nowadays such is a reasonable assumption—there is
one factor in the situation which is of the very
highest importance, which unfortunately we are not in
any way able to control. This factor is the .climate
of the place in which the sanatorium is situated.
There are, as you know, bracing and sedative climates,
and in private practice the success or otherwise of a
sojourn in a sanatorium may depend largely upon the
suitability of the climate in which the selected insti¬
tution is situated. The circumstances which lead us
to select one climate rather than another in an indi¬
vidual case are so complicated that I cannot even
outline them here. I may, however, say that young
people, about the age of our present patient, do best
in a climate which is neither too sedative nor too
bracing, and that the older people grow the more
sedative should be the climate to which they are
advised. There is a certain type of lymphatic tuber¬
culous person, generally young, who does so sur¬
prisingly well in bracing climates, such as that of
Margate, that one is apt to think there must be some¬
thing specific against tuberculosis in climates of that
type. Against this pitfall I wish you particularly to
be on your guard. The results of Margate in suitable
cases approach the miraculous, but in unsuitable cases
such a climate will frequently send a patient down¬
hill with a rapidity which is truly alarming.

OPERATING THEATRES.

ST. THOMAS’S HOSPITAL.

Amputation of Thigh for Senile Gangrene.
Lumbar Analgesia. —Mr. Edred Corner operated
on a woman, aet. about 76, who had been admitted
with senile gangrene of the right leg extending nearly
up to the knee. There was no pulsation in the right
anterior and posterior tibial arteries. There was
pulsation of the same arteries of the left leg. She had
been ill for a fortnight. Her heart and arteries were
extensively diseased ; in fact, so much so that it
would be unwise, Mr. Comer said, to give her a general
anaesthetic. It was therefore decided to perform an
amputation at the upper third of the thigh, stovain
being injected through a lumbar puncture. In this
case there was some slight difficulty in performing
lumbar puncture because the patient had some osteo¬
arthritis of her spinal joints which caused rigidity of
the spine in consequence of which it was impossible to
flex the spine and separate the laminae of the vertebrae.
Anaesthesia came on rapidly after j the -injection and
extended nearly up to the nipple line. The ampu¬
tation was carried out with skin flaps and the patient
experienced no discomfort whatever. Both femoral
artery and vein were thrombosed at the point of sec¬
tion, but though the main vessels did not bleed, the
branches from above bled copiously, therefore showing
that there was plenty of blood supply for the flaps.
Anterior auid posterior skin flaps were cut and reflected
then the muscles were divided circularly and retracted.
and the bone sawn through a little higher. The steps
of the operation were carried out quickly and quietly,
the patient’s ears having been closed with wool just
before the bone was sawn through. The vessels were
ligatured and the flaps united without drainage.
During the operation the patient conversed freely
with the anaesthetist, Dr. Mennell, and declined the
offer of a cup of tea, as she said she was not thirsty.
Mr. Comer said this case illustrated the uses and
advantages of lumbar anaesthesia ; it was a method,
he thought, which could never be used for general
purposes on account of the patient remaining con¬

scious, the headache, pain, and sickness it sometimes
causes, and the slight risks which it entailed, such as
the occurrence of meningitis ; moreover, he had seen
it produce severe symptoms, incessant vomiting, and
feeble pulse during the period of anaesthesia ; in addi¬
tion, on rare occasions it has failed to produce any
anaesthesia, as, for example, in a young man about to
undergo an operation for varicocele, when the dis¬
coverer of stovain, Professor Fournier, of Paris, was
present; but in cases such as the present in which it
was undesirable to administer a general anaesthetic,
the use of lumbar anaesthesia was invaluable. As a
general rule, it produces an anaesthesia which lastsabout
three-quarters of an hour, and extends up to the ninth
or tenth dorsal nerve, so that any operations on the
legs or the lower part of the abdomen can be done
painless ly. The method of producing anaesthesia by
spinal injections, he remarked, has been used in the
cervical region to enable operations to be performed on
the neck, chest and arms, but its use in this region has.
never been popular on account of the greater difficulty
and danger of the operation.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Ptrt*. Sept. ISthi 1907-

Atrophy of thf Tongue.

Lingual atrophy is either total or partial ; the for¬
mer is rare but can be observed in glosso-labio-laryngeal
paralysis of bulbar, cerebral, or basilary origin.

The development of the affection is slow and pro¬
gressive, and commences by paralysis of the tongue,
followed gradually by that of the lips, larynx, and
pharynx, producing difficulties in mastication, deglu¬
tition, and phonation.

The patient salivates incessantly, becomes emaciated,
and succumbs after several months.

Where both lingual nerves are paralysed simul¬
taneously, the tongue is atrophied, although the lips-
and face may preserve their normal mobility. Total
atrophy has also been observed in progressive muscular
atrophy.

Such are the usual causes of total atrophy of the
tongue, which, however, is a very rare affection.

On the other hand, hemi-atrophy is more frequent,
and has been observed in cerebral affections, encepha¬
litis, haemorrhages, softening, etc. But the origin of
this curious lesion is found particularly in affection of
the bulb. The lesion can affect the nuclei of the lingual
nerve from meningitis or pachymeningitis, producing
compression and atrophy of centres of origin. Accord¬
ing to Ballet, hemi-atrophy of the tongue is seen some¬
times at the commencement of ataxia and constitutes
an excellent element of diagnosis.

In syringo-myelia, partial atrophy coincides with
paralysis of the velum palatum as in all bulb lesions ;
the same is observed in the course of sclerodermia or
tropho-neurosis, and especially observed in the female
sex.

Lesions of the lingual nerve, due to traumatism or
neuritis, can produce partial atrophy.

Generally, the patients are unaware of the deformity,
which is discovered frequently by chance. But,
nevertheless" it, when recognised, puts us on the track
of certain nervous affections, as ataxia, for instance—
hence its importance. •

Cervical Adenitis.

Dr. Calot, of Berck-sur-Mer, the well-known autho¬
rity on diseases of children, recommends the following
treatment for cases of cervical adenitis, which, when
operated upon without precaution or left to themselves,
leave behind very unsightly scars.

,GoogIe

Diqiti:

312 The Medical Press.'

CORRESPONDENCE.

Sept i 8. 190.7

If the abscess is very ripe, the following should be
injected—

Creosote, 4 m.

Iodoform, x. grs.

Olive oil, 1 dr.

If the abscess is not ripe—

Camphorated naphtol, xv. gr.

Glycerine, 1 dr.

The amount injected should correspond with half
the cavity of the abscess, so as not to distend the
walls. The injections should be made every four or
five days, and seven or eight given in all.

If the abscess when first seen is ready to open, a
small puncture should be made beneath the tegument,
but without injection, and repeated if necessary
several days consecutively until the skin has recovered
its integrity; then the injections might be given.
After the eighth injection, compression is made so as
to bring the sides together.

In case of non-suppurating ganglions, general treat¬
ment should be prescribed, and the patient counselled
to have patience. Warm compresses of salt water
might be applied several times a day as a resolvent,
while antisepsy of the nasal fossae, the mouth, and the
teeth so as to disinfect all the tributary territories of
the ganglions, should be practised with care and per¬
severance. The patient might also be sent to the
country, to the sea, or to the saline waters of Biarritz,
Bex, &c.

In very many instances, improvement takes place,
and a total cure follows at the end of a few months.

If softening of the ganglion sets in a favourable
moment will be awaited to operate as above.

It sometimes happens that the ganglions remain
torpid ; they maintain their hardness and volume.
In such cases, says Dr. Calot, a modifying liquid should
be injected into the ganglion. Five or six drops of
camphorated naphtol (pure) injected every three days,
favours the absorption of the gland, which, at first
swells, increases in volume, and then gradually subsides
and disappears finally at the end of four or six months.
The number of injections to be given are seven or
eight, with three days' interval between each injection.

If from six to twenty drops of camphorated naphtol
were injected every day, suppuration would set in,
and then the usual treatment could be applied.

It is preferable, in general, to provoke the suppura¬
tion as a cure is more quickly obtained.

Fortunately, adds Dr. Calot, a cicatrix is much more
easily avoided than effaced. It can be almost always
avoided by the treatment he recommends. It is true,
this treatment requires perseverance and a much longer
time than a rapid and brilliant extirpation, but this
last leaves an indelible mark, while his treatment cures
without a trace.

Warts.

Apply a thin layer of black soft soap at night to
the hands, and dust them with talc or any other
absorbent powder in the day time ; or,

Sulphur, 5 dr.

Glycerine, 2 oz.

Acetic acid (diluted), 2 dr.

Applied the same way as the soap ; or
Salicylic acid

a a xxx. gr.

Lactic acid
Resorcin,

Collodion, 4 dr.

Touch the warts by means of a brush or the cork
morning and evening.

Internal treatment acts on the imagination of the
patient and for that reason should not be omitted.

Calcined magnesia, xv. grs. For one wafer to be
taken daily ; or

Tincture of thuja occidentals, 4 drs.

Twenty drops three times a day.

Whooping Cough.

Ichthyol, \ dr.

Syrup, 4 oz.

Peppermint, q.s.

Two teaspoonsful daily.

Under the influence of this simple remedy the

attacks diminish rapidly and at the end of two or three
weeks the child is cured.

Nasal antisepsy by instillations of liquid vaseline
and menthol and also intestinal antisepsy by castor
oil administered frequently, constitute a good adjunct
treatment.

GERMANY.'

Berlin. Sept. !5th. 1907.

At the Medizinische Gesellschaft Hr. Bickell com¬
municated a note on

The Influence of Metals on Gastric Secretion.
He said that all metals that gave off hydrogen in
dilute solutions of hydrochloric acid stimulated the
mucous membrane of the stomach to secretion ; for
example, iron, manganese, aluminium. Tin, bismuth,
silver, and gold were therefore weak or only slightly
active. “ Escaline ” (metallic aluminium with gly¬
cerine) had a powerful action on the gastric secretion,
and for this reason it was contra-indicated in cases of
ulcer of the stomach, although it was recommended
for that purpose. “ Escaline ” had no haemostatic
properties as experiments on animals had shown. It
was decomposed in the presence of human blood.
(This reaction was demonstrated).

Hr. Rumpel showed two patients with
Cystic Disease of Bones.

1. The patient had been ill for two years. The
disease began with pain in the right ankle, which
resisted all the various kinds of treatment made use
of. The talus was puffed, whilst the joint of the foot
was free. A diagnosis was made of new growth in
the talus. Rontgen illumination showed a cystic
tumour. The operation undertaken for removing
the talus confirmed the diagnosis. Microscopic
examination revealed a round-celled sarcoma. The
patient was now walking quite well.

2. A female with cystic tumour of the femur. The
disease began a year and a half ago with pain in the
left hip joint. All treatment was in vain. The
patient came to the surgical clinic in the beginning
of April. Examination showed that the hip joint
was free, the disease being situated in the upper part
of the femur, which was swollen and very painful.
One had the sensation, on pressure, as if a ’“pit”
was made in the part. Rontgen illumination showed
a solitary bone cyst. At the operation a cyst the size
of an hen’s egg was found in the upper part of the
femur, this was cleared out, and no remnants of tumour
were left in the cyst walls. The soft parts were united
by suture, and healing took place by first intention.

Hr. Senator showed a case of

“ Mikulicz’s Disease.”

The patient was a girl, zet. 6, her face was swollen
and of a yellow colour. All the glands of^the face
were swollen and indurated—the lachrymal gland
as well. There was also hard swelling of the eyelids,
and slight exophthalmos from swelling of the retrobul¬
bar tissues. The case was one of Mikulicz’s disease.
Moreover, all the lymph glands of the body were
greatly swollen. Examination of the blood showed
lymphatic leucaemia. To this collection of symptoms
was superadded swelling of the periosteum of the
flat bones of the skull, especially of the frontal bone ;
the ethmoid bones also appeared to be affected—one
as chloroma or chlorolymphoma or chloromyeloma.
There was here, therefore, a triad of rare diseases.
The speaker was reminded of a case in which his
views did not agree with those of Heubner ; he was
of opinion, however, that the autopsy showed that
his view, that the case was a chloroma, was correct.
Two other cases were then shown, one a case of
acromegaly, with two rare complications—strabismus
convergens and enlargement of the larynx ; and the
second a case of fibroneuromata.

Hr. Heubner observed in regard to Senator’s case,
that it was not a chloroma, but a lymphoma of the
thymus with leucsemic new growth. At the autopsy
there was nothing but leuczemic swelling on the
periosteum, and there was no green colouration.

Hr. Marcuse said that he had shown a case of
Mikulicz’s disease before the Society two years ago,

Digitized by GoOgle

Sept. 18, 1907.

CORRESPONDENCE.

The Medical Press. 313

and he would like to report its further course. There
was swelling of all the glands and extension of the
cardiac dulness. Then great oedema came on, and
death took place with ascites and cardiac weakness.
The autopsy showed no leucaemia, and only immaterial
changes were found in the blood. All the lymph
glands, especially the bronchial, were enlarged, some
to the size of the fist. According to this the case
was one of pseudoleucaemia.

Hr. Senator reiterated that by Mikulicz’s disease
was understood enlargement of the salivary and
lachrymal glands, and there were round-celled growths i
in the glands. The grey colouration of chloroma was
“ akzidentell,” and was not present in leucasmia.

At the Medizinische Gesellschaft Hr. C. S. Engel
gave an address on

Reversion in Embryonal Blood Formation and
the Origin of Malignant Tumours.

He sketched briefly the development of blood in
the human embryo, and concluded with saying that
the marrow of bones was the place where the red
blood corpuscle was formed, and where it remained
all through life, with this distinction that youthful
bone marrow was red, whilst that of adults was yellow.
The red blood corpuscle also differed in their different
stages ; first, the only slightly differentiated macro¬
cyst ; later, the highly differentiated erythrocyst of
the adult.

Regeneration of the blood might take place normo-
blastically and megaloblastically. The latter process
was a reversion in the embryonic condition, with
which an end-differentiation of the cell was associated—
an atavistic process.

The end-differentiated cells could now develop j
without limit, without again taking on a distinct i
character, or they might again assume their specific I
character.

The same thing happened in malignant tumours, j
where an end-differentiation of the cells preceded the
unlimited development. I

He then discussed the question why did not the 1
cells of the embryo grow into the maternal uterus, j
destroy this like a malignant tumour, and with it |
the maternal organism ; he traced the parallels and ]
enumerated the protective appliances of the maternal |
organism, and held it here to be not impossible that
further inquiry should yield important disclosures
for the successful treatment of malignant growths.

AUSTRIA.

Vienna, Sept. 15th, 1907.

Stationary Paralysis.

At the Psychiatry Meeting, Rocke raised the
question of Stationary Paralysis. Was there such—
And was it curable ? Under this terra a nerve disease
was recognised, which went on for years without
much change to the onlooker ; indeed, some question
if paralysis exists. If any one takes the trouble to
enquire at a mental institution he will often meet
with a history like the following :—A patient is
received with paralysis, which may go on for four or
five years with very little change, but the patient
suddenly dies. The post-mortem reveals no cause of
paralysis, but on the other hand, the brain will indi¬
cate the presence of the syphilitic virus, arterio¬
sclerosis of the cerebral vessels with signs of alcoholic
degeneration and dementia pracox. Such cases
only teach'Jus how difficult it is to diagnose, and at
the same time warn us in the management of large
institutions to be careful of sudden deaths.

Alyheimer related the history of a similar case with
supposed stationary paralysis. The patient was
32 years of age, and died suddenly. The microscope
revealed a syphilitic condition, which undoubtedly
caused the paralysis, which could not in the real
sense of the word be “ stationary.”

Kraepelin thought such cases of paralysis were only
transitory conditions in the progress of other diseases,
and should be carefully observed; but with the
serum and cerebro-spinal fluid tests the differential
diagnosis and treatment should not be so difficult.

Mental Moral Weakness.

Gudden drew attention to the essential difference
of opinion on this subject. Lombroso was convinced
that property of the brain was the natural sequence
of the mental organ returning to its original level as
found in the savage, which is only translation of the
animal disposition. On the other hand, Naecke
opposes this view as impossible that such a disposition
can be transferred from the animal to the human
being, and attributes the condition to disease.

Forel has preached for years that the law of evolu¬
tion is as true of the intellect as it is of the body.

Wasman teaches that a gulf between the animal
and human intelligence exists which we cannot
exactly fill in. We recognise the one side by intellect,
the other by instinct. We may acknowledge the
phylogenetic development of the human psyche from
the lower animal, and the psyche of the cultured
man from the savage; but the question still remains :
Is this mental moral weakness similar in quality and
character to the savage ? Take the negro race of
America. It is now established beyond doubt that
we are not able by culture and education to raise the
black race above that mental plane. Cases are
reported of success in this direction, but these are
only white-washing—the black never changes in
nature.

Nothing will raise them to the higher ethics of
self sacrifice, gratitude or truth; even repentance
in the negro is unknown, or when it does appear, it
is only hypocrisy. The capacity for learning is
there, but the power of thinking in the abstract or
reasoning from premises with a correct judgment
are lamentably absent. We cannot compare the
diseased brain of the white man with the healthy
organ of the negro ; there is no disturbance in the
latter, no vision, fancies or imaginings that we have
in the diseased brain. The brain of the negro was
not first diseased then become sound, and no morbid
process had ever entered into its composition—it
was an inhibited virgin brain and would remain so
by atavism. More importance must be placed on
the race than the size of the brain, its coverings,
central ganglia, and its peripheral connections.

Experience teaches that punishment by imprison¬
ment or fines has no effect as a deterrent on the
negro, but enforced work has some influence.

Concurrent Antagonistic Bodies.

Bresina has been experimenting with animals in
the laboratory, and comes to the following conclusion—
The animal treated with different blood or erythro-
citefc forms a power of antagonism against all in a
greater ratio than the control animal with only one
sort of blood, or. in other words, a reciprocal limit¬
ation of the antigene is absent. The presence of this
antagonistic body in the former does not prevent
the formation of other new bodies. The presence or
absence of a normal haemolysin in a serum does not
therefore prevent the formation of an immune haemo-
lysin.

The injection of one sort of blood into a guinea-pig
increases the lytic power of other sorts of blood that
may follow. We have therefore not only agglutinating
bodies formed, but also haemolytic antagonists and
antigenes at the same time, the concurrence of the
antagonistic bodies playing no active part whatever.
Should prophylactic innoculation be required, one
or more make little difference in the result.

Spontaneous Bigemina.

Vanysek, at his clinic, exhibited a young man,
aet. 28, who when 24 developed sexual neurasthenia,
followed by this inversion of rhythm of the heart’s
action, coming under the generic term of “ Allor-
hythmia,” which includes bigemina and arhythmia,
the former inverting the beats, the latter an irregularity
of movement. Since his illness paroxysms oi this
bigemina come on with a painful burning sensation
over the cardiac region with ice-cold extremities,
which he considered was produced by an extra-systole
movement which Hering termed an unabridged
bigemina.” There was no organic change or other

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314 The Medical Press

CORRESPONDENCE.

Sept. 18, 1907.

morbid condition present to account for the disorder.
There were chronic contractions 'of the sphincter
iridis, making it difficult to examine the fundus exalted
vaso motor reflex, isolated bending of the phalanges
of the third fingers, with prominent spasms of the
platysina myoides present. A strange feature of
this case was that the patient could now sponta¬
neously call forth these phenomena and check them
at will by different movements, positions, or holding
the breath.

Cerebro-Spinal Therapeutics.

Radman has been experimenting with animals on
this disputed question of injecting or inoculating
under the skin against the original idea of injecting
into the dural sac. With cultures of the epidemic
cerebro-spinal virus he was unable to produce the
disease in animals but when injected into the dura
sac the disease was virulent. He therefore concludes
that cutaneous or subcutaneous tissue is unsuitable
or adverse to the growth of the meningeal cocci and
therefore no local or constitutional effects would
result from vaccination. Injecting the fluid drawn
from the same animal was equally worthless as far
as cure was concerned, as it had no effect in alleviating
any of the symptoms.

HUNGARY.

Budapest, Sept. 15th, 1907 -

At the recent meeting of the Budapest Inter-hospital
Association, Dr. Schmidt read an interesting paper
on the

Value of Tuberculin Reaction.

He tried to prove that the tuberculin reaction is not
infallible in the diagnosis of tuberculosis. His technique
is as follows : After absence of fever has been assured,
for several days by four hourly measurements, one milli¬
gramme of tuberculin in fresh solution is injected,
then, after four to five days, five times this amount.
In eight cases with positive reaction, tuberculosis was
found at autopsy in only five, in three carcinomata of
(esophagus and stomach were the sole lesions. In one
there was no reaction, yet evident tuberculosis. Des¬
pite such small doses and great care in injecting, serious
accidents may occur and a latent process may suddenly
become active and even lead to a rapidly fatalijssue.
This happened to Dr. Schmidt in three cases—one of
leprosy, combined with tuberculosis, one of incipient
apical tuberculosis, and one of affection of the serous
membranes. A source of error is to be found in hys¬
terical patients, they sometimes: react after tuber¬
culin injections and even after injections of plain
water.

Dr. Feleki spoke of a case of

Henoch’s Purpura.

He referred to a patient who had been admitted to
the surgical side of the hospital with pain, tenderness
and a lcucosytosis. She was prepared for operation,
with the idea that there was some acute abdominal
trouble, but a bilateral purpura was discovered accid¬
entally, a diagnosis of Henoch's purpura made, no
operation done, and patient recovered. He referred to
another case of his own, in which there was recurrent
abdominal pain closely resembling attacks of gall¬
stone or kidney colic. The appearance of a marked
erythema, however, made it clear that the case was
one of a visceral crisis accompanying a skin lesion. He
said that he had also seen the condition after the admin¬
istration of the anti-toxin of diphtheria. In this patient
a violent erythematous urticaria appeared over the
whole body eight days after treatment. With it there
was oedema in both eyelids, a slight arthritis. The
symptoms promptly disappeared.

Dr. Barta read a paper on

Immediate Repair of Laceration of the
Perineum.

He pointed out the importance of closing up even small
tears of the perineum, so as not to leave raw surfaces
for septic absorption. It was important to close large
tears so as to retain the function of the pelvic muscles.
The best time to put in these stitches was just before
the head pressed on the perineum, while the patient

was nsesthetised and before the parts had lost their
relative positions. With the left finger in the vagina,
and the thumb in the rectum, a large perineum needle
on a handle was passed just under the vagina, threaded
with silkworm gut; the two or three stitches hung
loosely in a Pean forceps, until the placenta had been
delivered, when they were quickly tied, bringing the
parts exactly together as they were before the tear.

Dr. R6v6sz related his experiences regarding
Pulmonary Embolism.

This condition and its evil associate, femoral throm¬
bosis, are as inexplicable as they are to be dreaded.
Neither has any bearing on wound infection, in fact,
it is well known that each is more apt to occur in the
course of an uneventful convalescence than otherwise.
Have phlebitis and pulmonic embolism a common
origin ? Each, so far as can be determined at any
rate, is aseptic, and each occurs typically after the
most successful operations. It is possible that changes
in the blood occur which are not evidenced by known
methods of examining this tissue. But why should
thrombosis of the left femoral occur so frequently
after operations on the right side. That the two con¬
ditions are associated with each other and with some
form of anmmia is to be suspected at least from the
frequency of their occurrence in patients who have
suffered prolonged haemorrhage.

Care of the City Poor.

The Budapest Association for Improving the Con¬
dition of the Poor are doing a vast amount of good, and
while they are necessarily expending a large amount of
money it is more than saved when it is considered that
the people whom this association is helping would fall
to the care of the city hospitals. The following figures
show the extent of the work :— 37 mother and 81
children were taken recently to their summer home
on the coast of the Adriatic Sea at a total expense of
about ^50. The association hopes to send several such
groups from the crowded tenement districts, Twenty-
five shillings will send a mother and baby to the sea¬
shore for a week.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

BELFAST.

Belfast District Lunatic Asylum.— The annual
report of this asylum, just issued, is as usual a most
interesting document, for Dr. William Graham supple¬
ments the official statistics with his own comments,
often of a most original nature. The daily average
number of cases under treatment was 1,108, and the
total admissions 241. As regards causation of mental
disease, Dr. Graham says that heredity is given as
the cause in 62 of the admissions, but this is only the
way in which the insanity is transmitted, and does not
explain the original cause. Seventeen cases were
attributed to alcohol, but here again the statistics are
not satisfactory, and Dr. Graham evidently agrees
with the opinion, which he quotes, that about 50 per
cent, of the cases are due to syphilis and alcohol.
The recently published views of the Inspectors of Luna¬
tics that the Irish race is particularly prone to mental
disease drew some vigorously expressed opinions from
Dr. Graham. “ If the nation is in danger of becoming
a nation of lunatics, it does not much matter who
governs us, or how much land the peasant possesses,”
and such observations as the Inspectors have made
call for the most serious attention. He thinks that
there are no doubt preventable cau ;es at work both
in Ireland and America to bring about this degeneracy
in the nervous system among the Irish in both coun¬
tries, and that the race is not specially " contaminated
with the virus of insanity.” The Russian and Hun¬
garian peasant, emigrating under much the same
circumstances, does not show the same liability" to
insanity as do the Irish, and Dr. Graham suggests
that this may be due to the greater mental activity of
the last; his brightness of intellect, and keen suscepti,
bility to joy and sorrow render him more liable to
mental breakdown in the new conditions of life—the

feed by Google

Sept. i*. I 9 ° 7 -

SPECIAL ARTICLE.

The Medical Press. 3*5

crowded tenements of big cities, and the keen com¬
petition for a livelihood. The ratio of recoveries to
th.- total number of admissions was 28.6. Of the
deaths, 15 were due to general paralysis of the insane,
a disease a few years ago almost unknown in Ulster.
As regards finance, it appears that after deducting
receipts from paying patients and other sources the
net capitation cost is ^21 is. 8d. per annum and the
amount payable out of the general purposes fund of
the city is £11 3s. 6d. for each patient chargeable to
the ratepayers.

LETTER TO THE EDITOR.

AN APPEAL TO THE MEDICAL PROFESSION.
To the Editor of The Medical Press and Circular.

Sir,— Allow me to bring under your notice a dis¬
tressing case that has occurred in this neighbourhood.
In January last, Dr. J. P. Maguire was seized with
sudden and severe illness, and succumbed to an attack
of acute Bright’s disease. He left a widow and a
little boy, aged 10 years, quite destitute, and I am
trying to get together enough money to pay for the
widow’s training as a midwifery nurse. The little
boy we have a prospect of getting settled in a school
near Dublin.

So far I have only applied locally, but the response
has been so feeble I am forced to appeal to a larger
public, the charitable members of the profession.

The following have already generously subscribed :

Dr. Haurahan, Hollymount..

£

2

s.

2

d.

0

Dr. Temple, Cong

1

1

0

Dr. F. Golding, Headford ..

1

1

0

Dr. A. Gill, Westport

1

1

0

Dr. Corcoran, Ballinrobe

1

1

0

Dr. Macaulay, Ballina

1

0

0

Dr. Costello, Tuam ..

1

0

0

Dr. McNulty, Killala..

1

0

0

Surgeon-Gen. Joynt, Dublin

0

10

0

Dr. Hegarty, Clonbur

0

10

0

Dr. Mahon, Ballinrobe

3

3

0

Donation from Royal Medical
Fund

Benevolent

*5

0

0

^28 9 o

Of this sum, £4 has been disbursed for pressing
necessities, leaving £24 9s. in hand. If this could be
brought up to £zo, it would enable us to place the
widow in a position to support herself.

I am, Sir, yours truly,

R. B. Mahon.

Ballinrobe, Co. Mayo, Sept. 14th, 1907.

[We shall be very glad to receive subscriptions for
this most deserving object, and we appeal to our
readers for their aid. All subscriptions received will
be acknowledged in the journal and forwarded to Dr.
Mahon.—E d., M.P. & C.)

OBITUARY.

CHARLES MACKINNON., CLARK, M.D.Brux.,
M.R.C.S., L.R.C.P.

We regret to record the death of Dr. Charles Mac-
kinnon Clark, which occurred at his residence. Rose
Hill, Dorking, on September 4th. Dr. Clark, who
was only 42 years of age, was taken ill soon after
he began his summer holiday at Zermatt, in the early
part of June, and is supposed to have contracted
tomaine poisoning. In the beginning of August
e left for Cornwall, and at first he seemed to improve,
but gradually he became worse again, and was brought
home in a serious condition. He never regained his
strength, and passed away exactly a week after his
return home. Dr. Mackinnon Clark was very popular
among all classes, and his death has caused much
sorrow in the town, while sympathy is especially felt
for his widow and their child. Educated at St. George’s

Hospital, Dr. M. Clark, after qualification, joined his
father in his extensive practice at Dorking, and since
his father’s death he continued the practice alone.
He was one of the honorary medical officers of the
Dorking Cottage Hospital, and medical officer to the
Dorking Oddfellows.

THOMAS LOGAN, M.D.Aber., AND F.P.S.Glasg.

We note with regret that the death took place on
September 4th, of Dr. Thomas Logan, in his 67th year.
Dr. Logan was educated for the medical profession at
Glasgow and Aberdeen Universities, and on the com¬
pletion of his medical course he was appointed superin •
tendent of the Paisley Infirmary. He subsequently
went into general practice in Dumfriesshire, where
he was Medical Officer for the long period of twenty
years for the parishes of Penpont, Keir, and Tynron.
He then left that place to commence practice in
Wibsey, near Bradford. At Wibsey, he was first
partner with the late Dr. Warburton, and on his death
succeeded to the practice as well as to all the public
appointments connected with it. He was Medical
Otficer of Health for North Brierley ; indeed, in the
Wibsey district he was in public and private service
there for twenty-five years. On his retirement he
was entertained to a public banquet in the Midland
Hotel at Bradford by lay and medical representatives
of the city, the function being attended by many
from north and south. Dr. Logan came to Harrogate
about two years ago. He had for a long time been
diligently engaged in scientific study, and it is hoped
that the fruit of his labours in this direction will
eventually be made public.

STUART NAIRNE. F.R.C.S.Ed.. F.F.P.S.Glas.

We regret to announce the death of Dr. Stuart
Naime on September 8th, at his residence in Renfrew'
Street, Glasgow. A native of the burgh of Irvine,
Dr. Naime was educated at St. Paul’s Parish School,
at the Normal Training College in Dundas Vale, from
which he passed to the University, where he took
high honours and secuied a £50 bursary in the chemistry
class. At the close of his medical curriculum, Dr.
Naime began practice in Glasgow, his special interest
lying in surgery. He conducted for some time a ladies'
class for gynecology in the Western Medical School,
which was largely attended. Impressed with the great
amount of suffering among women, he was the moving
spirit in the foundation of the Samaritan Hospital for
the free medical and surgical treatment of women.
In association with Dr. George Halkett, the late Mr.
Thomas Jenkins, and Mr. Thomas MacQuaker, the
present secretary and treasurer of the hospital, and
several other gentlemen, he formed the project in
December, 1885, and on January 4th, 1886, the
hospital was inaugurated by Lord Blythswood. Dr.
Nairn was the first surgeon of the hospital and Dr.
Halkett its first physician. He took a great interest
in the recent extension of the institution, and he was
present at the opening of the new section by Lady
Blythswood in April last. On his retirement he was
the recipient of a public testimonial, consisting of a
cheque for about £300, a study chair, and of silver
plate for Mrs. Nairne. Dr. Naime was an occasional
contributor to the medical journals, and in 1883 he
published several medical works. Of the Glasgow-
Obstetrical and Gynecological Society Dr. Nairne was
the first honorary secterary. Dr. Nairne is survived
by his wife, one son, and three daughters.

SPECIAL ARTICLE.

VITAL STATISTICS OF IRELAND.

The “Annual Report of the Registrar-General for
Ireland ” for the year 1906 contains little that can
cause comfort even to the most optimistic. With a
stationary death and marriage-rate, an increased
emigration rate, and a progressively decreasing
population, it is difficult to deduce any sign of
prosperity from the Registrar-General’s figures.

Digitized by GoOgle

316 The Medical Press.

SPECIAL ARTICLE.

Sept i 8. 1907.

The number of marriages registered in Ireland during
the year 1906 was 22,662; the number of births,
103,536; and the number of deaths, 74>4 2 7- The
marriage-rate was 5.16 per 1,000 of the estimated popu¬
lation, showing a decrease of 0.10 as compared with
that for the year 1905, but is 0.08 above the average
rate for the ten years 1896-1905 ; the birth-rate was
23.6 per 1,000 of the estimated population, showing
an increase of 0.2 as compared with that for the pre¬
ceding year, and is 0.4 above the average rate for the
ten years 1896-1905 ; and the death rate (17.0 per 1,000)
is 0.1 under the rate for the preceding year, and 0.9
under the average rate for the ten years 1896-1905.
The natural increase of population, or excess of births
over deaths, was 29,109; the loss by emigration
amounted to 35,344; it would appear, therefore, that
there was a decrease of 6,235 in the population during
the year, but against this decrease there is a set-off
in immigration, of which there is no official record.
Its effect is probably very slight.

The Registrar-General expresses regret that there is
an increasing majority of instances in which the ages
of the persons married are not stated, and in which the
only information of age given is the word “minor” or
the words “full age.”

Of 22,662 men married during the year, 3x1, or 1.37
per cent., were minors; and of the women married
1,096, or 4.84 per cent., were under age. Of those
married under age in 1906 the highest proportion of
husbands (1.71 pear cent.) was in the province of
Leinster, and of wives (5.89 per cent.) in the province
of Ulster. The percentage of persons married in Ire¬
land, who were under age, is very far below the
corresponding percentages in England and Scotland.

The highest marriage-rate for county, or county
borough areas (7.9 per 1,000 of the population) was in
the county borough of Dublin; and the lowest 3.1 in
each of the counties of Clare and Mayo. Between
these extremes the most favourable rates were 7.8 for
the county borough of Belfast, 5.7 for the county of
Dublin, and 5.6 for the county and county borough
of Londonderry, and the least so 3.4 for the county of
Galway, 3.4 for the county of Roscommon, and 3.8
for the county of Meath.

The 103,536 children whose births were registered in
Ireland during the year 1906, include 100,845, or 97.4
per cent, who were legitimate, and 2,691, or 2.6 per
cent, who were illegitimate, being equal to the corres¬
ponding average percentages for the preceding 10
years. These results compare favourably with the
returns for most other countries.

The proportion of illegitimate children is as usual
highest in Ulster, and lowest in Connaught, the rates
for the four provinces being:—Ulster, 3.5 per cent. ;
Leinster, 2.7; Munster, 2.2; Connaught, 0.7.

Taking the county or county borough areas, the
four highest birth-rates were 33.0 for Dublin county
borough; 31.2 for Belfast county borough; 24.4 for
county Kildare; and 24.1 for counity Antrim. The
four lowest rates were—18.3 for county Cavan ; 18.4
for Queen’s county; 18.7 for county Roscommon ; and
19.0 for county Longford.

During the year 1906 the number of deaths registered
in Ireland was 74,427, equivalent to 1 ini 59, or 17.0
per 1,000 of the population estimated to the middle of
the year. The deaths of males amounted to 37,131,
and those of females to 37,296, the rate per 1,000
males and 1,000 females, respectively, being 17.1 and
16.9.

The five county or county borough areas having the
lowest mortality rates per 1,000 of the population
were:—County Mayo, 1 r.7 ; county Leitrim, 12.0;
county Galway, 12.8; county Kerry, 12.9; and county
Roscommon, 13.x. The highest rates are as follows : —
Dublin county borough, 25.0; Belfast county borough,
20.6 ; county Armagh, 19.0 ; county Monaghan, 18.9 ;
and county Down, 18.1.

More than 14 per cent, of the deaths registered took
place in workhouses or workhouse hospitals.

As usual Mr. Matheson represents by a diagram the
principal causes of death operative during the year.
Tuberculosis again presents the highest column with
11,756 deaths, old age coming next with 8,409. In
discussing the incidence of zymotic diseases the
Registrar-General comments on the great decline in

the mortality from enteric fever. The number of
deaths from this disease was only 394, as against an
annual average of 755 for the 10 years 1896-1905. In
1898, no fewer than 1,284 °f the inhabitants of Ireland
died of enteric fever. Of the deaths in 1906, 97 were
registered in Belfast county borough, and 48 in Dublin
county borough.

The deaths from typhus have during the past two
years shown a tendency to increase in number. They
declined from 128 in 1900 to 53 in 1904, rose in 1905
to 68, and last year to'86.

There was in 1906 a high mortality from diarrheal
diseases, the deaths registered mounting to 1,675. Of
these, 379 occurred in Belfast, and 359 in Dublin.

There has been no death from rabies since 1898.

To the subject of tubercular diseases the Registrar-
General devotes careful attention, and those Interested
in the campaign against tuberculosis cannot fail 10
be grateful to him for his graphic representation of
facts and his strong comments thereon. He attempts
to draw the special attention of the Lord Lieutenant
to the matter, and goes on :—

“In introducing this subject, I may state that the
fall of the mortality rate for tuberculous disease in
England and Wales during the 42 years from 1864 to
1905, as may be seen in the diagram facing this page,
is a proof that the disease is at least capable of being
successfully combated, and for the purposes of the
militant sanitarian may be looked upon as a prevent¬
able disease. I cannot, your Excellency, say that it
is a matter of much congratulation that the high death
rate of 2.9 per x,ooo in the year 1904 for all forms of
tuberculous disease has declined to 2.7 per 1,000 in the
years 1905 and 1906. When I come to enumerate the
figures which I have compiled, I find that there were
11,756 victims, inhabitants of Ireland ; in other words,
out of a total of 74>4 2 7 deaths registered in Ireland
during the year 1906, no less than 11,756, or 15.8 per
cent., were sacrificed to a disease which is in a great
degree preventable. It is a difficult matter for me to
dissociate myself from responsibility in such appalling
circumstances, and I cannot feel that my duty ter¬
minates in merely collecting and classifying these most
depressing statistics. Year after year these facts are
published, and although the members of the medical
profession are strenuous in trying to awaken the Dublic
mind to a state of affairs that can only be considered
as destructive to the community, yet, comparatively
speaking, our countrymen are not alive to the dangers
which threaten them. Our people have shown that
they are not slow to appreciate the benefits of vaccina¬
tion as a protection from small-pox, and when they
are thoroughly awakened as to the infectious character
of tuberculous disease they will be the first themselves
to aid in its prevention.”

The diagram comparing the condition of affairs in
Ireland with that in England and Scotland shows that,
while in England the rate has declined from 3.3 j-er
1,000 in 1864 to 1.6 per 1,000 in 1905, and in Scotland
from 3.6 per 1,000 in 1864 to 2.1 per 1,000 in 1905, it
has risen in Ireland from 2.4 per 1,000 in 1864, to 2.9
in 1904 and to 2.7 per 1,000 in 1905 and 1906.

The number of deaths due to phthisis was 8,933, an ^
it is noticeable that the highest incidence was between
the ages of 25 and 35.

Mr. Matheson mentions that “the large proportion of
uncertified deaths in Ireland (24.4 per cent, of all
deaths registered) during the year 1906 is a matter of
grave importance both from the public point of view,
as well as from the point of view of the profession of
medicine.” But there is little doubt that the explana¬
tion lies in the fact stated by him that a custom pre¬
vails in many parts of the country of not seeking
medical advice, especially for the aged and those
suffering from chronic forms of disease. The large
number of persons returned as dying of “old age”
bears out this view. The total number of deaths from
accident, homicide, and suicide which were recorded
in the death registers of Ireland in the year X906 was
1,875 —by accident 1,685, by I homicide 43, and by
suicide 147 deaths. Of the total deaths attributed to
accidental circumstances, 1,126 were of males and 550
were of females. With this number of deaths as the
result of violence, we fail to understand why there
is record of only 1,788 inquests.

y Google

D

Sept. 18, 1907.

REVIEWS OF BOOKS.

The Medical Press. 3*7

Mr. Matheson furnishes fuller information on the
subject of infant mortality than has been his custom
heretofore. Two illustrative diagrams give respec¬
tively the comparative infant mortality curves of the
three countries, and the effects of fourteen principal
causes in producing infant mortality in Ireland. In
addition, he furnishes a map showing the relative
rates in the different unions throughout Ireland. In
the rural districts there is, of course, a low rate of
infant mortality, but in the town districts it is high.
The rate for the 22 chief town districts is 135.02 jer
1,000 children born, dying in the year. In the aggre¬
gate, however, the infant mortality rate of Ireland
compares favourably with that of other •'ountries.
In England and Wales the infant mortality rate,
which in 1864 was 153 per 1,000 births registered, was
133 in 1906 ; that in Scotland in 1864 the rate was
126, and in 1905 it was 116; while the infant mortality
rate for Ireland in 1864 was 98 per 1,000 births regis¬
tered, and in the years 1904, 1905, and 1906 ihe r..tes
were 100, 95 and 93 respectively.

The general arrangement of Mr. Mat'neson’s repo."t
is, as usual, excellent, and gratitude is due to him, as
well as to Dr. Ninian Falkiner, Medical Superintendent
of Statistics, for the interesting manner in which
information is given to the public.

REVIEWS OF BOOKS.

THE NURSLING, (a)

Professor Budin’s last work has a peculiar fasci¬
nation in that it gathers up the threads of a lifetime’s
toil and places on record the thoughts and opinions of
an enthusiast who made the subject of which he
treats peculiarly his own. It may be owing to
France’s need for population that infant-rearing has
been studied so carefully in that country, but certain
it is that we have as yet very little to show in Great
Britain to match in interest or importance the organi¬
sation that is springing up in that country for the care
and protection of the infant. These practical results
are the outcome of the efforts of the school of obstetrics
of which Pinard and Budin were the foremost teachers,
and in the placing of infant-culture on a scientific
basis the last-named must ever take the credit due
to the pioneer. What Budin’s difficulties must have
been we are not told, but we can imagine him
triumphing over them all with that genial optimism
and delighted confidence which are so strongly in
evidence in this book. It is. indeed, just the sort of
book it takes a Frenchman to write—original, clever,
logical, even brilliant, so that the reader puts it down
with a sigh at his own denseness for not knowing how
easy it is after all to rear premature and weakly
children. But on second thoughts he begins to doubt
whether it is so easy, and to wonder whether the
genial professor does not see everything through
couleur de rose spectacles. Indeed, we have here in this
book something more than a mere professor; the
author is half Santa Claus, half fairy godmother.
Is anything wrong with the baby ? In pain ? Sick ?
So, a few kind remarks, a gentle turn of the wrist,
and lo ! it is well. But for all that let Professor
Budin be optimistic. It is the optimist who conquers
the world, and this work of his has gone a long way
towards systematising and placing on sure ground the
rearing of the babies of the State, and if we do not
agree with him in his estimate of sterilised milk, and
in all his other opinions, we can truthfully say that
this is the most important work on the subject that
has yet been published, and that if France is ever
again to have a grande arnu'e whether of war or of
industry, she will owe it more to Budin than to the
doctrinaires who prate in their armchairs of falling
birth-rates.

(•) “ The Nursling: the Feeding and Hygiene of Premature and
Full-term Infants." By Pierre Budin, Professor of Obstetrics, Uni¬
versity of Paris. Authorised Translation by William Maloney, M.B.,
Ch.B. With an Introduction by Sir Alexander R. Simpson, M.D.,
LL.D., D.Sc. in diagrams in colour. London: The Caxton Pub¬
lishing Co. 1907.

A TREATISE ON ORTHOPEDIC SURGERY, (a)

In this “ Treatise on Orthopaedic Surgery,” the author.
Dr. Whitman, has succeeded in presenting the subject
in a most interesting and instructive form. The
general appreciation of this fact is no doubt the reason
why this work has now attained its third edition.

In dealing with disabilities and deformities one is
led by the author to the rational method of their
treatment, by a study of the particular affection from
an xtiological and mechanical point of view’. For
instance, in the chapter on Weak or Flat Foot, where,
perhaps, we can form the best idea of the way in which
the subject is treated, we find paragraphs under the
following headings : General description of the foot
and of its functions, the arches, the foot as a passive
support, in activity—Improper postures—Movements
—Function of the muscles—Strength of the muscles
(with tables)—The foot as a mechanism—The weak
foot or so-called flat foot—Description—Anatomy—
Pathology — Etiology — Statistics — Symptoms—
Diagnosis—Varieties—Weak foot in children—Ex¬
ceptional forms—Treatment — Preventive — Exercises
—Support—Construction of brace—The rigid w'eak
foot—Forcible correction of deformity—Subsequent
treatment—Adjuncts in treatment—Operative treat¬
ment. In the work generally, operative treatment
(by the knife) is briefly indicated, and, as a rule, not
given in detail. We may say that each section is lucid,
concise, and to the purpose, making the work a useful
acquisition to the student, the general practitioner
ana worker in this special branch of surgery.

It is a difficult matter in a review to touch on all
the excellent qualities that might be alluded to in this
work. Considerable attention has been paid to the
methods of examining, measuring, and recording de¬
formities. Also careful descriptions are given of
exercises, manipulations, and apparatus used in their
treatment—a subject that is not always dealt with in
so thorough a manner as it is here. But in this con¬
nection, more might certainly have been said with
advantage on the manipulative treatment of con¬
genital club foot.

In conclusion, this Orthoprdic Surgery contains 554
well chosen illustrations, mostly reproductions of
photographs, and some skiagraphs. These numerous
illustrations, though not an essential part of the work,
as it is in some of the more recent medical text-books,
especially from America, add very materially to the
value and utility of the book.

ADAMSON ON SKIN DISEASES. (6)

As a " practical guide to the clinical study and
treatment of skin affections in children ” Dr. Adamson
has produced a book “ based very largely ” upon his
own personal experience, and, in common with other
works of a like character, it suffers from a certain want
of balance. We must confess that we expected to
find it brimming over with descriptions of cutaneous
lesions and manifestations such as are only found in
childhood, but, although some of the disorders treated
of are dealt with from the point of view as they appear
at this age, sufficient stress is not laid upon the clinical
differences between skin affections of children and
adults. 1 he best part of the book is that dealing with
ringworm of the scalp and its treatment by the X-rays.
The chapter on eczema is also good, the author taking
the view that “ an affection which is primarily microbic
is not eczema.” He has retained the not altogether
satisfactory term, “ tuberculous eczema,” while ad¬
mitting that the type thereunder described has no
relation, in his opinion, to tuberculosis. It is rightly
stated that the key-note of successful treatment iD

(а) “ A Treatise on OrthopjBdic Surgery." By Royal Whitman,
M.D., Clinical Lecturer and Instructor in Orthopiedic Surgery in the
College of Physicians and Surgeons of Columbia University, New York,
Ac. Illustrated with 354 engravings. Pp. xii. and 871. London :
Henry Kimpton. 1907.

(б) “Hkln Affections In Childhood." By H. G. Adamson, U.D.,
M.R.C.I’.. Physician for Diseases of the 8klu, Paddington Green
Children's Hospital, and the North-Eastern Hospital for Children.
Oxford: Henry Frowde. London: Hodder and Stoughton. Pp. xrl.
and 287 . Illustrated. Price 5 s. net.

Digitized by G00gle

3*8 The Medical Pees*.

MEDICAL NEWS IN BRIEF.

Sept. 18, 190 7

infantile eczema is protection from irritation,^and
that unless this be adequately secured the best reme¬
dies will fail in their action. The supposed danger
of curing an eczema in childhood rapidly is not treated
very seriously, and no caution is specially'advocated
against employing powerful or toxic remedies over
large eczematous areas. Only two lines are devoted
to caterpillar-rashes which, if not very important,
have attracted considerable attention both in this
country and also in America. The harvest-bug is
not mentioned, though its lesions are common enough
among children who romp in cornfields and play
among hayricks in summer. The photographic illus¬
trations are excellent, and there is a useful list of
formulae appended. The index might with advantage
have been much fuller.

TICS AND THEIR TREATMENT, (a)

The translator has conferred a service on his collea¬
gues by publishing this important work. The authors
favour the distinction, originally observed by Willis,
between continuous, permanent tonic convulsions,
and intermittent, momentary clonic movements.
They regard the use of the epithet “ convulsive ” as
superfluous, and prefer to employ the term “ tic ”
by itself, save in such cases as it may be found abso¬
lutely necessary to indicate the precise nature of the
muscular contraction. The pathogenesis of tic is dis¬
cussed in the third chapter. In this connection, a very
careful distinction is drawn between the two terms
“ tic ” and " spasm,” which are so apt to be used
indifferently as if they implied the same condition.
A tic is a co-ordinated, systematised, and purposive
act. It results from voluntary repetition of the same
movement by the patient; but mere repetition is not
sufficient to evolve a tic in every case. Psychical
predisposition is absolutely essential in the form of
volitional enfeeblement, and the authors lay consider¬
able stress on the important bearing of mental in¬
sufficiency.

The different tics are arranged and discussed under
separate headings, such as facial, auditory, vision and
arm tics. Numerous cases are given in illustration
of these varieties. The treatment of tics naturally
comes in for a considerable share of attention. To
neglect them or to consider them incurable is entirely
unwarranted. Drugs are of little value. Diet and
general hygiene must be attended to, while hydro¬
therapy is always of service. Massage ought to be
given a trial; but the use of mechanical apparatus in
order to avert muscular insufficiency is deprecated, as
is also electricity in all its forms. Hypnotic suggestion
is very useful in some cases. Re-education is the only
really valuable form of treatment, and the writers
detail the exercises which the patient should in every
case be made to carry out. He must be made to
perform certain slow, regular, and accurate move¬
ments limited to the muscles of the area involved.
These exercises must not be too prolonged. In addi¬
tion, the patient should be required to remain abso¬
lutely motionless for a few seconds at a time. Other
additional measures such as rest in bed and isolation
are not generally commendable. The translator has
done his woric well, and the book has been excellently
turned out by the publisher,

GENERAL SURGERY, (b)

This ambitious attempt to summarise all recent
contributions of importance in the domain of surgery
will doubltess be appreciated by “ pure ” surgeons.

(а) '* Tic* and Their Treatment.” By Henry Meige and E. Feindel.
With a preface bv Professor Brissaud. Translated and Edited with
a Critical Appendix by S. A. K. Wilson, M.A., M.B., B.Sc., Resident
Medical Officer, National Hospital for the Paralysed and Epileptic
London: Sidney Appleton. 1907.

(б) " Practical Medicine Senes.” Edited by Gustavus P. Head.
M.D., Professor of Laryngology and Rhinology at the Chicago Post-
Graduate Medical School Vol. II.—General Surgery. Edited by

i ohn B. Murphy, A.M., M.D., LL.D., Professor of Surgery in Rush
ledical College. Series 1906. Chicago: The Year Book Publishers
Glasgow: Gillies. Vol*. I. and VI.—“ General Medicine." Edited
by Frank Billings M.S., M.D., Dean of the Faculty of Rush Medical
College, and J. H. Salisbury, A.M., M.D., Professor of Medicine, Chicago
Clinical School.

For the general practitioner its interest will probably
not be so great. It at any rate serves the purpose
of indicating the trend of present-day surgical pro¬
cedure in the various departments. The task of
selecting and summarising the material seems to have
been very judiciously performed and, indeed, it
would hardly be otherwise in the hands of such an
accomplished and experienced editor as Mr. Murphy,
whose fame is world-wide. There are a fair number
of illustrations and diagrams in elucidation of the text.

We can quite believe, as stated by the editor,
that the advance in the year’s annual output of medical
literature put his powers of discrimination each year
to a severer test. Still, great advantage attached
to such a summary if only because no ordinary person
could possibly command so comprehensive a view of
contemporaneous work and thought. One has only
to look through the admirable synopsis of tuber¬
culous literature to grasp the importance of the
work here recorded. Text-books of the present day
so rapidly go old in the sense of failing to remain abreast
of the times that some such work as this is a well-
nigh indispensable companion to the ordinary works
of reference. Every practitioner wants, for instance,
to post himself in the latest news or data concerning
epidemic cerebro-spinal meningitis (which is dealt
with here as distinct from ” spotted fever.”). Malta
fever is fast becoming a subject of interest now that
its existence in widely distant areas has been demon¬
strated, with the promise of a further spread.

It may be that the practitioner of the future will
prefer this methodical way of adding to his store of
information instead of taking it by tablespoonfuls
in the medical journals, but after all the synopsis
cannot replace that from which it draws its being,
e.g., contemporaneous medical literature.

Medical News in Brief.

Award of Medals for Tropical Medicine Research.

The Mary Kingsley medal, instituted by the Liver¬
pool School of Tropical Medicine in memory of Miss
Mary Kingsley, who died in 1900, has been presented
to the gentlemen mentioned below for work of special
research into tropical medicine :—

1. Colonel David Bruce, F.R.S., C.B., Royal Army
Medical Corps, who in 1887 discovered the cause of
Malta fever, and proved that that malady was pro¬
duced by the milk of infected goats.

2. Professor Dr. Robert Koch, Nobel Laureate, who
ascertained the cause of cholera, and who has con¬
tributed much to the knowledge of tropical diseases,
especially the discovery of the frequency of malarial
infection in children.

3. Dr. A. Laveran, Pasteur Institute, Paris, and
D.Sc., University of Liverpool, who in 1880 made the
great discovery that malarial fever is caused by
parasites in blood.

4. Sir Patrick Manson, F.R.S., K.C.M.G., London
School of Tropical Medicine, who in 1878 discovered
that one of the parasites of man belonging to the group
of Filaria is carried by a kind of mosquito.

5. Dr. Basile Danilswsky, Professor of Physiology,
University of Kharkoff, who discovered numerous
parasites of blood in a large number of animals shortly
after Laveran’s discovery was made.

6. Dr. Charles Finlay, chief sanitary officer of Cuba,
who in 1880 originated the theory that yellow fever is
carried by mosquitoes.

7. Dr. Camirlo Golgi, Professor of Pathology,
University of Pavia, who in 1887 made a complete
study of the life cycle of parasites of malaria.

8. Colonel W. C. Gorgas, United States Army, who.
as chief sanitary officer of Havana gave practical effect
in 1902 to the discoveries of Finlay and of the American
commission in connection with yellow fever, and
succeeded 1 in banishing the disease from the city.

9. Waldemar Mordecai W. Haffkine, C.I.E., who in
1893 discovered a method of inoculation beneficially
used in India.

Sept. 18, 1907.

MEDICAL NEWS IN BRIEF.

The Medical Press. 3*9

10. Dr. Arthur Loos, Professor of Parasitology,
School of Medicine, Cairo, for work in connection with
parasitology.

11. Dr. Theobald Smith, Professor of Comparative
Pathology, Harvard University, who in 1893 dis¬
covered a new kind of blood parasite in the so-called
Texas cattle-fever.

Yet Another Medical Manifesto.

Miss May Yates, hon. secretary of the Bread and
Food Reform League, sends us a copy of a manifesto
on the subject of food which has been signed by
members of the medical profession and scientific
societies. In this they say :—

“ We desire to endorse the opinion expressed in
the report of the Inter-Departmental Committee on
Physical Deterioration that insufficient and improper
food is a prominent factor in the causes to which
degenerative tendencies might be ascribed, and that
it also tends to produce a craving for drink.

“ As the report shows that there is a very large
amount of ignorance about the right choice and proper
preparation of food, and as much distress would be
lessened by a knowledge of foods which nourish com¬
pletely at the least cost, we venture to urge the Lord
Mayors and Mayors of London and of other cities and
towns, all municipal authorities, societies, and in¬
dividuals interested in ameliorating the condition of
the people to direct attention to this important subject.

“ Without advocating any special system of diet,
we urge teaching the economic and nutritive value of
much-neglected staple foods such as oatmeal, wheat-
meal, barley, rice, maize, peas, beans, lentils, nuts,
fresh and dried fruits, green and root vegetables, as
their more general use would promote the health of
all classes of society.”

The manifesto is signed by, among others, Sir James
Crichton-Browne, A.R.S., Sir Lauder Brunton, F.R.S.,
Dr. John Beddoe, F.R.S., Mr. Edward Berdoe, Sir
William Crookes, F.R.S., Mr. A. D. Fripp, K.C.V.O.,
C.B., Mr. A. Pearce Gould, Mr. George Henslow,
Dr. Robert Hutchinson, Dr. Robert Miller, Dr. W. R.
Smith, Mr. W. B Tegetmeier, F.L.S., Dr. Sims Wood-
head, and Sir Samuel Wilks, Bart., F.R.S.

Signatures in support should be sent to Miss Yates
at 42A, Bloomsbury Square, London, W.C.

Infantile Mortality Congress.

The second international congress of authorities
and societies interested in the milk supply and the
protection of children against disease has been sitting
in Brussels. Fourteen Continental and other Govern¬
ments have sent official delegates. The British
Government sent no official representatives, but both
Australia and Canada did so. England was, however,
represented informally by the following ladies and
gentlemen : Drs. MacCleary, Taylor, and Liell, Miss
Marion Fitzgerald, Mrs. L. J. Greenwood, Councillor
\V. Fleming Anderson, Dr. A. K. Chalmers, Alderman
Broadbent and Dr. S. G. Moore, Dr. James Niven and
Miss M. G. Taylor, Councillor Dr. Cullen, Dr. J. Milson
Rhodes, Miss Zannetti, Dr. MacIntyre, Dr. Sydney
Davies, representing the Associated National Con¬
ference of England on Infantile Mortality. Dr. L.
Coit represented the American Association for the
Control of the Milk Supply, and other kindred societies
of the United States. A feature of the congress con¬
sisted in the practical demonstrations held at the Arts-
and Crafts Exhibition, now in progress at the Cinquan-
tenaire, of the Pasteurisation of milk according to the
method introduced by Mr. Nathan Straus in New York.
The system of Mr. Straus is best described in a paper
distributed at the congress.

London Consumption Conference.

A conference of representatives of metropolitan,
city, and borough councils was lately held at the
instance of the Paddington Council, at the Town Hall,
to consider the best methods of preventing pulmonary
tuberculosis, and various resolutions, including one in
favour of compulsory notification, were adopted.
These were sent to the President of the Local Govern¬
ment Board with a request that he would receive a
deputation from the conference. Mr. Burns replied

that ‘‘The subject (prevention of consumption) has
! received the serious attention of the Board, and a
report on the matter is being prepared in their medical
| department, which they hope will shortly be issued.

1 In the meantime, it does not appear to the President
I to be necessary that he should trouble the deputation
to attend, but he will be prepared to consider any
further statement which the councils may wish to
submit to him in writing.” Mr. A. W. J. Russell,
Town Clerk of Paddington, honorary secretary of the
conference, has, on its behalf, again asked Mr. Bums
to receive a deputation. Sir G. Fardell and Mr. L. G. C.
Money, the Members of Parliament for Paddington,
have been requested to co-operate in securing a re¬
vision of the President's decision.

The Proposed “Tuberculosis Exhibition" In Dublin.

A meeting of the Consultative Committee of the
Tuberculosis Exhibition, to be held under the auspices
of the Women’s National Health Association of
Ireland at the Home Industries Section of the Exhi¬
bition, Dublin, in October next, was held recently
in the Leinster House, Kildare Street.

Her Excellency the Countess of Aberdeen, President
of the Association, occupied the chair, and opened
the proceedings with a short speech, in which she
detailed the objects of the Exhibition. Short
descriptions were then given by the organisers of the
different sections of the nature of their sections.
Amongst the speakers were Professor McWeeney,
Dr. Lily Baker, Dr. A. Boyd and Dr. W. J. Thompson.
Sir Henry Swanzy, president of the Royal College
of Surgeons then proposed a resolution approving
l of the steps taken by the Executive Committee with
the object of forming a representative and instructive
collection of objects illustrating in a popular manner
the subject of tuberculosis and its prevention, and
pledging themselves to do all in their power to make
the forthcoming Tuberculosis Exhibition a success.
This was adopted, and Dr. W. Calwell, Belfast, repre¬
senting the Ulster Medical Society, moved a resolution
commending the Tuberculosis Exhibition to the
support of Irish public bodies and philanthropic
organisations, and urging that steps should be taken
to induce visitors to inspect it. This was carried
unanimously, and after a vote of thanks to her
Excellency for presiding the meeting ended.

R*yal College ot Surgeons In Ireland.

The second post-graduate course at the Royal
College of Surgeons in Ireland will commence on
September 23rd, and continue until October 15th.
As almost the entire clinical material in Dublin will
be available for purposes of instruction, the course
should prove to be of the greatest value to medical
men who desire to freshen up their knowledge and to
keep abreast of the times.

WE^have received the Annual Illustrated Guide of
the London and South-Western Railway (price id.),
and we can cordially recommend it to the notice of
those thinking of spending a holiday in the delightful
country served by that line. The Guide is exceedingly
well printed, illustrated, and got up. and it furnishes
a large amount of useful information about the chief
towns in the South-West of England. Nor is the
Continent forgotten, and prospective tourists will find
helpful descriptions of Paris and the Riviera to aid and’
guide them. Altogether itis quite a “ monster ” penny¬
worth.

Between 20 and 30 persons atTollesbury and others,
at Wigborough, Peldon, Layer, Birch, and Salcot.
have developed illness after eating brawn. Among
the sufferers is the Rev. F. E. Crate, curate-in-charge
at Salcot, and his family. Dr. Thresh is making
investigations into the cause of the malady.

The Committee of the National Association'for the
Establishment and Maintenance of Sanatoria for
Workers Suffering from Tuberculosis are about to-
open the second half of their main building at Benen-
den, Kent, which will accommodate 68 patients.

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3 2 ° The Medical Press.

WEEKLY SUMMARY.

Sept. 18, 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT MEDICAL LITERATURE.

The Transvesical Operation lor the Relief of Pro¬
statism.— C. Bowers, in a paper (American Medicine ,
July) on the relief of prostatism in the aged male,
■calls attention to the fact that a number of old men
have enlarged prostates—some 60 per cent.—but of
these not more than some 15 per cent, suffer from
prostatism ; on the other hand, many people suffer
from prostatism whose prostates are not enlarged,
the condition in these cases being caused by a con¬
tracture at the neck of the bladder. This may give
rise to the same symptoms as an enlarged prostate
does, and in many cases prostates are removed for
such a condition, in which a much less severe opera¬
tion would have sufficed to cure the patient. The
writer does not think that it is possible to make a
certain diagnosis of this contracted condition of the
neck of the bladder without a digital examination,
made through a suprapubic wound. The most noted
changes associated with prostatism are—bulging of
the posterior commisure, lengthening in, and distor¬
tion of the prostatic urethra, with some sclerosis of
the prostate itself, and contracture of the neck of the
bladder. This last condition being present in most

• cases and being the most important of the anatomical

• changes,*is largely responsible for the symptoms
of retention, congestion and inflammation at the neck
of the bladder. The author is firmly convinced that
the suprapubic method is far better for exploring the
bladder than the perineal, and that more conservative
.and rational operations will yield better results, and
lower the mortality of the former operation to equal
or less than that of the perineal route. An exact
-diagnosis can in many cases only be made on the ex¬
posure of the vesical outlet. The suprapubic route
is as rationally indicated for the relief of such obstruc¬
tive lesions at the urinary outlet, as it is in the case
of vesical calculus, the perineal operation offering only
30 per cent, of cures, with 1-07 per cent, mortality, and
a 50 per cent, chance of having exchanged one urinary
difficulty for another, and not infrequently a lesser
for a greater one. The transvesical operation entirely
relieves all who survive of their urinary troubles, if
due to obstruction in or about the vesical outlet,
except when carcinomatous in character. The con¬
troversy that is now going on relative to perineal
and suprapubic prostatectomy is only a repetition of
the one waged when lithotomy was undergoing its

• evolution. No one to-day cuts for stone in the male

bladder per perineum. It is most essential that the
profession should recognise, first, that prostatism is
due to other causes than hypertrophy of the prostate
gland, secondly, that the transvesical operation for
prostatism has attained a sufficient degree of per¬
fection to be recommended to this class of pitiable
sufferers, with the assurance of cure if availed of
before the inflammatory process has reached the
kidney, and arrested its functional activity ; thirdly,
that such cases should not be submitted to catheterism
in the future, as they have in the past, until it is
hopeless to interfere surgically. G.

Fibrolysin in Abdominal Adhesions. —Emmerlich
( Allg. Med. Zcitung, March) records the case of a man
who had been severely injured in the upper part of
the abdomen seven years before; this injury was
followed by numerous adhesions forming about the
stomach and intestines. A laparotomy was done,
.and these adhesions separated as well as possible, but
in a short time the symptoms began again and finally
the patient became worse than ever, the bowels only
moving after strong doses of purgative medicine, and
such medicine always caused intense pain before the
bowels acted. Fifty injections of Merck’s fibrolysin

were given, into the subcutaneous tissue of the upper
part of the abdominal wall, at first, but as this proved
painful, they were afterwards given in the gluteal
region, the patient’s chief complaint being the strong
taste of fibrolysin he felt in his mouth for some time
after each injection. At the end of the course the
bowels acted daily, without the aid of any aperients.
Five months after the last injection, digestion was
perfect, and defecation quite painless and normal,
so the cure is in all probability a permanent one.

G.

Plumbism Following Bullet Wounds. —Professor
Braatz (Munch. Wed. Woch., May, 1907) relates the
case of a beater, who received a charge of shot in
both legs. This accident was followed in a few weeks
by the onset of severe symptoms of plumbism. in¬
cluding neuralgia in the legs and both trigeminal nerves.
There was such severe stomatitis, that the dental
fangs were surrounded by pus, and twenty-four teeth
were extracted. There were tremors in the fingers
and tongue. In a very short time the patient lost
nearly three stone in weight. The X-ray examination
of the leg showed that there were only seven small
pellets imbedded in the patient’s leg. Only six other
similar cases are recorded, and from them it is evident
that the diagnosis is rendered unusually difficult by
the apparent capriciousness with which plumbism
occurs after such bullet wounds. Large bullets may
remain in the body for years and give rise to no symp¬
toms ; in other cases a few grains of shot after lying
latent for years, or within a week or two of the time
they were imbedded in the patient, may give rise to
a sudden attack of severe plumbism. Sometimes
the onset is extremely insidious, one symptom after
another appearing in the course of years. In doubtful
cases the blood should be examined for basophile
granules in the erythrocytes. G.

The Treatment of Chronic Constipation with Re-
gulin. — (Theapic d. Gegenwart, May, 1907).—Meyers’
results from the use of regulin (agar-agar plus a small
amount of cascara) in the treatment of chronic con¬
stipation have been excellent, like those of most
previous writers on the subject. Out of 71 cases 62
were favourably influenced, so that he considers
it by far the best drug for constipation. Its special
advantages lie in the fact that it is not necessary
to increase the dose after long continued use, and
that its action is almost wholly mechanical. The
dose is a teaspoonful to three dessertspoonsful a day,
according to circumstances. It is best given in soup,
mashed potato, or apple sauce. D.

A New Cutaneous Reaction in Tuberculosis. —Von

Pirquet (Berl. Klin. Woch., May 20, 1907) found that
if tuberculin is introduced into the skin of a tuber¬
culous child there will appear at the point a small
papule not unlike the papule of vaccination, at first
bright, later more dark red, and lasting about eight
days. A small quantity, about two drops, of diluted
tuberculin (old) is placed on the skin and a small
scarification is made with a sterile lancet right through
the drop. Von Pirquet has made 500 tests and
obtained a positive reaction in nearly all the cases
of clinical tuberculosis in infants. It was not absent
in any case of miliary tuberculosis or of tuberculous
meningitis in the last stage, or in infants markedly
cachectic. The most characteristic reaction was
obtained in cases of tuberculosis of the bones and
glands. The reaction possesses diagnostic value,
principally in the case of patients in the first year of
life, and here it may prove of great value in the diag¬
nosis of tuberculosis. In tuberculous animals a

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WEEKLY SUMMARY.

The Medical Press. 3 21

Sept. i8, 1907.

similar reaction becoming positive and distinct in
twenty-four hours is obtained. The reaction may
be regarded as indicating an increased degree of
sensitiveness of the skin to infectious material on the
part of those suffering at the time with actual infection
by the corresponding microbe. D.

Tetany. —Chovstek [Wien. Med. Woch., No. 23)
says that all those factors which previously have
been considered as being the etiological cause, are
merely exciting causes. In individuals affected
with tetany, the onset of menstruation, an angina, or,
as the author has seen, the injection of tuberculin,
is sufficient to excite an attack. The specific cause
of the reaction in tetanic individuals is a constitutional
one, and is probably associated with a functional
disturbance of the parathyroid glands. D.

Suprarenal Haemorrhage: A Usual Cause of Sudden
Death. —Munson [Jour. Am. Assoc., July, 1907)
reports a case of collapse and death in which at autopsy
the cause was found to be haemorrhage in both supra¬
renal glands. Suprarenal haemorrhage is said to be very
common in still-born and very young infants, but in
adults it is comparatively rare. Clinically the cases
simulated peritonitis or internal haemorrhage and show
symptoms of suprarenal insufficiency (i.e., prostration,
loss of weight, diarrhoea) or resemble apoplexy. D.

Lupus Vulgaris Secondary to Tubercular Lymph
Glands. —Jones [Brit. Journ. of Dermatology, September,
1907; discusses the origin of this disease in the light of
an analysis of the cases treated in the light department
of the London Hospital. The 923 cases so collected
are divided into six groups: (1) 47-3 per cent, begin
as a small spot on the face, cheek, or neck; (2) 28.9
per cent, begin on the nose or in the nostril ; (3) 11.4
per cent, are secondary to tuberculous glands, either
in the scar or in gland-abscesses ; (4) 1.8 per cent,
arise from mucous membranes, other than the
nasal, chiefly the margins of the lips; (5) 1.8 per
cent, secondary to tuberculous disease of bone;
(6) 8.5 per cent, arise in miscellaneous ways and on
various parts of the body. In this connection it is
interesting to note that quite a number of patients
gave a definite history of the disease, first beginning
as a swelling on the cheek, about an inch and a half
outside and three-quarters of an inch above the angle
of the mouth. The patients stated that this swelling
burst and the disease started from that. Dr. Jones
says: “ Naturally it strikes one that this was primarily
a tuberculous focus in the subcutaneous tissue of
that region, and possibly a tuberculous lymphatic
gland. Such a gland is described by Pourrier, lying
on the buccinator muscle, called the facial gland, and
believed to drain the region about the angle of the
mouth, both inside and out. (‘ Lymphatics' by
Pourrier, translated by Leaf, Chap. V., 2.)” K.

Fatal Case of Acute Lapus Erythematosls.—

Short (Brit. Journ. of Dermatology, August, 1907)
reports a case of this disease which was first described
by Kaposi, but which is very unusual in this country.
The patient, a woman, aet. 28, gave a history of four
months' illness on admission to hospital, when she
presented a condition of diffuse swelling at the bridge
of the nose and adjacent parts, and over the left
malar region a reddened patch about the size of half-a-
crown. The first sign of the disease was noticed
on the tips of the fingers and toes and on the lobules
of the ears where the skin became covered with coarse
scales of a dark red colour. On admission the finger
tips and toes were red and desquamating and there
was slight (Edema of the feet. A week later small
blebs containing pus appeared on the side of one finger
and of one toe near the nails, and .the eruption on the
face spread considerably and became covered with
herpetiform blebs which dried up into crusts. After
this small rings of follicular ulcers appeared on the
roof of the mouth, the vulvse became oedematous,
and the lymphatic glands generally enlarged, hard and
tender. The temperature averaged about ioi° F.
Five weeks after admission the patient had a con¬
vulsion and became unconscious, after which she

vomited and her condition improved for a time. A
week later the vomiting began again, the face swelled,
herpes appeared and, after a few days, twitchings
and convulsions were of almost daily occurrence.
In the gluteal region several painful subcutaneous
nodules appeared, the patient developed pneumonia,
and died eight weeks after admission. The urine
was always of low specific gravity, pale in colour,
reduced in quantity, and contained a small amount
of albumen. K.

The Beneficial Effect of One Disease on Another.—

Bury. (The Med. Chronicle, August, 1907) reports two>
cases in which it appeared that the occurrence of ai
second disease had a markedly beneficial effect on
an already existing disease from which the patient
was suffering. The first patient was a man set. 44,.
who was admitted to hospital with symptoms of
cardiac muscle failure and signs of mitral regurgitation.
This patient remained in hospital for seven weeks,
without any improvement, at the end of which time
he was so bad as to need subcutaneous injections of
strychnine. Infection resulted from one of these
injections and the patient developed a severe cellulitis
of the arm which ended in suppuration. From the-
date of the onset of the suppuration the cardiac
symptoms improved, and shortly after he left the
hospital apparently quite well. The second case
was that of a man admitted to hospital with symptoms-
of insular sclerosis, including marked hemi-atrophy
of the tongue. He was discharged without much
change, but sometime after he had a severe attack of
smallpox, on recovery from which his former symptoms
began to disappear and in a few weeks he was quite
well. Dr. Bury saw him three and a half years later,
and says he “ could detect nothing wrong with his
limbs ; the gait was normal; there was no nystagmus
and no difficulty in speech. The left half of the
tongue, however, was still atrophied.’’ K.

Thiokol and Myrtol. —Dibailow (Russ. Pract.,
Avzt., 1907. No. 24) has employed these drugs in
chronic bronchitis and pneumonia. They were at
first used for pulmonary tuberculosis, but more
extended experience seems to show that they are
valueless in that disease. The present writer has ob¬
tained most satisfactory results in 53 cases of bronchitis,
and five cases of lobar pneumonia with thiokol. The
doses varied from two to seven grains three times
daily after meals. The improvement noted consisted
in a diminution of the sputum, a lessening of the
dyspnoea, and a practical cessation of coughing.
None of the objectional symptoms described by
Rossi, such as vomiting and headache, were observed.
Myrtol was used in 26 cases of chronic bronchitis,
the drug being administered in two-grain doses in
gelatine capsules. It was well borne and seemed to
exert a similar effect to that of thiokol, but less marked-
It was particularly useful in foetid bronchitis. M.

Veronal as a Hypnotic. —As a result of 78 careful
observations, and after a study of the literature,
Likudy concludes (Russ. Med. Rundschau, 1907,
Heft. 6., p. 362), that veronal is the best of the newer
hypnotics, and formulates the following statements :—
(1) Veronal is characterised by the harmlessness and
certainty of its action ; in 78 per cent, of all cases
its action is efficient; the ordinary dose for women
should be five grains and for men seven and a half
grains. (2) The sleep after taking veronal usually
appears after half an hour, and lasts from six to nine
hours ; its character is the same as normal sleep.
(3) High temperature, dyspnoea and pain diminish
the hynotic influence of veronal. (4) The most im¬
portant field for veronal is in functional nervous dis¬
turbances, and in the insomnia of pregnancy ; after
using the drug for a week it is advisable to dis¬
continue it for some days as the organism rapidly
becomes habituated to its use. (5) Complications
seldom follow its use ; at most a little dizziness or
headache may occur, but neither are of long
duration. M.

Digi

322 The Medical Psess. NOTICES TO CORRESPONDENTS.

Sept. j 8 , 1907 .

NOTICES TO
CORRESPONDENTS,

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should be done when returning proofs.

Original Articles or Letters intended for publication
should be written on one side of the paper only and must be
authenticated with the name and address of the writer, not
necessary for publication but as evidenoe of identity.

Courier. —We have no particular desire to oross swords with
Mr. A. A., though ready enough to do so, if oocasion requires.
In the present instanoe the challenge is too clumsy and the
trap too obvious. If no notioe is taken of the document men¬
tioned, it will probably fall fiat. If it be oommented on it
would give it a chance of additional notioe. How can one argue
effectively on such subjects with people who do not know the
rudiments of chemistry P

Sybarite. —We are much interested in the legal anomaly that
you point out to us. The point is new, and we will make care¬
ful search for information as to the fsot. If it turns out that
what you believe is true, the matter ought to be dealt with,
and oannot be known too widely. At the same time we doubt
if it is quite a subject for a medical journal, unless a medical
man were direotiy involved in the injustioe. And that, we
take it, is not the case.

THE BABU AND THE DOCTOR.

Babu letters, it is to be feared, are, as a rule, either flotitious
or considerably edited and embellished. The following one from
Assam is as authentio as it is diverting. It is an application
from a native to the steamer agent at Dibrugarh (Assam): —

” Respectfully showeth that your humble practitioner is poor
man in agricultural behaviour, and much depends on season for
the staff of life, therefore he falls upon nis family’s bended
knees and implores of his meroiful consideration for a damnable
miserable like your honour’s humble petitioner. That your
humble petitioner was too poorly during last rains and was
trying vernacular medicine without effectuality, but was resusci¬
tated by muoh medioine of Dr. J. Lara tub, which made magni-
floent excavations in the coffers of your humble servant. That
your petitioner has a large family of seven lives, two males
and five females, last of whom is milking the paternal mother
and is very noiseful, through pulmonaiy catastrophe in the
inferior abdomen. That your humble petitioner prays that if
there is a plaoe ever so small in your honour’s benevolenoe, this
slave will be allowed to creep in. For this aot of kindness
shall, as in duty ever bound, pray for your honour's longevity
and prooreativeness.”— London Opinion.

Hants. —Many thanks for your suggestive letter. The subject
was carefully gone into by us a short time ago, and we oame
to the conclusion that it was better to bear the ills we have
than to fly to others that we know not of.

Congress. —The observations on the effeot of aloohol on animal
life on whioh you wish for information were made by H. E.
Zingler and H. FUhner. They showed that one per oent. of
aloohol (ethyl alcohol) added to water in whioh the embryos of
sea-urohins were placed retarded their development. A two per
oent. solution not only greatly arrested development, but tended
to produce monstrosities, while a four per oent. solution markedly
retarded all development.

Demoqhaph.—T he word demography is not perhaps a very
happy one, and a good many people, we fancy, like you do not
grasp its full signification. It does not mean, as was sug¬
gested at a oongress, ” teaching people to write,” but is the
name of the science dealing with the statistical estimation of
populations and such of their conditions as lend themselves to
enumeration.

HEATING FOR HEATING’S SAKE.

Business was bad in the Farringdon Road owing to the
weather, and a professor selling an invaluable speciflo had for

medioine works miracles. No; you 'as Co oonsider your eatin’
and drlnkin’. Wot does the ’ighest medical authorities syf
Eatin’ from ’abit, they sy, is a prolific cause of hindigestion.
You should only heat when you wants to heat.” ” Oo are you
gettin’ atf ” remarked the tramp indignantly. “I can’t eat
when I wants to eat, that’s wofs wrong with me. And as for
drinkin’—gor blimey I ”—Weekly Timet of Edinburgh.

Furuncle. —We are not prepared to recommend the treatment
of boils by tine sulphate baths, as we have no eEperienoe of it
ourselves, but the details of the treatment are as follows: —Into
a large bath an ounce of zino sulphate is put, making a
solution of about 1-1,000. In the usual way no irritation of
the skin is oaused, but if by idiosyncrasy of the patient there
be any, half an ounoe should be used subsequently. The baths
should be taken three times a week for half an hour at a time.
The skin should be nibbed with a rubber sponge after the
bath. There is no reason why soap should not be used, ezoept
that it does not lather well with the solution.

Scholar.— The question of disinfeofing sohools was dealt with
in a paper at the International Oongress of School Hygiene
lately held in London. Ton will find the matter treated
there at some length. Some school authorities regularly disin¬
fect their sohools. This is oertainly the oase at Nottingham,
Durham, Middlesex, Leeds, Birmingham, Willesden, Dundee, West
Ham, and East Riding.

Uacsmats.

Dorset County Hospital, Dorchester.—House Surgeon, to reside
and board in the Hospital. Salary, £100. Applications to
the Chairman of the Committee.

Norwich City Asylum, Hellesdon-next-Norwich.—Resident Medical
Superintendent. Salary, £400 per annum, with furnished
residence, fuel, light, rates, washing, eto. Applications to
Arnold H. Miller, Town Clerk, Guildhall, Norwioh.

Jersey Dispensary.—Resident Medical Offloer. 8 alary, £120 per
annum, furnished quarters, and attendance. Applications to
Secretary.

Farringdon General Dispensary, 17 Bartlett's Buildings, Holborn
Circus, E.O.—Resident Medical Offloer. Salary, £120 per
annum, with apartments, ooals, gas, and attendance. Appli¬
cations to the Honorary Secretary.

Royal London Ophthalmio Hospital (Moorfielda Eye Hospital),
City Road, E.C.—Senior House Surgeon. Salary, £100 a
year, with board and residenoe in the Hospital. Applications
to the Secretary.

Newcastle-upon-Tyne City Hospital for Infectious Diseases —
Resident Medical Assistant. Salary, £104 per annum, with
board and lodging, eto. Applications to the Medioal Offloer
o^Health, Health Department, Town Hall, Newoasfle-upon-

Birmingham General Hospital.—Receiving-Room Offloers. Salary
£160 per annum. Applications to Howard J. Collins, House
Governor.

Tunbridge Wells General Hospital.—House Surgeon. 8 alary
£100 per annum, with board, furnished apartments in the
Hospital, gas, firing, and attendance. Applications to the
Secretary.

University of Durham College of Medioine, Newoastle-upon-

I VHP -Tloninncfeo4c» n# _ n_i_ oom *

m " t- 7 ,— . . -*'~A*v***«» IICWWIBUC-Upon-

Tyne.—Demonstrator of Physiology. Salary, £200 per annum,
loations to Prof. Howden. Secretary of the University

Applic

* *_ --- " “ *aawwuvu, uwtuuai v U1 lHO oil

of Durham College of Medicine, Newcastleupon-Tyne.
Gravwend Hospital.—House Surgeon. Salary, £100 per annum,
with board and residenoe. Applications to A. E. Thomas
Secretary.

London Temperance Hospital, Hampstead Road, N.W.—Resident
Medioal Offloer. Salary, £120 per annum, with board, lodging
_ , “ d washing- Applications to A. W. Bodger, Seoretary!
Salford Union.—Resident Medical Officer. Salary, £130 per
annum, with furnished apartments and attendance in the
Infirmary. Applications to F. Townson, Clerk to the Guar-
dians, Union Offloea, Eocles New Road, Salford.

Durham University College of Medioine.—Demonstrator of Physio¬
logy. Salary £200 per annum. Application! to Prof4sor
Howden, Durham College of Medioine, Newcastle-upon-Tyne
(See aavt.) *

Jtppoitttttuntg.

McWalteb, J. C., M.D.Brux., M.A., F.F.P.S.Glasg.. D.P.H.
Bamster-at-law, Examiner in Medioal Jurisprudence to the
Apothecaries Hall of Ireland.

Palmer, F W. Morton M.B., B.C.Cantab., Ophthalmio Sur¬
geon to the Teignmouth Hospital.

Phippen, Harry G„ M.R.O.S.Eng., L.R.O.P.Lond., Assistant
Medical Officer at the Western Hospital, Fulham, London,

girths.

MACRVOT.-On Sept. 11th, at 41, Buckley Road, Brondeabury
London, the wife of H. J. Macevoy, M.D., B.Sc.Lond., of a son
McClintoce.— On 8ept. 12th, at The Chestnuts, Loddon, Norfolk
the wife of Lawson Tait MoClintook, M.B., of a daughter ’

JHarriagcB.

Iles—Pine -On Sept. 12th. at St. Barnabas’, Bexhill, Alfred
John Hopkmson nes, M.RC.S., L.R.C.P.. son of Alfred
Robert lies, M.R.C. 8 ., L.R.C.P., of Taunton, to Florence
Mabel, elder daughter of Edward Pink, of 5 Gwendolen
Avenue, Putney.

—Waller.— On Sept. 14, at Emmanuel Church, West Hamp¬
stead, William David Hoee, M.B.O.M.. of Luton, to Mabel
daughter of Charles Ashton Waller, Long Compton Manor
Warwickshire. ’

Crowfoot.—O n Sept, llth, at Beetles, Suffolk, William Bayly
Crowfoot, M.A., M.B., B.C.Cambridge, aged 29. * 1

°°gl

The Medical Press and Circular.

“SALUS POPULI SUPREMA LEX.*

Vol. CXXXV. WEDNESDAY, SEPT. 25, 1907. No. 13

Notes and Comments.

With all the talk there has been,
Examination* and rightly been, about maternal
lor ignorance and its lamentable conse-
Wive*. quences, there has risen a desire
that mothers—actual and potential-
should be educated in the duties of housewifery
and motherhood. No doubt, if the instruction be
as good as the intention, such classes will do much
to prevent women falling into the mistake of
giving children whatever they cry for, or even a
“bit of what we ’as oursel’s,” and they cannot but
help in the promotion of a sense of responsibility
on the part of mothers towards their children, and
thus tend to preserve the physical and moral
welfare of the race. Now, the logical corollary to
instruction is examination, and there can be no
harm in testing the aptitudes of pupils to retain the
knowledge that has been imparted in these classes,
but we confess to being somewhat staggered at
the proposal made in a contemporary that there
should be an examination for women before they
became wives- The examination craze has reached
heights of imbecility which its most ardent initia¬
tors could hardly have dreamed of, but if the
maidens of Great Britain have to pass an examina¬
tion before they can become eligible for the honour
of a man’s hand, we fancy we should range our¬
selves on the side of the angels and oppose the
plan with all possible vigour. The plain fact is
that the prettiest girls are notoriously the stupidest,
and if none but the ugly girls could get married,
whatever result their ability might nave on the
nature of the infant, it would not take long before
there were no types of British beauty left to lighten
the burden of a drab world.

Sir James Crichton-Browne’s pre-
Chops sidential address to the Sanitary
Inspector’s Association, in which he
Logic. praised the virtues of a substantial
meat dietary, has brought about
his ears the clamours of all the food faddists and
.self-advertising folk who enjoy the notoriety attend¬
ing free contributions to the September newspapers.
It is a curious comment on the influence gained
bv such folk on the mind of the public that it
should be necessary for a well-known medical man
to utter such a platitude as that mutton-chops
and roast beef are good things to eat, and, still
more so, that it should excite any attention in a
nation whose boast has always been that beef and
beer have built up an empire against which the
caters of sauerkrout, horse-sausage, and frogs’legs
rage impotently.. In the days before people took
to analysing their sensations so minutely, and took
more exercise in the open air, beef and beer esta¬
blished their reputation as a dietary by the ex¬
ceedingly comfortable feelings they produced when
taken by tired and healthy people. If it has come
to this, that there really are a large number of

folk in this country who actually cannot get their
ordinary wants supplied by beef and mutton, but
find satisfaction only in the cauliflower and lettuce,
then we can only deplore the loss of national
vigour which such anaemic taste connotes. Indeed,
did the vegetarian realise it, he should hide his
habits in the corner, for to confess them is to write
himself down a subnormal person, and while, we
take it, he would not boast of an asymmetry of his
face, a high arch to his palate, or any of the stig¬
mata of degeneration, he delights to parade in
public the ineffectiveness of his gall-bladder and
pancreas.

The Southend Town Council, after
Soatheod a due period of reflection, have made
v. their choice, and decided to give up
Dr. Nash. their medical officer of health, Dr.

Nash. The battle is one of great
moment, and the issues cannot be too clearly, laid
before the profession. Dr. Nash was appointed
Medical Officer of Health to the Council in ipoi
at a salary of ^400 a year, the agreement being
for three years. In 1904 he was duly re-appointed
at j€5 °° a year, and the period of his appointment
at that rate expired this summer. The Health
Committee proposed his re-appointment at ^650,
the extra hundred being the normal triennial ad¬
vance, and the extra fifty being payment for work
for the Education Committee. However, when
the matter came before the full Council, it was
proposed and carried that he should be offered the
appointment but for one year, and that the salary
should be only ^500. Now, this opposition to the
Health Committee’s recommendation was not dic¬
tated by any simple desire for economy, or any
suggestipn that Dr. Nash had been remiss in his
duties. It was, in fact, due to the precise opposite,
namely, that Dr. Nash had been too energetic
and thorough, and had thereby brought himself
into conflict with certain interests of the town.
In a question extending over several years it is
not possible or wise to apportion blame exactly,
but whereas the Health Committee, which may
be supposed to know the real merits of Dr. Nash’s
administration better than anyone, strongly sup¬
ported him, certain members of the Council were
actuated by a spirit of hostility. Dr. Nash refused
to accept the rebuff, and would have resigned im¬
mediately, but for being persuaded to continue
temporarily with a view to the matter being
thoroughly thought out.

The Council then prepared advertise-
No ments for insertion m the medical
“ Blackleg*.” press, but they found themselves
faced with the difficulty that the
medical press would not accept the
advertisement. Moreover, the medical practitioners
of the town, many of whom did not see eve to eye
with Dr. Nash, unanimously condemned the action

Digitized by GoOgle

324 The Medical Press.

LEADING ARTICLE.

Sept. 25. 1907.

of the Council. Only one man, and he, presumably,
unsuitable, came forward to apply for the post, and
the Council consequently found themselves in a
quandary. Accordingly, on the 17th, another meet¬
ing—a long and stormy one—was held, and the
Health Committee’s recommendation that Dr. Nash
be appointed at the increased salary was thoroughly
considered. This time the force of the opposition
was disclosed, the charges being then made that
Dr. Nash had brought the sanitary dangers of
Southend too much to the fore, and thereby got
the town a bad name. Eventually the increased
salary was refused by a majority of one vote, and
Dr. Nash’s temporary occupancy of his post will
consequently expire in a month or two’s time. We
strongly add our advice to that already given that
Dr. Nash be supported in his protest, and that no
medical man apply for the post. To do so would
be to stultify the effect of the action taken, apd to
postpone the operation of the urgently-needed
rinciple that a medical officer of health may set
imself to remedy wrong without fear or favour.
If Southend cannot get a medical officer, the Town
Council will be brought to their senses in the most
effectual and practical way.

A curious ethical point has arisen
Medical in Sicily by the refusal of the medi-
Boycott of cal practitioners of Palermo to attend
Dnellbag. duels. The profession of that island,

being more civilised than their lay
colleagues, see the criminal absurdity of “affairs
of honour,” by means of which an expert swords¬
man is at liberty to bully any ordinary folk with
impunity, or to have the pleasure of spitting them
with his sword if they have enough spirit to resent
his insults. This boycott has given rise to a variety
of opinions among French medical men who have
been interviewed by the Libertd. There are those
who hold the doctors justified in their action, and
there are others who consider that the function of
a medical man is to relieve suffering, and that he
has no concern with the causes of the dispute by
which the suffering was incurred. Now, while it
is true it is the doctor’s function to patch up a
burglar whom he has shot while breaking into
his house, it is straining the medical ideal very far
to say that medical men are not justified in making
a collective, practical protest against a barbarous
custom which could not go on but for their con¬
nivance. We take it that none would refuse to
dress a wounded duellist who was brought to their
surgeries, but it certainly is below the dignity of
civilised gentlemen to sneak about dodging the
police to reach the duelling field in order to
assure the minimum of danger to quarrelsome
people who seek the arbitrament of the
sword. In our opinion, the Palmero doctors
are not only justified in their action, but they are
playing an enlightened rdle, and one which does
them much credit. Almost any action would be
justified if it succeeded in putting an end to such a
ridiculous anachronism as duelling.

LEADING ARTICLE.

A SUPREME NATIONAL HEALTH
AUTHORITY.

The proposal to unite the chief local sanitary
authorities of the United Kingdom by the common
bond of a Central Representative Union is so ob¬
viously sound as to deserve close attention on the
part of all who may be directly or indirectly con¬
cerned. It has emanated from Dr. H. E Arm-,
strong, the well-known Medical Officer of Health
for Newcastle-upon-Tyne, at which place an
executive committee has been formed. After due

consideration, it has been decided to hold a pre¬
liminary conference in London of the representatives
of the sanitary committees of the county councils,
county boroughs and municipal boroughs (metro¬
politan and provincial) and port sanitary authori¬
ties of England and Wales. At this stage
of the proceedings it is felt that it would
be unadvisable to include all the local sani¬
tary bodies in the United Kingdom, owing
to their great number. The circular letter
which has been sent out to the chairmen of the
invited committees, however, expressly states that
every Authority in the Kingdom should be duly
represented on the National Authority it is now
proposed to constitute. The germ of the movement
is contained in the distinction thus drawn between
the local and the national handling of questions
concerning the public health. Under present con¬
ditions local administration is more or less chaotic;
nor, in the absence of common standards of com¬
parison and of methods of exchanging views and
experiences, and of formulating model codes, can
this developmental incompetence be a matter of
wonder. It is pointed out in the Newcastle circu¬
lar that the absence of conformity of action on the
part of sanitary authorities generally has been
recognised for a long time past, and, on account of
the diversity of interests involved, has hitherto
been regarded as a matter of almost insurmountable
difficulty, as well as a cause of much waste of
energy and time in attempting to carry out broad
measures of sanitary reform. This difficulty Dr.
Armstrong and his supporters hope to overcome by
starting a kind of sanitary parliament, to act as a
central body and to consist of representatives of
every sanitary authority in the United Kingdom.
The function of this body would presumably be to
draw up responsible recommendations which would
be available for the legislature on the one hand,
and for local administrations on the other. As the
Newcastle Committee remarks, the necessity for
such an organisation has been experienced by most
of the sanitary authorities of the Kingdom. The
movement to provide it has been rightly interpreted
as the result of a desire to bring into existence a
body which will focus the opinion of all engaged
in public health work, and make their experience
effective in requiring legislation to promote the
object in view. Perhaps the greatest function so
far allotted to the proposed union is that of ad¬
vising the legislature. It is obvious that sanitary
authorities, from their daily experience of the work¬
ing of Public Health Acts, must be familiar with
legal shortcomings, just as they must necessarily
be the best judges of sanitary defects that are not
met by existing legislation. To a great extent a
competent central union would be able to frame
practical measures for meeting national issues of
such tremendous importance and complexity as
infant mortality, the pollution of rivers, tubercu¬
losis in man and animals, and the meat and milk
supplies. A great public discussion, say, on the
housing problem by an assembly of informed de¬
baters could not fail to bring home to the nation
with irresistible force the wrongs inflicted upon the
community by the jerry builders and the privileged
landlord. The impulse to Parliament to pass new
building Acts would be of a nature unlike any¬
thing at present in existence. Similarly, it is
unlikely that after a few years of persistent ex¬
posure by the Union of the evils of contaminated

Sept. 25, 1907.

CURRENT TOPICS.

The Medical Press. 325

drinking-water supplies that Londoners would
contentedly continue to drink water drawn from a
river extensively polluted by sewage. There is no
need to multiply instances. The field is a large one,
the workers are earnest and multitudinous, but
the problem is to render them articulate and to
bring them into touch so that their individual ex¬
periences may be crystallised into general proposi¬
tions of value and authority. The whole scheme,
if properly carried out, bids fair to mark one of the
most important departures ever yet made in the
public health history of the United Kingdom.
The first conference, it is announced, will be held
in London between November 12th and 15th next.
As the future of the movement will largely depend
on its reception at the first meeting, we trust that
all the local sanitary bodies that have been ap¬
proached will make an effort to be represented at
the preliminary conference in November.

POOR-LAW MEDICAL.

The recent resignation of the whole of the medi¬
cal staff of the Fir Vale Union Infirmary, at
Sheffield, opens up a subject that has for some time
past been in need of revision. With the immediate
cause of the resignations we are not here concerned.
It suffices for present purposes to know that the
conditions of professional work at the Poor-law
institution in question have been such that five
medical men have taken the serious step of throw¬
ing up their posts. Those who have had any
extended experience of such positions know that in
the majority of cases friction arises from an un¬
warranted assumption of authority on the part of
the lay officials of the institution concerned. In
these cases the lay officers are often permanent,
while the resident medical officers are young men
who have a limited tenure of office. From the
necessities of the position, therefore, the guardians
are naturally more likely to favour those whom
they have known for the longer period of time.
Apart from that particular phase there are other
and deeper principles involved. One of the fore¬
most of these is the proposition that in a sick
infirmary medical control should be permanent.
If it were so the public would be spared many of
the scandals arising directly out of understaffing
in Poor-law infirmaries; scandals which are now
only too frequent. The Sheffield case is not suffi¬
ciently ripe for discussion. At the same time, it
will be well to point out one serious error that has
crept into the lay newspapers, namely, the state¬
ment that the resignations have been prompted by
the local branch of the British Medical Associa¬
tion. As a matter of fact, the question has not yet
been considered by that body. In view of the im¬
portance to the medical profession of the readjust¬
ment of the present unsatisfactory conditions, it is
to be hoped that the matter will not be allowed to
drop until is has been threshed out between the
guardians, the Local Government Board, and the
medical profession in Sheffield. We hope to keep
our readers fully informed of the course of events.

CURRENT TOPICS.

Poison Epidemic in Essex.

An outbreak of fortunately mild ptomaine poison¬
ing occurred recently in several Essex villages near
Colchester. About fifty persons were attacked, but

all recovered within a few days, and the epidemic
was ultimately traced to some infected brawn. The
incident is one of a far too familiar type, but it
is difficult to see how accidents of a similar kind
can be altogether prevented. Even in the case of
careful and conscientious tradesmen, carrying on
their work in a cleanly environment, it is quite
possible occasionally to overlook the tainting of so
perishable an article as butcher’s meat. There is
the further fact that meat may be capable of
causing disastrous illness, although it bears little
or no evidence of the danger by signs appreciable
to the senses of sight, smell and taste. The only
scientific way that suggests itself of preventing
the possibility of contamination would be to have
food prepared with aseptic precautions, and stored
in a sterile environment, with directions to be con¬
sumed within a certain number of hours. In
human affairs, however, the counsels of perfection
will always have to be modified by the requirements
of daily life. Incidentally, in the Essex epidemic, a
dog which had stolen some of the incriminated
brawn was reported to have suffered severely. This
incident, while it afforded valuable evidence to the
sanitary authorities, has, at the same time, fur¬
nished a somewhat knotty problem for the moralist.
In this case Providence seems to have punished
alike the guilty dog and his innocent owners,
although the one stole his brawn, and the other
bought and paid for it.

Germany and Patent Medicines.

The German legislature usually takes a short
cut in dealing with offenders against the public
weal. Since 1903 it has completely altered the
conditions of the patent medicine trade by compel¬
ling the makers to state on each packet or bottle
the ingredients and their quantities. Now it has
gone a step further and adopted a further plan that
bids fair to kill the most noxious of all trades.
From October 1st next all written or printed praise
of the specific is forbidden, and all public adver¬
tisement. No chemist, moreover, who does not
know what a patent medicine is made of may
supply it without a doctor’s order. Why should
not a similar law be passed in the United King¬
dom? The evil wrought upon the health of the
community by the sale of patent medicines is in¬
calculable. The medical man who is scientifically
trained in the remedial treatment of disease has no
secrets. Why, then, should the ignorant charlatan
be permitted to claim for alleged specifics the power
of curing manifold maladies? The transaction is,
in plain words, a fraudulent attempt to procure
money under false pretences. The growing in¬
telligence of the community must One day put an
end to a trade that is carried on at the cost of
untold injury to the health of the people. What is
possible in Germany is surely possible in our own
country.

Maternity Homes and Syphilis.

The recent appearance in a police court of the
matron of a maternity home suggests various ques¬
tions of medical general interest. The institution
in question was called a school of midwifery, and
one of the witnesses produced a certificate stating
she had undergone a course of instruction there,
and was qualified to act as a monthly nurse. It
will be interesting to learn what control the Central.

Google

Digits

326 The Medical Pbess.

CURRENT TOPICS.

Sept. 2$, 1907.

Midwives’ Board had over the institution as re¬
gards the quality and the quantity of the teaching.
Another point arises out of the evidence of a police
surgeon to the effect that a child was suffering
from hereditary syphilis of a bad form. In his
opinion the condition of the child might have been
alleviated by medical attention. So far as can be
gathered, there appears to have been no systematic
medical treatment attempted. Apart from the
merits of this particular case, however, it is of con¬
siderable interest to enquire whether the neglect to
treat an infant suffering from constitutional
syphilis might be legally construed into an act of
criminal neglect. A maternity home might reason¬
ably be supposed to have the experience necessary
for the recognition of such a malady. It would be
obviously a first duty to instruct midwives upon
the chief facts of syphilis, both in mothers and in
infants. The obligation to provide medical atten¬
tion probably applies to institutions as it does to
other responsible guardians, and not less so in
syphilis than in other diseases.

Edible Fungi.

The recent lamentable occurrence at Ipswich
whereby a whole family was poisoned by eating
fungi has led to enquiry as to how edible mush¬
rooms may be distinguished. Now, there are two
kinds of mushroom. First, the common mush¬
room (Agaricus campestris), which has a white
stem and cap. Underneath the head are a number
of gill plates radiating from, but not attached to,
the stalk. They are pink in colour, and form the
under lining of the head. In the developed mush¬
room an annulus is found round the stem. In the
earlier stages of growth, when the mushroom re¬
sembles a solid white button, the annulus is
attached to the white covering of the cap or pileus.
The colour of the fungus darkens with age. The
second kind of mushroom is the Agaricus arvensis.
It is also called the meadow mushroom and the
horse mushroom. It is the larger of the two, the
grills below the cap are whitish instead of pink,
and with age they become very dark. It is not
as good as the common mushroom for making
ketchup, and still less for eating purposes. While
the most of people eat mushrooms with relish and
impunity, there are others who are liable to attacks
of sickness from their use. On the gills of fungi
the spores are to be found, and these spores show
whether a particular fungus is to be regarded with
suspicion or not. Mr. M. C. Cooke, in “ British
Edible Fungi,” describes how the spores of a fun¬
gus should be examined. The fungus should be
placed on a sheet of paper, with the gills down¬
ward, for a few hours or over-night. When
removed, a very fine dust is observed to have been
thrown down on the paper from the gills. This
deposit is either white, salmon-coloured, brown or
tawny, dark brown or black. In the common
mushroom the spores are of a dark purple-brown.
A great number of species which have purple-
brown spores are edible, whilst it is very rare in¬
deed for a species with salmon-coloured spores to
be worth eating, and some are poisonous. The
colour of the gills and of the spores are of con¬
siderable importance, and must be taken into
account in determining a fungus. Mushrooms
ought to be cleaned before being eaten, and re¬
jected if any parasites are found on them.

A Source of Tuberculosis in Pigs.

Now that the identity of tuberculosis in man
and in the lower animals is established, we are
likely to be faced with many fresh precautions
arising logically out of that far-reaching law. An
instance in point came recently from a northern
town, where the guardians have adopted an atti¬
tude that might well be taken as a pattern by all
Poor-law authorities called upon to deal with the
problem of tuberculosis. A medical man pointed
out to his fellow guardians that all waste food
collected in the phthisis ward of the local union
hospital was placed in the swill-tub, and afterwards
sold for the purpose of feeding pigs. The risk of
spreading tuberculosis, first amongst pigs, and,
secondarily, amongst the consumers of the diseased
flesh, is obvious. Of all the lower animals, the pig
is one of the most susceptible to invasion by the
bacillus tuberculosis. We are pleased to say
that the guardians immediately resolved that in
future all the waste food from the ward in ques¬
tion should be burned. The matter is deserving of
the widest publicity, as it is only by attention to
details of this kind that the “'white scourge”—as it
is sometimes aptly termed—will be one day eradi¬
cated. There are many points in connection with
waste food to which the attention not only of the
public, but also of medical men and nurses, might
be drawn with advantage.

The Lord Mayor and the Cripples’ Homes.

The scheme which the Lord Mayor has done so
much to promote—namely, the establishment of
an institution for cripples, partly hospital and
partly educational home, has been greatly helped
forward by the gift from the War Office of the
Princess Louise Military Hospital at Alton. The
value of this property runs to many thousands of
pounds, and we believe that such a presentation
from a Government to a body of eleemosynary
trustees, without consideration, is the first of its
kind in this country. As the Lord Mayor has re¬
ceived ^50,000 in donations wherewith to start his
home, and ^60,000 is all that is needed to put it
on a firm financial basis, it may be presumed that
the success of the institution is assured. It is
certainly difficult to see. how without this gift Sir
William Treloar would have been able to have
carried through his scheme in anything like an
adequate manner, and now accommodation for only
a hundred and fifty will be forthcoming. Yet we
seem to remember the statement being made some
time ago that j£6o,ooo would relieve all the crippled
children in London. While thoroughly recognising
the Lord Mayor’s kindness of heart in seeking to
provide still further for the cripples, it must be
hoped that his spirited efforts have not drawn
away support from the excellent institutions at pre¬
sent in existence, many of which find it very diffi¬
cult to keep up their subscriptions-list as it is.
Whilst wishing every possible success to the new
home, may we express the hope that the committee
will place themselves under trustworthy medical
guidance as regards the treatment of the children,
and eschew the blandishments of interested quacks?

Consumption and Breach of Promise of
Marriage.

We do not know that the fact of a person’s
suffering from consumption has ever been put for¬
ward in this country as a justification for breach

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Sept. .25, 1907.

PERSONAL.

The Medical Press. 327

of promise of marriage by the other party. In the
Supreme Court of Washington, however, a decision
has just been given in which the case rested on
this plea. It appears that the engagement had
been entered into by the man with the knowledge
that the woman suffered from consumption. He
afterwards broke the engagement on that ground,
and the Supreme Court held that he was justified
in so doing. There are doubtless good reasons
why a woman suffering from phthisis should not
marry, but we can hardly understand how a con¬
tract can be justifiably broken on account of facts
known at the time the contract was entered into.
It is more than doubtful whether such a plea would
be upheld in this country, but in America there is
a much greater tendency to limit the freedom of
the diseased or degenerate individual to propagate
his kind.

Consumption in the Hebrew Race.

The comparative immunity of the Hebrew race
from consumption has always been regarded as one
of the facts of racial natural history. That belief,
however, has been somewhat rudely shaken by
Dr. S. A. Jacob, a non-medical philanthropist, who
was until lately President of the Consumptive Aid
Association in Leeds. That position he has now
resigned in order to devote himself entirely to the
formation of a Jewish branch of the Tuberculosis
Association. This step was prompted by the rapid
increase of consumption amongst his co-religionists.
Dr. Jacob has given a powerful description of the
miserable houses of the local Hebrew population
amongst which the cases are found. It may be
gathered that he refers to slum districts peopled
by poverty-stricken alien Jews from Russia, Poland
and other parts of the Continent, who have of late
years invaded the great towns of the United King¬
dom. There is, of course, no absolute racial
insurance of the Jews against tuberculosis. Given
the conditions of bad air, poor feeding, overcrowd¬
ing, and an unfavourable slum environment, and
the Hebrew will contract the disease as easily
as the Christian. We presume that Dr. Jacob
is alive to the probability that slum tuberculosis
is to a certain extent due to infected milk and
flesh. Although incapable of exact proof, that , is
the inference most likely to be adopted by the
educated medical man, in view of the recent
authoritative finding of the Tuberculosis Com¬
mission as to the identity of the malady in man
and the lower animals.

Smoke and Disease.

There is little doubt that the constant breathing
of smoky, soot-laden air is injurious in some
■degree to the lungs. Probably the irritation
caused by particles of soot is one of the most
important predisposing causes of tuberculosis, and
It has been shown by experiment that guinea-pigs
which had lived in a smoke-laden atmosphere died
of pulmonary tuberculosis more quickly than those
which showed smoke-free lungs. It is, of course,
notorious that people already afflicted with phthisis
thrive better in a pure than in a smoky air. Not¬
withstanding all this, but little support has been
given by the medical profession to the movement
for the abolition of the smoke nuisance. It is true
that in many of the English cities there are by-laws
controlling the issue of black smoke, but the prob¬
lem as a whole has, as yet, hardly been touched.

Possibly in the long run the solution will be found
in the substitution of coal-gas for coal for manu¬
facturing purposes, as has been done on a limited
scale in South Staffordshire and some other dis¬
tricts. It has been found possible there to produce
at cheap rates a gas very suitable for manufacturing
purposes, though useless as an illuminant.

PERSONAL.

Queen Wilhelmina and Prince Henry were present
at the opening of the International Congress of
Psychiatry and Psychology held at Amsterdam at the
beginning of this month.

The Annual Presidential address of the West London
Medico-Chirurgical Society will be given on October
4th at 8.30 at the West London Hospital, the subject
being “The Relationship of Disease of the Ear, Nose,
and Larynx to General Medicine.” The new Presi¬
dent is Mr. Richard Lake.

It is announced that Dr. H. P. Motteram has been
nominated for the Mayoralty of Smethwick.

Dr. C. T. Wright, Professor of Midwifery at Leeds
University, has resigned his office after forty years’
service in connection with the Leeds Medical School.

The Royal Dental Hospital of London, Leicester
Square, has received £250, less legacy duty, from the
Executors of the will of the late John Lawrence
Toole, Esq.

Dr. George Newman has resigned his post of
Medical Officer to the Finsbury Borough Council, on
his appointment as Chief Medical Officer to the Board
of Education.

Professor Francis Gotch, M.A., D.Sc., F.R.S.,
will present the prizes awarded by the Faculty of
Medicine in the large hall of University College,
Bristol, on October rst.

The Order of the Hospital of St. John of Jerusalem
in England has been conferred on Dr. Arthur J.
Evans, of Liverpool, for his services to the wounded
at the earthquake in Jamaica.

The Second Norman Kerr Lecture of the Society for
the Study of Inebriety will be delivered by Dr. Robert
Welsh Branthwaite, on Tuesday, October 8th, at 20,
Hanover Square, London, W.

The Inaugural Address of the Winter Session of the
London School of Clinical Medicine will be delivered
by Sir Richard Douglas Powell, Bart., K.C.V.O.,
M.D., on Tuesday, October 8th.

First-Class Hospital Assistant P. S. Ramachandrier,
of the Mysore Medical Service, has been awarded the
prize offered by the Indian Medical Gautte for the best
essay on the prevention of plague.

Sir Arthur Conan Doyle was married very quietly
on September 18th at St. Margaret’s Church, West¬
minster, to Miss Jean Leckie, daughter of Mr. and
Mrs. James B. Leckie, of Glebe House, Blackheath.

At Friday’s session of the International Tuber¬
culosis Conference, Dr. Klemens Pirquet presented an
interesting report on his experiments in the inocula¬
tion of infants with tuberculin in order to detect the
presence of tuberculous germs.

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CLINICAL LECTURE.

Sept. 25, 1907

328 The Medical Press.

A Clinical Lecture

ON

CONGENITAL ANOMALIES OF THE EYE. (a)

By SYDNEY STEPHENSON, M.&, FJLG&Ed^

Ophthalmic Surgeon to the Kensington General Hospital, the Evelina Hospital, the North-Eastern

Hospital (or Children, etc.

The expression “congenital anomalies of the eye
chosen by the Reader in Ophthalmology for the title
of this lecture, is in itself somewhat anomalous—at
least, without further definition. As generally applied,
however, it means some malformation in structure or
some anomaly in function present when a baby is
bom, or (much more rarely) arising soon after birth,
as in the curious condition known as “opaque nerve-
fibres of the retina.” In short, it is usually a birth
anomaly—that is, an inherited as distinguished from
an acquired defect. We must carefully exclude those
defects, as corneal opacities, paralysis of the ocular
muscles, irido-dialysis, ptosis, ectropion, and so forth,
which are liable to result during the progress of birth
by the use of instruments and otherwise.

There is perhaps no part of the human body whose
congenital anomalies are more numerous and impor¬
tant than those of the eye and its appendages. This
is doubtless connected with the extremely complex
structure of the eyeball. The readiness with which
practically every part of the eye can be examined, too,
has led to the discovery of many defects that would
probably have escaped attention in any other organ of
the body.

Many of the so-called congenital anomalies of the
eye, however, are of interest merely from the embryo-
logical point of view, but others, such as infantile
glaucoma, microphthalmia, cryptophthalmia, and
coloboma of the choroid, may result in such defective
sight as to render them matters of importance to the
practising surgeon. In this event such malformations
may rightly be looked upon as “congenital diseases”
if only for the purpose of distinguishing them from
the others, which may be called “congenital defects.”

At the outset we are constrained to confess our
essential ignorance of the causation of many con¬
genital anomalies of the eye. Certain of them, parti¬
cularly perhaps the conditions known as opaque nerve-
fibres and ectropion of the uveal layer of the iris,
appear to represent a reversion to a type found in
the lower animals, and a similar explanation, as will
be explained later,.has been applied by Mr. E. Treacher
Collins to account for cases of infantile glaucoma. In
other words, these are examples of atavism. Many
anomalies may be accounted for by delay, failure, or
perversion of the normal processes of development.
This factor adequately explains many of the de¬
formities, among which may be mentioned persistent
pupillary membrane and hyaloid artery, and, in parti¬
cular, coloboma of the choroid downwards. At the
same time it is inadequate to account for some others,
such as coloboma of the eyelids, cryptophthalmia, and
congenital staphyloma.

Two alternative explanations have been offered for
some of these cases:—(1) an inflammation of the
tissues of the eye during the sojourn of the foetus in
its mother’s womb; and (2) the influence of adhesions
between the amnion, on the one hand, and the integu¬
ment of the foetus, on the othe* - .

(1) The theory of intra-uterine inflammation (closely
connected with Deutschmann’s name) is capable of
explaining certain malformations, as congenital leu-
coma and staphyloma, which it is difficult or impos¬
sible to account for on developmental grounds.

(2) Adhesions are known to be liable to occur when
the quantity of amniotic fluid is unusually scanty,
as in cases of oligo-hydramnios. But many such ad¬
hesions are now believed to be the cause of spon¬
taneous amputation, of encephalocele, and of fissures

(a) A Clinical Lecture delivered July l&tb, 1907 . In the Poet-
Graduate Courae of Ophthalmology In the University of Oxford.

of the face, lips, or jaw. Coloboma of the eyelids,
could be satisfactorily accounted for on the adhesion
theory, as could also a singular congenital condition
described by Schapringer as “epitarsus,” in which
adventitious folds of conjunctiva exist upon the inner
surface of the upper eyelid.

It is impossible that more than one of the foregoing,
factors may come into play in the production of
certain malformations. Thus, an arrest of or per¬
version in development may be the direct or indirect
outcome of an intra-uterine inflammation, and so
forth.

Another point is that our knowledge of the develop¬
ment of the human foetus is still incomplete. It may
accordingly be assumed that some anomalies that can¬
not at present be explained on developmental grounds
may yet be accounted for in that way when we com¬
prehend more completely the processes of develop¬
ment, normal and abnormal, as we some day shall
surely do. This suggestion is exemplified by the
modern explanation of so-called “central coloboma of
the choroid,” a more or less circular defect in the
choroid occasionally met with in the neighbourhood
of the macula lutea. It is difficult to account for this
defect as connected in any way with the foetal ocular
cleft, which, as will be explained in detail later on,,
develops early in foetal life and is directed downward.
In order to meet this anatomical stumbling-block, the
ingenious but unconvincing hypothesis was pro¬
pounded that the eye rotated go deg. during its
development. The explanation of the anomaly
appears to lie, however, in the occasional existence of
a subsidiary foetal cleft, of which examples have been
seen in some of the lower animals, as the sheep, the
chicken, and the calf.

Other factors that can scarcely remain without in¬
fluence in the causation of anomalies of the eye, as of
other parts of the body, are syphilis, diseases of the
placenta, or foetal membranes, and general conditions,
such as tuberculosis and alcoholism, in the parents.

As to the influence, if any, played by “maternal
impressions ” in determining congenital anomalies, we
remain in complete ignorance.

The transmission of certain eye defects, such as
irideremia and ptosis, opens up large and complex
questions, not peculiar to opnthalmic work, upon
which no consensus of opinion has yet been reached.

Before describing some of the more important abnor¬
malities, something should be said in outline as to the
development of the eye, perhaps the only subject con¬
nected with the eye not yet discussed in the post¬
graduate course of ophthalmology provided by the
University of Oxford.

Development of the Eye.

At a very early stage in foetal life, at a time when
the nervous system is represented merely by a narrow
tube provided at one end with certain dilatations
known as the three primary brain vesicles, the rudi¬
ment of the eyes appears as a hollow bud, called the
primary optic vesicle, arising from each side of the
anterior primary cerebral vesicle. The hollow con¬
nection between the two vesicles, ocular and cerebral,
becomes narrowed, is occupied by vascularised meso-
blastic tissue, and is eventually differentiated into the
optic nerve.

The primitive ocular vesicle, in common with the
rest of the embryo, is covered with a layer of closely-
packed cells, the opiblast. Enclosed within the
epiblast lie the so-called mesoblastic cells. The hypo¬
blast takes no share in the formation of the eye.

Now the cells of the epiblast at a point correspond¬
ing to the optic vesicle, become both thickened and

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Sept. 25. 1907.

CLINICAL LECTURE.

more numerous, so that several layers of embryonic
cells are closely packed together at that point. This
collection of cells represents the rudiment of the
crystalline lens. The primary ocular vesicle lying
contiguous to the lens rudiment becomes pushed back,
like the finger of a glove, in such a way as to produce
a pouch, of which the closed end is directed towards
the vesicle. This, which is known as the secondary
ocular vesicle, is merely the primary ocular vesicle
folded upon itself—invaginated, as it were—and like
the latter, is composed of epiblastic cells. Simul¬
taneously with these changes, the collection of
epiblastic surface cells becomes separated from the
superficial epiblast, and at last lies quite apart from
the last-named. The surface epiblast grows over the
detached group of cells, the edges of which cohere,
so as to form a closed sac, known as the lens sac or
vesicle. At a later period of development this sac
becomes converted into a solid body, the crystalline
lens, by the continued growth of its component
epiblastic cells.

While these changes are going on, the lower aspect
of the primary optic vesicle becomes invaginated by a
process of mesoblast, a tissue Which surrounds the
optic vesicle. The optic cup is accordingly incom¬
plete below, the hiatus being known as the foetal
ocular cleft, a structure of considerable importance
from our present standpoint. In mammalia the hieso-
blast pushes its way through this fissure, carrying a
vessel with it, so as to reach the interior of the eye,
where it separates the lens rudiment from the rudi¬
ment of the retina, and eventually forms the vitreous
humour. At a subsequent period (in man during the
sixth or seventh week of life) the edges of the cleft
unite, with the consequence that the eye again be¬
comes a closed spherical sac. A delay in closure
accounts more or less satisfactorily for coloboma of
the choroid downwards.

The two layers of the secondary optic vesicle
speedily commence to differentiate, so that the internal
layer eventually forms the retina proper, and the ex¬
ternal, the pigmented epithelium appertaining to that
structure. The rudimentary choroid is produced from
mesoblastic tissue lying outside the optic vesicle.
Similar tissue also pushes its way between the outer
epiblastic layer and the lens rudiment, and produces
the rudiment of the cornea. The epithelium of the
cornea, however, is the product of the outer epiblastic
layer of cells. The sclera is a mesoblastic structure.

The foetal lens is provided with special provision
for nourishment in the shape of a vascular enveloping
capsule, the tunica vasculosa lentis, the anterior por¬
tion of which is known as the pupillary membrane.
This is developed as early as the second month, and,
its work having been finished, should be absorbed
shortly before birth. The familiar appearance known
as persistent pupillary membrane is due to the survival
of portions of the membrane.

The tunica vasculosa lentis obtains its blood supply
from a branch of the central artery of the retina, the
forerunner of which enters the eyeball through the
foetal ocular cleft along with the intruding mesoblastic
tissue. The hyaloid artery, an offset from the central
artery of the retina, passes through the vitreous from
the optic nerve to the posterior pole of the crystalline
lens, enclosed in the canal of Cloquet. Persistence of
this vessel, which in rare cases may even continue to
carry blood, is one of the best-known and most
striking congenital anomalies of the eyeball. Traces
of the anterior attachment of the hyaloid artery to the
lens are, in my experience, quite common, appearing
as a tiny grey opacity situated on the posterior surface
of the lens somewhat to the inner side of the posterior
pole. Several observers have described appearances
which they considered pointed to persistence of the
canal of Cloquet.

The eyelids are produced at an early period by two
folds of epiblast, together with included mesoblastic
tissue, growing one from above and the other from
below the cornea. They are not formed, so far as we
know, from several centres, as they should assuredly
be if deficiencies were to be explained on develop¬
mental grounds. The rudimentary lid-folds eventu¬
ally meet, and become united along their edges by
proliferation of the epithelium. In man this tem-

The Medical Press. 3 2 9 _

porary closure of the conjunctival sac begins in the
third month, and undergoes retrogression a short time
before b'irth (Hertwig), although in rare instances
babies are born with a more or less complete union
between the eyelids (ankyloblepharon).

The lacrymal gland is formed by budding of the
epithelium of the conjunctival sac. The buds, at first
solid, gradually become hollowed out. Absence of the
lacrymal gland has been described, but in most in¬
stances upon somewhat slender evidence, such as the
mere absence cf the tears.

The lacrymo-nasal duct is formed from a solid rod
or ridge of proliferated epidermic tissue, which ex¬
tends from the mesial side of the eye into the nasal
cavity. This solid cord becomes hollowed out by
liquefaction of its contents. Should differentiation
be delayed, we may have the condition of so-called
“congenital dacryocystitis,” which is not infrequent
in newly-born children.

Congenital Anomalies.

In describing the congenital anomalies of the eye,
I shall attempt a rough classification in consonance
with what has already been said as to the cause of the
several conditions—I. Anomalies due to arrested or
perverted processes of development. II. Anomalies
due to amniotic adhesions; and III. Anomalies due
to intra-uterine inflammation.

I.—Anomalies due to Developmental, Defects.

Defects due to developmental anomalies form the
largest group. We shall describe as perhaps the most
important members of this group, persistent pupillary
membrane, coloboma of the iris, lens, and choroid,
irideremia, opaque nerve fibres, ptosis, persistent hya¬
loid artery, certain developmental anomalies of the
eyelids and lacrymal apparatus, and, lastly, dermoid
tumours of the eyeball and elsewhere.

Persistent Pupillary Membrane. —It is not very rare
to find, on an attentive examination of an eye, one
or more fine strands of tissue arising from the anterior
surface of the iris, near the small circle, or corona
iridis, and passing to an insertion elsewhere in the
corona. These are examples of persistent pupillary
threads. This is one of the commonest congenital
anomalies of the eye. For instance, it was present in
68 of 3,414 eyes, or in 1.99 per cent., examined by me
some years ago (Trans. Ophthalmological Society ,
Vol. XIII., 1893). It is usually limited to one eye,
and the anomaly is apt to reproduce itself in several
members of the same family. As a much rarer con¬
dition, the filaments may be so extensive and thick
as actually to interfere with sight, and it has now and
then been found necessary to treat such cases sur¬
gically. As might be expected, persistent pupillary
membrane is not infrequently associated with other
congenital deformities of the eye, such as micro¬
phthalmia, opaque nerve fibres, congenital crescent of
the optic disc, and various forms of cataract and
colobomata. A rare but interesting association is with
anterior synechia, as in cases reported in this country
by Silcock, Treacher Collins, and Ballantyne. The
distinction between persistent pupillary membrane, on
the one hand, and posterior synechia, on the other,
can generally be established without difficulty by
careful examination of the eye. It must not be for¬
gotten, however, as in a case figured by Fuchs (Text-
Book of Ophthalmology, second American edition,
1899, p. 292), that the two conditions may co-exist. It
has been suggested that pupillary remains are likely to
disappear during the earlier years of life. Although
my own figures lend no support to such a view, there
is nevertheless a certain amount of direct evidence to
show that absorption may occur after birth (Hirsch-
berg).

Coloboma of the Iris. —Coloboma iridis is the name
applied to a congenital cleft, often affecting both eyes,
much resembling the result of a cleverly-made iridec¬
tomy. The cleft is directed downwards, although it
may have a slight inclination inwards or (less com¬
monly) outwards. It may be small, or, on the con¬
trary, extend from the pupil to the ciliary body. It
is not infrequently associated with a coloboma of the
choroid. A “bridge coloboma” is a coloboma of the
iris which is crossed by one or more bands of tissue
pigment or pupillary membrane, as the case may be.

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CLINICAL LECTURE.

Sept. 25, 1907,

Coloboma of the Lens. —In this condition the crystal¬
line lens shows a defect, almost always in the lower
margin. The deficiency is generally notch-like and
single, although Meyer [Rev. Genlrale d'Ophtalmologie,
January, 1893) has reported a case in which a couple
of gaps existed at the lower edge of the lens of one
eye. In coloboma of the lens it is not uncommon to
find the fibres of the suspensory ligament to be absent
from an area corresponding to the deficiency in the
lens. This observation is of interest, since it has a
bearing upon the explanation of the production of the
deformity. It is thought that the continued growth
of the lens equatorially is due to centrifugal traction
exercised by the fibres of the suspensory ligament
(E. T. Collins). Hence, a limited deficiency of the
fibres would entail as its necessary consequence mal-
development of the corresponding part of the lens—
or, in other words, the production of a coloboma.
The explanation of the curious case reported by Mr.
R. W. Doyne (Trans. Ophthal. Society , Vol. XI., 1891,
p. 220), where coloboma of iris and choroid was asso¬
ciated with a projection from the corresponding part
of the lens, is still to seek.

Coloboma of the Choroid. —Colobomata of the choroid
may be described as (a) typical, and (bj atypical. Both
forms have what may be called a fissurial origin.

(a) Typical cases show, when examined with the
ophthalmoscope, a larger or smaller area of nacreous
exposed sclera, extending downwards from the optic
disc towards the visible periphery of the fundus oculi.
The optic papilla may or may not be involved. The
exposed sclera is often ectatic—that is to say, thrust
outward, forming what is sometimes called the
“scleral protrusion of Von Ammon.” The exposed
area generally shows here tnd there pigment and
small vessels. Retinal vessels may cross the surface of
the coloboma. Eyeballs containing colobomata are
often much smaller than normal—microphthalmia.
Even when the dimensions are good, colobomata
usually produce a gap in the field of vision, and owing
to imperfect differentiation, sight is often extremely
poor. Coloboma of the choroid, according to Fuchs,
“is in a marked degree transmissible by inheritance.”
Other defects of the eye, particularly coloboma of the
iris, are commonly associated with coloboma of the
choroid. With regard to the explanation of the con¬
dition, it is usually taught that coloboma arises from
incomplete closure of the foetal ocular cleft. To this
view Mr. E. T. Collins has opposed the fact that in
some instances the retina exists over the cleft in the
choroid. This he attempts to explain by an abnormal
adhesion' between retina and mesoblast, whereby if
this occurs before closure of the fissure, the coloboma
is devoid of a retinal covering, and, if after, the
retina is present, so that no scotoma exists in the field
of vision.

(b) Apart from the condition described above, defi¬
ciencies in the choroid may occur in practically any
part of the fundus oculi. We then speak of atypical
coloboma. The most striking of these forms goes by
the name of “coloboma of die macula,” a condition
in which a round or oval area of sclera is exposed in
the region of the yellow spot. Its size is generally
several times that of the optic disc. It is often bordered
by pigment, and crossed by pigment or by vessels.
The retina may or may not be present, as judged by
the course of the retinal vessels and by the presence
or absence of a scotoma in the field of vision. Sight
is generally defective in such cases, which not infre¬
quently develop a squint, convergent or divergent, as
the case mav be. The origin of macular colobomata
has given rise to considerable difference of opinion,
and the question even now cannot be said to have

R assed beyond the realms of controversy. Thus, by
ettleship and others they have been assumed to be
due to severe foetal inflammation of the parts; by
Lindsay Johnson that they represented degenerated
nasvi; and, lastly, by v. KOlliker and others that they
were connected with the foetal ocular cleft. In order
to account for the fact that while the ocular cleft was
directed downwards while the coloboma was situated
in the macular region, it was assumed that the eyeball
underwent a rotation of 45 or 90 degrees during its
development. This view has now been given up. The
modern theory is that the defect originates from in¬

complete closure of a subsidiary ocular cleft occupy¬
ing the position of the future macula. Such atypical
clefts were found as long ago as 1858 by V. Ammon
in the eye of the chicken and the sheep, and more
recently Van Duyse (Rev. Ginerale d'Ophtalmologie,
Tome XX., 1901, p. 119) has demonstrated such a
cleft in a calf.

Irideremia. —It is doubtful whether the iris is ever
wholly absent. In the cases to which the name “ aniri-
demia ” is sometimes applied, critical examination
(supposing that to be possible) generally reveals the
fact that remnants of the iris are present in the shape
of fragments of tissue situated towards the periphery
of the anterior chamber. In some of the cases, indeed,
as in two brothers shown by me at the Ophthalmolo-
gical Society ( Transactions , Vol. XVI., 1896, p. 184),
a narrow rim of iris, not exceeding 0.5mm. in width,
was present. The condition affects both eyes. Defec¬
tive sight and nystagmus are the rule. Heredity is a
marked feature. This is well shown by a series of
cases recently reported by Dr. T. K. Hamilton
(1 Ophthalmoscope , October, 1905), where a father and
three children (two girls and one boy) were found to
suffer from irideremia.

Opaque Nerve Fibres. —There is, perhaps, no con¬
genital anomaly of the fundus oculi that presents more
characteristic ophthalmoscopic appearances than so-
called “ opaque *’ or “medullated nerve fibres of the
retina.” The glistening, brush-like processes of beau¬
tiful white hue, radiating from the optic disc into the
neighbouring fundus, form a picture that, once seen,
is not readily forgotten or mistaken for anything else.
The condition finds its anatomical explanation in the
fact that the medullary sheaths of the nerve fibres,
which normally cease abruptly at the lamina cribrosa,
are regained by some of the nerve fibres at the margin
of the optic disc, and are continued into the retina
as such for a longer or shorter distance. When
examined with the microscope, the medullated fibres
are varicose, owing to the existence of small globular
or fusiform swellings along their course, but it has
been suggested that these are so many artefacts. In
certain animals, as the rabbit and the Tasmanian devil,
opaque nerve fibres occur normally. It has been
pointed out by V. Hippel (V. Graefe’s Archiv fur
Ophthal ., Band XLIX, 3, p. 591) that the appearances
in the rabbit do not develop until about three weeks
after birth. The same writer maintains that a similar
observation holds true in man. Strictly speaking,
therefore, opaque nerve fibres is not a “congenital
anomaly.” Medullated nerve fibres is not a common
abnormality. According to some figures I published
last year ( Ophthalmoscope , December, 1906), dealing
with the eyes of 4,212 children, the anomaly was
present in 29 cases, or 0.68 per cent, of the entire
number; 72 per cent, of the cases were unilateral, and
27 per cent, bilateral. My statistics further brought
out the fact that opaque nerve fibres were, roughly
speaking, twice as com non in the eyes of males as of
females. With respect to the ophthalmoscopic appear¬
ances of my own cases, the commonest was that of
one or more white, comet-like processes extending into
the fundus from the upper or the lower edge of the
optic disc or from both of those positions. In a much
smaller number of case' the optic papilla was more
or less surrounded by the glistening masses. In a
single instance did the opaque fibres encroach upon
the optic disc itself. In four eyes the rare condition
of “ eccentric *’ nerve fibres was noted—that is to say,
areas of medullated fibres not in visible connection
with the optic papilla. Cases of this description have
been described by Frost, Randall, Dodd, Nettleship.
Blascheck, Ulbrich, and Hawthorn. Before leaving
the subject, it may just be said that opaque nerve
fibres have been known to disappear in cases of optic
atrophy (Sachsalber, Nettleship), or of glaucoma
(Frost), presumably from degeneration of the fibres.

Pseudo-Neuritis. —The next anomaly to be described
has received the name of “pseudo-neuritis,” or the
“hypermetropic disc.” The condition is a common one
both in children and in adults. In order to ascertain its
frequency in the class first-named, some few years ago
(Reports of the Society for the Study of Disease »«
Children , Vol. III., 1903, p. 342), I examined the eyes

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Sept. 25, 1907.

CLINICAL LECTURE.

The Medical Press. 3 31

of 114 children, whose ages ranged from 2 to 16 years.
Of the total number, I found as many as 26—that is,
22.80 per cent.—presented a greater or less degree of
pseudo-neuritis. It is rather a singular coincidence
that Dr. H. C. Bristowe (Ophthalmic Review, 1891,
p. 321) found the condition to exist in 29 amongst 123
patients—that is, in 23.2 per cent—or in almost the
same proportion as that given above. Some of Dr.
Bristowe’s best marked cases were met with in indi¬
viduals over 30 years of age. The ophthalmoscopic
appearances of pseudo-neuritis vary from a slight
haziness to a decided woolliness of the nasal edge of
the optic disc, or in extreme examples to a diffuse
blurring of the papilla. The slighter grades present a
deceptive resemblance to a commencing optic neuritis,
while the more pronounced may be readily confounded
with a well-developed optic neuritis. The change,
although invariably bilateral, is not necessarily equal
in degree as regards the two eyes. Two other ophthal¬
moscopic appearances are commonly associated with
pseudo-neuritis—(1) traces of glistening connective
tissue alongside the central vessels of the optic
papilla ; and (2) some tortuosity of the retinal arteries
and veins over the fundus generally. How can we dis¬
tinguish between pseudo-neuritis, on the one hand,
and true neuritis, on the other? The main diagnostic
points appear to me to be:—1. Pseudo-neuritis is a
congenital condition, neither receding nor advancing,
no matter how lone a case may remain under observa¬
tion. True neuritis, on the contrary, begins, attains
its height, and is then replaced by atrophy or (very
rarely) by recovery. Therefore, if the disc become
blurred while a patient is under observation, or if
blurring become more marked under those conditions,
we may safely conclude that we have to deal with
veritable optic neuritis. 2. Normal sight and visual
field are points against the diagnosis of neuritis.
3. In pseudo-neuritis the disc, in my experience, is
never appreciably swollen, although, judging from the
appearance of the retinal vessels, it often appears to
be so. In reference to this point I note that the latest
book on diseases of the eye , by Mr. J. Herbert Parsons,
contains the caution not to diagnose pseudo-neuritis
“ unless at least 2D. of swelling can be demonstrated ”
fp- 397 )- The exact etiology of pseudo-neuritis is not
known, although my own investigations render it
certain that it is a congenital condition. Certain
writers regard it as the expression of an actual
hypersemia or congestion of the optic disc, due to eye¬
strain produced by hypermetropia or hypermetropic
astigmatism. Hence the name “ hypermetropic disc. ”
With this view I am unable to agree, for two reasons—
first, if the condition is caused by hypermetropia, it
should be relatively more frequent and assuredly more
pronounced in the higher than in the lower grades
of hypermetropia. The figures at my disposal, how¬
ever, prove that such is not the case. Secondly, it
should undergo an improvement when eye-strain is
relieved by suitable glasses, but I have repeatedly
satisfied myself that such is not the fact. Moreover,
seudo-neuritis may occur in association, not with
ypermetropia, but with myopia or myopic astigma¬
tism. If it is more frequent in hypermetropia, it is
simply because in children that condition is at least
five times as common as the reverse condition, myopia.
I may say that my investigations justify me in claim¬
ing that pseudo-neuritis is relatively as common in
the one condition as in the other. Accordingly, I
reject the name of “hypermetropic disc ” uncondition¬
ally. I regard pseudo-neuritis as a congenital non-
differentiation of the optic disc, a view supported by
the frequent existence of shreds of connective tissue
and also by the state of the retinal vessels
Ptosis .—Ptosis may be counted among the commoner
congenital defects. It may be complete, or almost so,
but is usually incomplete, and both eyes, as a rule,
are affected. It may be so slight as scarcely to attract
attention until the child looks upwards. When ptosis
is marked enough for the eyelids to cover the pupils,
the patient manages to see by throwing his head back¬
wards and at the same time evoking the action of the
occipito-frontalis muscle. This gives such patients a
very characteristic appearance. An interesting point
about congenital ptosis is that the condition is not
seldom associated with defective movements of the

eyeball upward; other defects of movement are more
rare. Many cases have now been recorded in which
the ptosis became modified during movements of the
jaw, such as occur during suckling or mastication.
Similar modification has been known to take place
when the eye is adducted or abducted. These cases
have an interesting bearing upon the innervation of
the muscles concerned, and are thought by some to
confirm the theory of Mendel, according to which the
levator palpebrae superioris is supplied not cnly by
the third nerve, but also by fibres belonging to the
fifth cranial nerve, which supplies the muscles of mas¬
tication. W'ith regard to the explanation of congenital
tosis, in some cases the levator has been found to
e absent, replaced by fibrous tissue, inserted
abnormally, or imperfectly developed. The alternative
view—namely, that the defect is due to aplasia of the
nerve nuclei—is supported by a case of Wilbrand and
Sanger (Die Neurologic des Auges, 1900), where such
changes were found in a man afflicted with congenital
ptosis, who died at the age of 47 years.

Persistent Hyaloid Artery .—As already explained,
up to a certain period of foetal life, the hyaloid artery
runs from the optic disc through the vitreous to the
lens, where it breaks up into a vascular plexus, in
order to nourish the enveloping membrane of the
crystalline, the so-called capsulo-pupillary membrane.
Its persistence in whole or in part is responsible for
several congenital anomalies of the eye. For example,
in typical form it may persist as a blood-bearing vessel,
originating from the optic disc, and reaching to the
hirider surface of the lens or to some structure in the
neighbourhood of the latter. More commonly, how¬
ever, one sees merely a greyish cord, attached at one
end to the disc, and at the other to the lens or else
lying free in the vitreous. The vestige, again, may
reveal its existence as a mere tag of tissue, attached
to the optic papilla, and moving in response to the
excursions of the eyeball. In connection with the
hyaloid artery, it may be well to recall the fact that
in some animals, as the frog, the vessels of the vitreous
persist throughout life.

Anomalies of the Eyelids.—A. congenital anomaly of
the eyelids that seems to be connected with perverted
development was described by me some years ago
(Trans. Ophthalmological Society, Vol. XIV., 18^4,
p. 13), under the name of congenital trichiasis. The
condition, which is not exactly rare, affects the lower
lid of one or both eyes. It is characterised by the
fact that more or less of the free border of the lower
lid is concealed behind a horizontal fold of skin the
mechanical effect of which is to push the lashes up¬
wards, with the consequence that they come into con¬
tact with the surface of the eyeball. The cilia appear
to be normal, except as regards their direction. The
intermarginal space is almost, if not quite, normally
situated. The condition may be combined with epi-
canthus. Heredity is marked. The condition, I
believe, depends essentially upon a relative mal-
development of the tarsus of the lower lid. A more
pronounced maldevelopment of that structure, as sug¬
gested by Guibert (Archives d'Ophtalmologie, Feb¬
ruary, 1892), would produce the exceedingly rare con¬
dition of congenital entropion. A few cases have been
known (Jago, Streatfeild) where patients could invert
the lower lid at will.

Another interesting but very uncommon malforma¬
tion affecting the cilia goes by the name of distichiasis,
of which I reported a typical case to the Ophthalmo¬
logical Society in 1901 (Trans. Ophthalmological
Society, Vol. XXII., 1902, p. 192). This malformation
is marked by the existence as a congenital condition
of a second row of lashes lying behind the normally
placed ones. Upper as well as lower lid may be in¬
volved. Mr. A. R. Brailey (Trans. Ophthalmological
Society, Vol. XXVI., 1906, p. 16) examined micro¬
scopically a small piece taken from the upper eyelid
of a patient with distichiasis. He found that the most
striking feature was absence of the Meibomian glands.
Kuhnt regards distichiasis as a congenital condition
in which the Meibomian glands have been replaced by
a row of accessory cilia with all their attributes as
sebaceous glands. The influence of heredity was well
shown by Erdmann's cases (Zeitschr. fiir Augen *

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33 2 The Medical Press.

CLINICAL LECTURE.

Sept. 25, 1907.

heilkunde, May, 1904), which occurred in three genera¬
tions of the same family, affecting grandmother,
mother and child.

Anomalies of the Laerymal Apparatus. —In a singular
case reported by A. S. Morton (Trans. Ophthalmological
Society, Vol. IV., 1884, p. 350), there was a congenital
absence of lacrymation as regards one eye, and in
another case by G. Sommer (Klin. Monatsbl. f ,
Augenheilk., 1903, Band I., p. 482) as regards both
eyes. It does not quite follow that the laerymal gland
was absent, although that was actually proved to be
the case in an instance of cryptophthalmia examined
by Van Duyse. Fistula of the laerymal gland has
been reported by several authors, as Mackenzie and
McGillivray. As relatively common conditions the
puncta lacrymalia may be absent, replaced by a
shallow groove, or blocked up—all as developmental
anomalies. The puncta, moreover, may be multiple.
By far the commonest and most important anomaly,
however, is due to the imperfect differentiation of the
naso-lacrymal duct, together with subsequent in¬
fection, a condition to which the name “congenital
dacryocystitis ” is sometimes applied. Should canalisa¬
tion of the duct be incomplete at birth, it needs only
infection by pyococci or other organisms, as the
pneumococcus, to cause a discharge of muco-pus
from the puncta. The infection, indeed, may occur
in the maternal passages, in which event the baby is
actn&lly born with a discharging laerymal sac. In
other cases, which perhaps form the majority, the in¬
fection is post-partum, so that the characteristic
appearances do not manifest themselves for several
days after birth.

Dermoids. —Dermoid cysts or growths are found
with tolerable frequency, either alone or associated
with other anomalies, upon or about the eye. All of
them are to bq explained by epiblastic sequestration
taking place while the embryonic clefts are in process
of closure. They thus form one of the best examples
of the well-known embryonic hypothesis of Cohnheim.
Few of the dermoids about the eye deserve the more
dignified title of teratomata— i.e., growths which in¬
clude highly organised structures such as bone or teeth.
The commonest place for a dermoid to occur is at
the outer end of the eyebrow, where it forms a lenti¬
cular swelling, hot attached to the skin. These small
growths seldom penetrate deep into the orbit. It is
therefore more correct to speak of them as “peri¬
orbital ” than as “orbital.” Their wall contains some
or all of the elements found in skin, while their con¬
tents consist of sebum, or—much more rarely—of oily
liquid—the so-called “oil cysts.” Although the cysts
are, of course, congenital, yet they may grow con¬
siderably subsequent to birth. I nave known them
appear more or less suddenly after injury to or opera¬
tion on the parts. The peri-orbital dermoid may occur
at the inner side of the eye, near the root of the nose,
a position in which it must be carefully distinguished
from a meningo-encephalocele, now believed by many
to result from intra-uterine hydrocephalus. On the
other hand, true orbital dermoids are extremely rare.
I have seen one case only of the kind. The dermoid
of the eyeball usually takes the form of a small, solid,
whitish growth, of firm consistence, astride some part
of the limbus conjunctivae, as a rule, on the lower
and outer aspect. Fine hairs may protrude from the
surface of the dermoid, and towards puberty these
may grow to inordinate length. In Wardrop’s famous
case (Essays on the Morbid Anatomy of the Human
Eye , 1808, p. 31), upwards of a dozen long and very
strong hairs grew from the middle part of such a
tumour, passed between the eyelids, and hung over
the cheek. The patient remarked that these hairs did
not appear until he advanced to his sixteenth year, at
which time also his beard grew. Dr. Argyll Robert¬
son, under the name “trichosis bulbi,” has described
{Trans. Ophthalmological Society, Vol. XIV., 1894,
p. 196) a similar but slighter growth of hair from a
dermoid thickening of the ocular conjunctiva. The
last form of dermoid to be mentioned appears beneath
the ocular conjunctiva, usually in the interval between
the insertion of the superior and external rectus
tendons, as a soft, fatty-looking mass, the conjunctiva
over which may show no particular changes to the
i nked eye. These growths, formerly spoken of as

“congenital fibro-fatty tumours,” are now generally
recognised to be lipo-dermoids. They are not encap¬
sulated, and their contained fat is continuous with
that belonging to the orbit. Their complete removal
is therefore an impossibility.

II.— Anomalies Due to Amniotic Adhesions.

As explained earlier, certain anomalies of the eye
are now believed by many to be due to the bad effects
upon development exercised by adhesions between
the amnion, on the one hand, and the tegument of
the foetus, on the other. As to the exact conditions
under which such adhesions occur, we have still much
to learn. It is, however, admitted that scantiness of
the amniotic fluid—that is to say, the condition known
as oligo-hydramnio 9 —is a predisposing factor.
Gonorrhoeal infection in utero is probably also a
factor in some cases of amniotic adhesions (J. B.
Hellier).

The outstanding anomaly for which amniotic adhe¬
sions seems best to account is coloboma of the eyelids.
Dor and Nicolin (Revue Generate <TOphtalmologie,
December 31st, 1888) trace coloboma to an interfer¬
ence with the development of the eyelids by imperfect
closure of the oblique facial fissure. On the other
hand, in recent times more particularly, Van Duyse
thinks the malformation to be closely connected with
the presence of amniotic bands. Van Duyse’s theory,
as pointed out by J. H. Parsons (The Pathology of
the Eye, Vol. III., Part I., p. 778), explains not only
the coloboma, but also the cutaneous ridges and der¬
moids as persistent portions of the constricting bands.
Dor’s objection, that amniotic adhesions cannot ac¬
count for the existence of bilateral and symmetrical
colobomata (loco citato, p. 532), is met by the observa¬
tions of V. Bruns, Pollailon, and Lannelongue, who
observed such bands inserted into the middle of the
cornea and passing symmetrically over the eyelids.

Coloboma of the eyelids is far from common, as
may be inferred from the fact that Nicolin, writing
in the year 1888 (Thise de Lyon, 1888), was able to
bring together 46 cases only from the collective
literature.

Coloboma may range as regards degree from a tiny
notch in the free border of the eyelid to a wide gap
extending through the entire structure and exposing
the cornea. The cilia are nearly always absent from
the hiatus. In about 50 per cent, of the cases one
eyelid is alone affected, and the upper is the seat of
election. For example, among 90 cases of coloboma
collected from literature for the purposes of this
lecture, in 46 one eyelid was alone involved—that is,
the upper in 36 and the lower in 10 instances. The
collection included only two cases—namely, those by
Lannelongue and by Morian respectively—where all
four lids were implicated. Morian’s case is suggestive,
since the colobomata were associated with amniotic
strangulations of the patient’s fingers and toes, in
addition to oblique facial clefts healed in utero. In
some of the cases the coloboma was connected by a
cutaneous fold with the eyeball, and in many others
a dermoid growth existed in such a position on the
eyeball as to fill more or less completely the gap left
by the coloboma when the lids were closed. At the
same time it cannot be denied that these defects in
the lid, especially when large, predispose to ulceration
of the cornea, as in cases reported by Conradi (18881,
Cowell (1891), Juler (1892), and myself (1906). Hence,
besides the deformity often caused by the coloboma,
we have another and a very good reason for closing
the gap in the lid as early as may be. In this con¬
nection it may be stated that 16 of the 90 patients
included in my series had been treated surgically.

It is worth mentioning that in only six of the ninety
cases of coloboma of the lid no associated deformities
of the eye or of other parts of the body were alluded
to in the authors’ descriptions (Talko, Gillette,
Despagnet, Major, Galezowski, and Creutz). Details,
however, were often scanty. Curious tufts of hair
arising from the eyebrow and directed towards the
coloboma have been reported by Nuel, Frost, Morian,
and Ohse. In Manx’s case (V. Graefe’s Arch, f.
Ophthalmologic ) of coloboma of the median part of
each upper lid, the middle third of each eyebrow was
absent. Notched orbits or deficiencies of the eyebrow
have been reported by Nuel, Hassalmann, Schanz, and

Sept. 25, 1907-

ORIGINAL PAPERS.

The Medicat. Press. 333

Geissmar. Cicatrices, representing Nature’s attempt
at cure, have been noted by Snell (Trans. Ophthalmo-
logical Society, Vol. 1884, p. 348), Berry, and Rosa
Ford ( Ophthalmoscope , 1907), extending in the

skin from the cleft towards the orbital margin.
A similar line has been seen by E. T. Collins (Trans.
■Ophthalmological Society, Vol. XXV., 1905, p. 319) in
■the palpebral conjunctiva. The ocular complications
of coloboma, in addition to those mentioned before,
include epitarsus, pupillary membrane, coloboma of
iris and choroid, adherent leucoma, notched optic
disc, multiple or absent lacrymal pur.cta, and ectasia
•of the lacrymal sac. The general deformities most
commonly noted in these cases have been deformed
or supernumerary auricles, ill-developed malar pro¬
minences, macrostomia, post-anal dimple (so-called
fovea sacralis), highly-arched palate, bifid tongue or
uvula, stenosis of the nostril, absence of the external
auditory meatus, hare-lip, cleft palate, and, lastly,
oblique facial fissure or its remains.

It may be added, before passing from the subject,
that cases have been described by Berry, E. T.
Collins, Tyrrell, and Rosa Ford, where a small notch
in the outer part of the lower lid, generally of both
eyes, coincided with mal-development of the malar;,
bone, as shown by flattening of the side of the face.
The group, although not large, is important, inasmuch
as the cases can be readily explained by the theory
of amniotic adhesions.

(To be continued.)

Note. —A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture
for next week will be by Sydney Stephenson, M.B.Edin.,
F.R.C.S., Ophthalmic Surgeon Evelina and North-
Eastern Hospitals for Children, Kensington General
Hospital, 6-c. Subject : “ Congenital Anomalies of the
Eye” (Part II.)

ORIGINAL PAPERS.

THE DISEASES AND DISPLACEMENT

OF THE

TESTICLE IN CHILDHOOD, (a)

By D’ARCY POWER, F.R.C.S.Eng.,

Surgeon to and Lecturer on Surgery at St. Bartholomew's Hoepltal.

The diseases of the testicle in children group them¬
selves naturally under the headings of tubercle,
syphilis, malignant growths, innocent tumours, and
teratomata. The displacements are due to faulty
processes of development carrying with them certain
additional predispositions to disease and injury.

In opening a discussion on the subject the results of
personal experience are given and questions are asked
m regard to points which appear to stand in need of
further elucidation.

Tubercle.

Most of the swollen testicles seen in the wards and
out-patient rooms of a children’s hospital are caused
by tubercle or by syphilis, or, perhaps, speaking more
correctly, by tubercle growing in tissues which have
been prepared for infection by changes due to con¬
genital syphilis. In private practice they are nearly
always tuberculous without any admixture of syphilis.

Tuberculous disease of the testicle is rare in children,
for Demme records 16 cases in 1932 tuberculous
children, whilst Jullien only saw it 16 times in 5,516
children. But tuberculous inflammation of the tes¬
ticle in children is much more common than these
statistics show, and there is never a year in which
two or three children do not come under my care for
this form of disease. The inflammation is sometimes
primary, but it is more often associated with other
signs of tubercle, and there is frequently a definite
history of injury. It is usual, therefore, tor only one
testicle to be affected. The diagnosis is easy, but the
disease runs a somewhat different course in children

(a) Abstract of Paper read In the Section for Dlseaiei of Children
ef the British Medical Association Meeting at Exeter, August 1907.

from that which it follows in adults, because the
gland is not functional in children.

When the infection is simple and the child is fairly
healthy, the disease may remain localised to the
affected gland. The swollen testicle is enlarged
for a longer or shorter period, and then slowly di¬
minishes. The inflammation disappears completely
and the testicle may resume its original condition, or
the process of involution may be carried beyond the
normal, the testicle atrophies, and the child becomes
monorchous. This, at least, is the statement generally
made, but I should like to know if anyone has followed
out the progress of a tuberculous testicle until it ended
in atrophy. I have seen atrophy four years after an
operation for the radical cure of a hernia in a child,
and I have seen it after enlargement of the testicle
due to congenital syphilis, but never as a result of
tubercle.

The treatment of these cases of pure tuberculous
infection may safely be palliative. Fresh air, cream,
or cod liver oil, good food, and plenty of sleep, with a
light suspensory bandage, are sufficient. But a jealous
eye should be kept upon the child, and he should be
weighed at frequent intervals. If the weight falls a
careful and systematic examination should be made
to ascertain whether there is any evidence of dissemi¬
nation ; the lymphatic glands, the bones, more
especially the vertebrae, the peritoneum, the pleurae,
and the meninges of the brain are the most likely
parts to become affected. The testicle should be
removed at once when there is even a suspicion of such
an infection.

The prognosis is not so good when the infection
consists of a mixed culture of tubercle bacilli and
pyogenic organisms. In such cases an abscess is soon
formed, and the neighbouring lymphatic glands quickly
become affected.

I would, therefore, counsel early removal of the
testicle when suppuration occurs, because I do not
believe that any good follows such partial operations
as the scraping or excision of the softened parts of
the testicle, but rather harm, for I have often seen
these cases associated with tuberculous dactylitis,
spinal caries, and tuberculous peritonitis.

Syphilitic Inflammation.

Syphilitic inflammation of the testicle occurs at all
ages from birth up to four and twenty, though it is
most common before the age of three years. Both
testicles are affected, and often at the same time. A
hydrocele of the tunica vaginalis is an almost constant
accompaniment, whereas in a tuberculous testicle a
hydrocele does not occur in more than a third of the
cases. The patient, if he be an infant, always pre¬
sents evidence of inherited syphilis, often in a severe
form. The testicles are extremely hard, and the bene¬
ficial effects of administering gray powder are so
marked as to leave no doubt about the diagnosis.

The inflammation is usually diffuse, and leads to a
general enlargement of the body of the testicle, but it
is occasionally gummatous, in which case the outline
is irregular. The epididymis may be affected, but it
is much more usual for the tunica vaginalis to be in¬
volved in the inflammation, a feature which accounts
for the frequent co-existence of a hydrocele. It is
rare for suppuration to take place in syphilitic inflam¬
mation of the testicle so long as it is free from tubercu¬
lous infection ; but it is quite common for the two
infections to co-exist in the miserably marasmic child¬
ren who are the subjects of these swollen testicles.
The condition is so painless and chronic that it is often
overlooked, and children are occasionally brought for
advice in whom the process has continued for so long
that cicatricial contraction of the inflammatory
fibrous tissue has occurred and the testicle is atrophied.

I should like to know in connection with syphilitic
inflammation whether any observations have been
made as to the retardation of puberty which takes
lace as a result of inherited syphilis. I believe it to
e part of a general failure of development and that
it is not a mere consequence of the atrophy of the
testicles, or of the ovaries, for the delay occurs in

zed by GoOgle

334 Th b Medical Press,

ORIGINAL PAPERS,

Sept 25, 1907.

both sexes. It is certain that the patient is impotent
as well as sterile when both testicles are wasted owing
to inflammation due to inherited syphilis.

Teratomata.

Teratomata of the testicle are always cystic, for they
are either dermoids or sebaceous tumours. Dr. Hilton,
of Nebraska, collected the records of 79 cases. In
these the teratoma was testicular in origin in 40 patients
and scrotal in 21; in 14 cases it was situated in the
inguinal canal and in one case it was derived from the
tunica vaginalis.

These tumours form an interesting group and open
up many points for discussion, as well as for elucida¬
tion by more careful examination. It is not yet known,
for instance, whether a dermoid of the testicle is. or is
not, a true tumour of the testicle itself. Indeed, the
ease with which it can sometimes be dissected away
from the gland makes it highly probable that in many
instances a dermoid is in reality a teratoma, using the
term in the sense of a parasitic foetus. It is highly
desirable, therefore, to determine, as far as possible,
in each case whether the dermoid is within the tunica
albuginea; whether it merely lies in the connective
tissue between the tunica vaginalis and the testicle, or
whether it is clearly attached to the scrotum, and, if
so, whether the attachment is due to its being the
place of origin of the tumour or the result of inflam¬
matory changes between the scrotum and the wall of
the dermoid. A section through the wall of the dermoid
may show the presence of atrophied seminiferous
tubules if the tumour has been developed within the
substance of the testicle.

Dermoids are so rare that an error of diagnosis is'
pardonable, and it seems that they are most likely to
be mistaken for epiploceles and for hydroceles of the
cord. They are distinguishable from hydroceles by
the absence of that translucency which is invariable
in infants, and from omental hernia by the fact that
teratomata are more uniform in outline, whilst the
careful examination of an epiplocele will often reveal
the presence of nodules. Complete reduction is no
more possible in the case of a teratoma than in that of
an encysted hydrocele, but in both cases it may be
possible to push the tumour out of sight through the
external abdominal ring.

There is no question as to treatment. The swelling
in the scrotum should be explored, and the dermoid
removed without sacrificing the testicle, if possible,
but if it be actually incorporated with the gland the
whole organ must be removed, as there is a definite
liability to inflammation, suppuration, or haemorrhage
after slight injuries. It would be interesting to learn
if any one has yet seen teratomata affecting both
testicles—for teratomata of both ovaries are not very
rare.

Malignant Disease.

Sarcoma of the testicle occurs in boys aet. 10 and
upwards, and, like sarcomata elsewhere they follow
directly upon an injury in a considerable proportion
of cases. The tumour primarily involves the epididy¬
mis, and the body of the testicle is less frequently
involved at first. But the growth often runs a very
rapid course, and much time is usually lost because
it is painless and there is early loss of testicular sensa¬
tion. The patient therefore does not apply for relief
until the tumour has attained a sufficient size to
make it inconvenient by its weight. The tumour is
then found to be smooth, heavy, and hard, but its
shape and even its very existence may be masked by
the presence of a hydrocele or a hematocele. The
affection is most likely to be mistaken for a thick-
walled hydrocele, for tubercle, or for syphilis, but the
rapid growth of a sarcomatous testicle soon indicates
its real character.

I believe the prognosis of sarcoma of the testicle to
be worse in boys and young men than it is in old
people, for all the cases I have seen have ended fatally,
even when an early operation has been performed.
A misleading feature about the patients is that they
remain in singularly good health for a long time, and
it is difficult, therefore, to persuade either them or

their friends that they are suffering from a deadly
disease. Too much stress in these cases must not be
laid upon the existence of enlarged lumbar glands,
because, although they are often affected, I have seen
more than one case in which there was diffuse sarco¬
matous infiltration of the whole peritoneum spreading
from the epididymis up the spermatic cord without
any infiltration of the lymphatic glands.

Mr. Eve (Trans. Path. Soc., Vol. 38, p. 201) and
Mr. A. G. R. Foulerton (the Archives of the Middlesex
Hospital, Vol. s, p. 234, and the Lancet, 1905, Vol. II.,
p. 1827) have shown the need for reconsidering the
whole question of those tumours of the testicle which
are usually called sarcomatous. Many of the tumours
are really columnar-celled carcinomata beginning in
the tubules of the rete testis or in the vasa efferentia.
It would be interesting, therefore, to know whether,
in the light of Mr. Foulerton’s work there is any
difference in the course and dissemination run by
malignant tumours of the testicle when the deep lumbar
glands remain unaffected and when they become
early affected. I think it will be found that there
are two classes, and that the patients in whom the
lumbar glands are unaffected die sooner than those
in whom they are early enlarged.

Imperfectly descended Testicle.

The questions connected with imperfect descent of
the testicle open up such wide fields for discussion that
it would easily form material for an entire debate.
I shall, therefore, endeavour to narrow it down to a
few practical points. Brushing aside all theory, I
should like to ask, what is the general feeling about
orchidopexy or the freeing of a testicle, which is im¬
perfectly descended, with subsequent fixation to the
bottom of the scrotum, the pillars of the external
abdominal ring being afterwards sutured to prevent
the testicle from re-entering the inguinal canal ? I
have done the operation many times, but, except in
the very simplest cases, I have never satisfied myself
that it was advantageous, and in a few cases the result
has appeared to be so unsatisfactory that I have after¬
wards removed the testicle.

I think, therefore, that it is better to advise removal
of the testicle in nearly all cases where it is imper¬
fectly descended and can be felt, especially if there is
evidence of a hernia and the abnormality is limited to
one side.

When a hernia is present the sooner the operation
is done the better after the patient has attained the
age of four or five years. When there is no hernia,
or only a small bubonocele, I generally advise the
parents to wait until the child is seven or eight years
old in the hope that the testicle may descend further
into the scrotum. But I do not think it is worth while
waiting until puberty, because a fairly accurate prog¬
nosis can be arrived at much earlier if the child is
seen a few times at intervals of two or three months.

I have lately had two cases of acute torsion of the
spermatic cord under my care, and in both cases the
testicle was imperfectly descended. I contented
myself in the first case with untwisting the cord, and
was rewarded for my forbearance, but in the other
case the testicle was removed, and the ring sewn up.

But the really difficult cases of imperfectly descended
testicle are those in which the only son of influential
persons is brought for advice at the age of five with
both testicles lying within the inguinal canal close to
the external abdominal ring. I see my way clearly
when only one testicle is imperfectly descended, when
the imperfect descent is associated with a hernia, as
is the case in about 80 per cent., and when pain or
symptoms of torsion have appeared. I know also
what to advise when both testicles are situated com¬
fortably in the abdominal cavity; but I confess that
I am doubtful as to the best course to pursue when
both testicles are situated within the inguinal canal
at a point where they may be readily injured in the
ordinary course of school life. They ought not to be
removed, especially if large interests are at stake, and
I therefore suggest that the wisest advice is either to
leave them alone until they become troublesome, or

Sept. 25 . I 9°7»

ORIGINAL PAPERS.

else to put them straight back into the abdominal
cavity. But if the latter course be adopted, the opera¬
tion should be done early, as there is evidence to
show that testicles thus replaced after puberty do not
undergo development, whilst if they be replaced
earlier the testicle may produce spermatozoa a few
years between eighteen and twenty-five. It is then
possible that the testicles may become functional, at
any rate for a short time, though too much must not
be promised to the parents. All that one can say is,
that the boy will not then present the characters of a
eunuch, and that he has been put into the best possible
condition, under the circumstances, for the subsequent
procreation of children.

An ectopic testicle must be treated on its merits.
When it lies in the perineum, the gland may easily be
put into the scrotum, for it is often attached to the
tuber ischii, to the external sphincter of the anus, or
to the skin by a single band of fibres which can be
made tense. The subcutaneous division of this band
sometimes allows of the testicle being replaced in its
proper position, or, if this fails, an open operation
may be performed, and the testicle can then be put
into the scrotum. But when the testicle lies in the
groin or in the femoral region, I do not hesitate to
remove it, first, because testicles so placed are said to
be always functionless, and, secondly, because they
are more especially liable to injury.

Hydrocele.

Of all the tumours in the scrotum of children, I
think that an ordinary hydrocele is the most often
overlooked or misinterpreted. Everyone is alive to
the fact that children suffer from hernia, but students
and practitioners alike seem to forget that hydrocele
is nearly as common in infants as it is in adults. Child¬
ren are, therefore, constantly brought to the surgeon
with a diagnosis of rupture when a little care in exami¬
nation would have shown that the swelling was in
reality a hydrocele. The mistake is not very excusable
in a case of hydrocele of the tunica vaginalis, though
it is venial if the swelling be limited to the cord, espe¬
cially if it be situated at or near the inguinal canal.
The error in diagnosis is unimportant if a woollen
truss be ordered, but serious harm may be done if
determined attempts are made to replace the swelling
within the abdomen, or if it be treated as a strangulated
hernia, because from other causes the child has become
constipated. In my own case I base the diagnosis
very largely upon the sense of touch. A hydrocele
always appears to me to be much more tense and
elastic than any hernia I have ever felt. I am careful
to place no reliance upon the translucency of the
tumour, because I know that in young children the
walls of the bowel are so thin as to transmit light
quite easily. I know, too, that in babies a hydrocele
is not so often pear-shaped as it is in adults. It may
be so tense and well defined round the testicles that it
moves quite easily in the scrotum, and it is often
taken, therefore, for an enlarged testicle. Treatment,

I think, should consist in simple puncture, but if the
hydrocele refills there need be no hesitation in per¬
forming a radical operation even in very small babies,
the operation being carried out on the same lines as
in adults.

MEDICAL SUPERVISION OF SECON*
DARY SCHOOLS IN SWEDEN, (a)

By Dr. MED. GOTTFRID TORNELL.

To a certain extent Sweden may claim to be regarded
as a pioneer country in respect of the appointment of
medical officers in conjunction with the State schools.
Mention is made of such officers as long ago as
between 1830 and 1840, and in 1863 there was issued
an ordinance prescribing the duties they were lequired
to fulfil. It is fair to assume that as early as 1868
all the public schools in the kingdom had medical
officers attached to their staffs. The school Codes
of 1878 and 1892 contained paragraphs which still

(■») Re»d before the International Confreu on Sobool Hygiene,
London, July, 1907.

The Medical Press. 335

[ further extended the sphere of activity in the school
allotted to the medical officer. The Code at present in
force bears date February 18th, 1905. It contains
detailed prescriptions concerning the duties of school
medical officers, drawn up entirely in accordance with
modem hygienic principles.

The work which is considered in this country
(Sweden) to come within the purview of a school
medical officer may be summarised under the follow¬
ing headings:—

1. To examine the scholars medically, in order to
find out the state of health of each.

2 . To adopt preventive measures against the spread
of infectious complaints.

3. To superintend the school premises as regards
their sanitary condition.

4. To provide against the scholars being over¬
burdened with lessons, etc., and thereby becoming
overworked.

5. To attend indigent children in case of illness,
free of charge ; and

6. To draw up statements upon any problem that
may arise regarding school hygiene, and to hand in
periodical reports of the work that it has fallen to
their lot to discharge.

It is in accordance with the principles above stated
that the “Instructions to School Medical Officers,”
issued as one section of the new Code of 1905, have
been formulated.

The State Secondary Schools Supervisory Board
has at its disposal the services of an expert in hygiene,
and he is consulted on matters belonging to that aspect
of education.

On the staff of every school there shall be a medical
officer—appointed and remunerated by the State—
whose duties are :—

1. To examine candidates for entrance to the school
free of charge, if they are in indigent circumstances.

[In order to obtain entrance into a State secondary
school, a candidate must be furnished with certificates
to show: That he or she has been vaccinated, and
that he or she is not a sufferer from any illness or
defect which would render him or her unfitted to
take part in school work, or which might exercise a
deleterious influence on his or her schoolfellows.]

2. At the beginning of every term, in the presence
of the teacher of gymnastics, to carry out a careful
investigation of each one of the pupils, and to hand
in to the headmaster or the class superintendent a
report upon the result of such investigation. The
pupils’ sight and hearing are to be tested once every
year.

3. To conduct a medical examination of any pupil,
either at the suggestion of the headmaster or other¬
wise, whenever his or her state of health seems to
require it.

4. To afford the headmaster any advice that may be
necessary or expedient in case of an outbreak in the
school of any infectious complaint, and to take
measures to prevent the spread of the infection. A
definite period of absence from school in the case of
pupils having caught seme infectious complaint, vary¬
ing with the nature of the disease, is not prescribed
by the school Code. In no case, however, is it per¬
missible for a pupil who has had any such illness to
return to school until the school medical officer shall
have pronounced him or her free from infection, and
have drawn up a certificate to that effect.

5. To attend indigent children free of charge. This
article does r.ot now appear in the school Code; it
has long been in force with reference to Swedish public
schools.

6 . To inspect all the school buildings thoroughly,
and to be present at the teaching of gymnastics at
least once a month. In regard to the latter duty,
attention should be particularly directed to seeing that
the pupils are not set to execute movements or do
exercises which are unsuited to their physical powers.

7. To spend at least one hour per week on the school
premises, for the purpose of affording advice, if such
be needed, to the headmaster, the other masters, or the
pupils. This hour of attendance is to be employed
partly for the reception of any member of the school
community who desires to consult a medical man, and
partly for the inspection of the conditions under which

Digitized by

Google

ORIGINAL PAPERS.

Sept. 25. 1907.

336 The Medical Press

the pupils do their work; how they are seated as
regards light and air, etc., how they sit at their desks,
the posture of their bodies, etc., and what degree of
mental alertness they display at their lessons, etc., etc.

8. To supervise the curriculum of work. The chief
point for the medical officer to observe here is whether
work and leisure are suitably apportioned in the cur¬
riculum, so as to avoid the occurrence of overstrain
among the pupils. If the medical officer finds cause
to disapprove of the curriculum in any particular, he
should bring the fact to the notice of the headmaster.

9. To hand in annual reports upon duties performed
by virtue of office.

10. When new buildings are being erected or old
ones altered or repaired, to make sure, provided no
other specialist in hygienic matters is called in, that
the requirements of hygiene are being duly and
adequately fulfilled in the building work as it proceeds.

xi. To be present at any meetings of the staff of the
school where questions pertaining to the health of the
pupils or the sanitary arrangements on the school pre¬
mises are being debated ; to take active part on such
occasions not only in the discussion, but likewise in
the voting or drawing up of the resolution of the
meeting.

[Thus, as far as hygienic matters are concerned, the
school medical officer is not merely an advisory mem¬
ber of the staff; he is also empowered to assist in the
framing of decisions.]

The school medical officer has furthermore to do
what in him lie 3 to see that the regulations laid down
respecting physical education and the sanitary arrange¬
ments at the school are duly observed and carried out.
These regulations are, briefly, as fellows:—

(a) The schoolhouse should be in a healthy situation,'
with plenty of space near it for outdoor games; a
so-termed play-shed for resting, sheltering or hanging
clothes in should be erected on the outskirts of the
playground.

(d) The rooms intended for teaching in, etc., are to
be constructed in accordance with regulations issued
specially in regard to them.

(c) The gymnasium must be provided with a
changing-room, a douche and a bath-room con¬
veniently near at hand.

(d) Opportunities shculd be provided during the
summer for the pupils to receive instruction in
swimming.

(e) With reference to the heating, ventilating, light¬
ing and cleaning of the various rooms, lobbies, etc.,
in the school buildings, the headmaster shall draw
up, in consultation with the school medical officer, a
detailed plan of procedure, to be scrupulously followed
out by those whom it concerns. A copy of that plan
of procedure should be nailed up on the wall in some
suitable place in the school building.

(/) To each pupil there should be allotted about 6
cubic metres of space and square metres of floor
area. The pupils’ desks should vary in size to accom¬
modate scholars of different heights. Short-sighted
and deaf pupils are to have suitable places assigned
to them by the school medical officer.

(g) Text-books, etc., are to be printed in a type
which is sufficiently large and clear to preclude any
danger of the sight of the pupils being injured by the
use of them.

The school medical officer is not required under the
present Code to do any teaching work.

Any qualified doctor may apply for and obtain the
appointment of school medical officer. It has not been
considered essential that he should have gone through
a special course in school hygiene, inasmuch as in¬
struction in hygiene forms part of the course of study
which all medical students take up when preparing
for their qualifying degree.

What the effect of the new Code will be as regards
the health of the school children it is as yet difficult
to determine, for only a brief period of time has
elapsed since it became law. If it is fair to judge,
however, from the results already obseived, and, above
all, from the exceedingly cordial co-operation that pre¬
vails between the teachers and the medical officers at
the schools, there is e*ery reason to believe that the
new Code will work very beneficially in the interests
of the generation now attending school.

THE BEGINNINGS OF DISEASE-
THE PASSAGE FROM HEALTH TO
DISEASE.

By J.

LIONEL TAYLER, M.R.C.S., L.R.C.P.,
Lond.

It seems probable—though no figures worth
quoting are available, as there is no general regis¬
tration of disease—that quite 30 per cent, of the
general practitioner’s patients could be classed
under the above heading as being midway between
the state of health and that of disease; and, as far
the greater proportion of all illnesses are seen by
the ordinary medical man, this means that from
20 to 25 per cent, of all practice is concerned with
such phenomena.

I am purposely excluding from this article the
beginnings of specific diseases, for these can be
more appropriately considered by themselves in
reference to certain more or less obvious, possible
channels of infection by which specific germs can
gain access to the organism. The question of
simple impairment of health can thus be studied
by itself, and as this constitutional failure accounts
for the presence of at least three or four patients
out of every ten in the ordinary doctor’s waiting-
rooms and for nearly a like proportion of cases on
his visiting lists, it is surely profitable to give the
matter some attention.

There are many popular designations for this
condition of which “ run down,” “ out of form,”
“seedy,” “below par,” “ off colour,” are examples,
and such a phrase on a patient’s lips calls up to
the medical man’s mind a definite, or rather very
indefinite, group of related symptoms. For this
state the general practitioner uses one word—de¬
bility—more frequently than any other, and he
recognises a chronic as well as a temporary form,
and often refers, when granting medical certifi¬
cates, in writing to them. It would, however, be
more accurate if patients suffering in this way were
divided into three instead of two groups. The
first, to be restricted to those individuals whose
breakdown is slight, and the subsequent convales¬
cence, complete and relatively permanent; the
, second, to those who recover much of their original
health but tend to breakdown again at frequent
intervals, the recurrent cases; and the third, those
who seem to have acquired a chronic ailing habit
and are never, or very seldom, free from a weary
, tired feeling and general malaise.

It has, however, to be borne in mind that an
even earlier condition exists which medical men
are very seldom indeed consulted about, namely,
those slight failures in health that last for a few
hours, and only come to our notice when they re¬
peat themselves sufficiently frequently so as to be
an annoyance to the patient. Chemists, however,
often have customers drop in for a dose of “ tonic”

■ or a “ pick-me-up,” and though in many cases
such people are only feeling the reaction of un¬
healthy excesses of the day before, yet there are
others’in whom this feeling marks the first onset
of a failing constitution. Hence we may speak of
these “low,” “done up,” “limp” feelings as
symptoms of the earliest form of divergence from
health, and therefore these occasional or recurrent
indispositions are intermediary' stages, shading
more and more deeply by insensible gradations
from health towards debility and disease.

The importance of these phenomena has never
been sufficiently appreciated. Their prevalence is
so common and widespread over the whole popu¬
lation that no single individual, however healthy,
entirely escapes, and the inconvenience that is
caused is manifest, so that the need for good treat-

Sept. 25, 1907.

ORIGINAL PAPERS.

The Medical Peess. 337

orient is great, while their scientific value is not less
obvious, as the practitioner is presented with the
most generalised pathological data that exist.
Disease is thus seen in its embryonic state, and its
development from this point to definite recogniz¬
able disorders should be clearly traceable.

The symptoms are legion, and the diagnosis is
always arrived at by a process of exclusion, for on
examination organic disease is found to be absent.
The central factor, however, that meets one, from
whatever point of view the symptoms are studied,
is that of lassitude, weakness and flaccidity. The
flabby, pendulant character of the voluntary
muscles, when placed in a relaxed position, is
obvious to the eye and touch. The collapsible con¬
dition of the smaller arteries is shown by the pas¬
sive modifications in circulation that posture
makes—defective peristalsis by constipation, flatu¬
lence, and occasional diarrhoea. In a woman, often
menstrual irregularities disclose a weakened
uterine wall. The skin is deficient in elasticity, is
readily marked by any external body, and the
impression thus made disappears slowfy. Every¬
where there is evidence of lack of tone. There
may be nervous irritability or apathy, excitability
•or depression, but the one common complaint of
patients is, “ I can’t settle to anything.” Boils or
small spots are quite common, and a loud throat
cough, with thick relaxed voice and slightly red¬
dened congested throat, are often noticeable. In
nearly all people there is some increase of pallor,
due possibly to a defective blood condition, and in
some a muddy, putty-like complexion, with a
damp, cold skin, are typical associations. In ex¬
treme cases the whole appearance is strikingly
feeble, drooping shoulders and stooping figure,
and a resigned, effortless, beaten expression of
face.

The causes of this disordered functioning are
multiform—overwork, unsuitable vocation, bad
housing, monotony of life, dissipation, self-indul¬
gence, sexual excess and abuse, laziness—any¬
thing, in fact, that impairs by excess of use or
from too little exercise the tone of the body and
mind.

Advice differs according to the cause. For the
overworked, rest; for the underworked, activity;
for the dissipatedj restraint, but tonic treatment
and change are rightly prescribed to all. In the
vast majority of instances the patient benefits sur¬
prisingly, and a few weeks are sufficient to produce
a nearly complete recovery. But there are, as we
have seen, recurrent and chronic cases, and in
these the disability once established tends to pass
into a permanent neurasthenic condition, and it is
then, when it is really too late, that the specialist
is often called in, and he may fail to realise that
the patient has been getting weaker and weaker
for many years, treated first by some local chemist,
later perhaps by some quack, later still by a local
practitioner, till at the last, as a forlorn hope, a
mental expert is consulted. Many of the poorer
smuggle on, especially those who are overworked,
without treatment, because their living depends on
their daily attendance at their employment. And,
because no disease can be specified so that leave
for convalescence might be granted, they drag out
a weary existence till a final breakdown occurs.
Sometimes this termination ends in insanity;
sometimes a shiftless feeble character is produced;
sometimes an acute illness, such as rheumatic fever
or influenza, may still further cripple or afford the
necessary opportunity for rest and recuperation;
but from any point of view, I am convinced that
more care is needed than is ordinarily given to
such patients.

There are many interesting questions that this

study of indisposition and debility raises. I think
it will be generally admitted that the presence of
excess of toxic material in the blood and tissues is
one of the principal factors in the situation. This
is shown by the similarity of this debilitated state
to the prodromal stages of ascertained infectious
and contagious diseases, and also by the happy re¬
sults that follow suitable exercise, rest, simple
dietary, and mild elimination treatment. But the
aspect that should be of greatest importance to the
scientific and practical medical man is the relation
of the particular constitutional bias of the indivi¬
dual patient to the individual peculiarities of the
symptoms that appear. For while weakness is
complained of by all, no two cases are identical.

One mentions headache; another neuralgia;
another sleeplessness; another sharp twinges and
stiffness in the muscles and the joints; yet others
allude to backache ; difficulty in breathing and a
sense of suffocation ; persistent nausea at the sight
of food, and so on. In not a single instance, if care
be taken in obtaining particulars, will it be found
that general debility, always the principal symp¬
tom, is the only one; for local disturbances varying
with the patient are also present, and the same
local phenomena tend to reappear in the same per¬
son. To the scientific practitioner, therefore,
these minor differences afford clues, if the same in¬
dividual symptoms are evident in more than one
attack, of a probable natural constitutional predis¬
position to disease in the direction of the distinc¬
tive symptoms. And were careful records kept, I
believe it would be found, in the majority of in¬
stances, that later specific diseases tend to follow
the line of susceptibility thus revealed. If this be
so, methodically compiled medical notes of patients
would enable us to trace more accurately the be¬
ginnings of disease and treat it more scientifically,
in addition to being able to warn patients how to
avoid what is thus early threatened.

But apart from this, the individual treatment of
debility leads at once to more favourable results.
For while the major symptom is always in some
degree benefited by tonics, yet the minor ones,
differing in each case, are often sufficiently import¬
ant to check recovery. Sleeplessness, for instance,
is often due to flatulent distention of the bowel, and
when the tonic, alone or even continued with a
hypnotic, fails, the simple addition of a harmless
carminative, like ginger or peppermint, perhaps
combined with carbonate of soda, will often give
very favourable results. In like manner pain in
the back, which is neither of ovarian nor of dys¬
peptic origin, will disappear by the use of citrates,
and with it a depression that had before persisted,
showing, though no albumen be present in the
urine, that the kidneys had been unable to elimi¬
nate toxic substances from the blood. Similarly,
a feeling of suffocation will give way at once to
better ventilation or to a change to the seaside.

One other consideration is worth dwelling upon.
Is the debilitated individual exposed to greater
immediate risks by the mere fact of his or her de¬
bilitated state? It is not easy to answer this ques¬
tion positively, but it seems likely that, as in tuber¬
cular diseases, debility is now an accepted predis¬
posing cause. It is extremely likely to be so in
others, but how far it is a small or large factor
has yet to be determined.

A good deal might be written on the variable
physiognomy that patients present: the care¬
worn appearance of the overworked, the soft,
round fatness of form of many who owe their
trouble to wealth and inactivity, and the lined,
baggy look of the dissipated. But, through all, as
I have mentioned, runs the one common feebleness
that relates them.

33& The Medical Press.

Sept. 25. 1907.

ORIGINAL PAPERS.

To summarise, probably at least one-third of
medical practice is concerned with minor depar¬
tures from health. Both from the widespread in¬
convenience that such indispositions give rise to,
and from their scientific value, as the starting-
points of disease, such borderland phenomena are
well worthy of attention. There is here a field for
investigation that is a wide and important one, and
it is for the general practitioner to cultivate it and
bring its richness into the common medical
harvest.

THE EARLY DIAGNOSIS AND
TREATMENT OF PROGRESSIVE
PARALYSIS.

By KARL HEILBRONNER, M.D.,

Profettor of Medicine, Unlrermity of Utrecht.

If in the case of progressive paralysis, which, as
experience shows, with all its oscillations and
varieties of course leads eventually to death,
we may not expect actual recovery, the physician
can still by timely interference do much good in
the early stages; and, on the other hand, by fail¬
ing to recognise the disease, the consequences of
his sin may be very serious. Very frequently, how¬
ever, the disease may not be recognised, or it may
be recognised too late. The non-recognition of the
very earliest stages depends on the very gradual
and insidious development of the disease, so that
even to the experienced the symptoms become dis¬
tinct only after a time. But even after this point
of time the diagnosis that might be made is not
made, partly from want of familiarity with the
features of the disease, and partly because the
physician really “ does not think.”

But the designation of the disease, “ dementia
paralytica,” or “ progressive paralysis,” shows the
nature of it—a disease running a progradient course
and characterised by dementia and paralytic symp¬
toms, that even, if often, interrupted by remissions
frequently lead to death after a few months, but
mostly after a few years. Though mainly a disease
of the “ best years,” it attacks men more fre¬
quently than women. It only appears on a foun¬
dation of syphilis, and its anatomical substratum
is a diffuse atrophy in all parts of the central ner¬
vous system in varying participation, but without
any gross macroscopic lesion.

Dementia and paralytic phenomena are the in¬
dispensable symptoms of the disease; but they do
not yet justify a diagnosis of paralysis, as other
processes also may give rise to the combination,
such as typical multiple sclerosis, cerebral tumour,
idiocy with paralysis and convulsions, post apoplec¬
tic dementia of the aged, intoxication (saturnism,
bromism, uraemia, alcoholism), injuries, cysticercus
of the brain, a typical multiple sclerosis, many
diffuse meningeal tumours, syphilitic meningitides,
pachymeningitis. There are also combinations of
tabes with diminished psychical activity, which at
least practically require a different valuation from
the average of paralyses on acoount of the very
slight tendency to progression.

Moreover, in the early stages of the disease by
dementia, one must not think of gross insanity.
The intellectual failure is of a much slighter grade,
and just as little by paralysis does one mean com¬
plete paralysis in the usually accepted sense, but
rather a more delicate disturbance of innervation.

If the paralysis runs its course purely under the
symptoms described, so there is the pure demential
form. To this may be associated still other symp¬
toms of any other psychoses (anomalies of affection,
delusions, hallucinations). In numerous cases the
paralysis runs a purely demential course.

We can divide the somatic symptoms into cere¬
bral and spinal, the latter again into lateral (spas¬
tic) and posterior (tabetic).

The symptoms connected with the lateral coen-
urus (exaggerated reflexes, hypertonicitv, or pare-
ses), especially at the commencement, are not be¬
hind those connected with the posterior column in
frequency. They must be appraised with caution,
however. Simple exaggeration of the patellar
reflex is met with in the healthy and in functional
disorders. A symmetrical exaggeration is at the
most to be taken into account, along with other
very suspicious symptoms. The same may be
said of the pseudo-clonus that soon passes off and
does not always make its appearance, whilst the
prolonged ankle clonus, that increases in intensity,
and that patellar clonus produced by pushing the
patella downwards are characteristic symptoms.
Babinski’s reflex is also in the latter category, ».e.,
the typical slow dorsal flexion of the great toe
with extension or flat-position of the remaining
toes.

The symptoms referable to the posterior
column, the tabetic, may be properly divided into
two groups. In one the tabes long precedes the
other symptoms, and is quickly recognised. More
frequently the posterior column symptoms develope
only just before the paralytic ones or simulta¬
neously with them. Its symptoms, therefore, do
not strike the eye as in old tabelics, but they must
be looked for. Testing of sensibility gives with
tolerable frequency a “ hypalgesia,” partly purely
of psychical origin, and generally very widely
spread; the ataxy is rarely extreme. Romberg’s
sign (swaying when the eyes are closed and the
feet placed together) fails with striking frequency.
The attention is to be principally directed to (a)
The absence of the patellar reflex. Proof of this
is difficult in people wanting in intelligence from
their straining. One should be careful not to
conclude that the reflex is absent when involun¬
tary contraction of the quadriceps prevents its
taking place. The attention of the patient must
be drawn away from the examination, as his per¬
sonality increases during it, and he should be
asked rather abruptly how he gets on with—his
mother-in-law. Simple lessening of the patellar
reflex is of importance only when unilateral dimi¬
nution is constant on one side. The absence of the
reflex of the tendo Achillis is less markedly shown,
but it is a warning to be cautious, especially if
unilateral. ( b) Pupillary changes. By far the
most important disturbance is reflex rigidity
(failure to contract on light). It justifies the
strongest suspicion of locomotor ataxy or para¬
lysis. Absolute rigidity is more frequently a con¬
sequence of syphilis, exceptionally also of trauma
or alcoholism. Slow reaction to light is also to be
looked upon seriously. Pupillary differences are
also frequent in paralysis, but as they are frequent
under very various conditions, they are not, when
unattended, of much diagnostic value. Pupillary
rigidity and loss of the patellar reflex always, there¬
fore, call to mind paralysis or tabes; but it is not
by any means the case that every paralytic shows
them, and still less every commencing paralytic,
(c) Hypotone (increased passive movement, especi¬
ally of the lower extremities) in its lesser degrees
is only demonstrable in patients who can easily ex¬
clude their voluntary’ movements. Its value is
much increased when associated with considerable
increase of the reflexes, or other symptoms of
disease of the lateral columns. The cerebral symp¬
toms are in part general (headache, sense of pres¬
sure, etc). These have no specific character. For
the rest they may be looked upon as expressions
of disturbance of definite, cortical, mostly motor

Google

Sept. 25, 1907.

ORIGINAL PAPERS.

The Medical Press. 339

lesions. They appear in part insidiously, in part
in distinct attacks.

Amongst the first, a change of expression is
often a very early sign ; without any proper paresis
there is a flabbiness and emptiness of the features,
which is not fully explainable by dementia. Nearly
allied to this is exaggeration in mimicking and
clumsiness in carrying out movements; a certain
unreadiness in the arms and legs, not altogether
explainable by the spinal symptoms, is frequently
an early phenomenon. Further than this, paresis
of the facial appear early, deviations of the tongue
and tremors; but these from the frequency of
their occurrence, especially in drinkers, are when
alone not of much value.

Disturbances of speech are very early symptoms—
symptoms in the strictest sense. Often there is
only a certain slowness, often associated with ab¬
sence of accent, or with it wrongly placed ; in other
cases the slight precision of innervation leads to
mere chattering, to literal paraphrasing, dropping
of letters and syllables, turning things over and
repetitions, tripping over syllables; something like
stammering also takes place.

Where all these component parts are found to¬
gether, a diagnosis may be formed almost with
certainty from the speech alone; but it must be
borne in mind that an excited neurasthenic, and
especially in presence of the doctor who is examin¬
ing him, will at tunes talk queerly—“ reel off,” as
it were. Some of the symptoms are shown off
much better in conversation than in special test¬
ing, in which, moreover, the celebrated special test
words can be well dispensed with, and are often
bewildering.

The disturbances in writing correspond in their
elements to those of speech, consisting partly in
change of the form of the letters, tremor and wan¬
dering movements in consequence of motor defec¬
tive innervation, and in part the same transposing
and leaving out of letters as in speech. Only
serious disturbances in writing are made evident
in short “writing tests.” Not infrequently for
the rest the handwriting remains good for a very
long time.

Amongst the most important of the early symp¬
toms are the attacks of paralysis, as they are
often the first occasion for calling in a medical
man. But in spite of this, on account of the
transient character of the symptoms, their im¬
portance is often under-valued. The customary
grouping, even if it cannot be carried out in its
entirety, distinguishes apoplectiform and epilepti¬
form attacks. The first-named vary between the
slightest grades (giddiness, mental confusion)
and the severe attacks of loss of consciousness,
with succeeding grave unilateral lesions. Serious
conditions also that are of almost pathognomonic
import as regards paralysis often recede,
usually within a few days, leaving only incon¬
siderable remnants that correspond to the per¬
manent cerebral condition.

The epileptiform attacks in the lightest form
appear as localised Jacksonian spasms that leave
behind paralysis and paresis. The severest attacks
resemble those of genuine epilepsy. The attacks
have a great tendency to recur, and even a state of
grave status epileptious is not uncommon.

The dementia of paralysis does not lead at first
as such to formal disturbance. What strikes me
frequently at first is a defect in the ethical rela¬
tions, from a slight want of tact to a grosser
offence against the proprieties. Neglect of ex¬
ternals, and in regard to clothing, belong to a simi¬
lar category; further voracity, sudden exaggerated
sexuality (often with diminished sexual power), the
sudden giving way to alcoholic excess, tendency to

sudden outbursts of anger, associated with indif¬
ference when more important interests are in dan¬
ger, caprice, alternating with excessive positive¬
ness.

The intellectual failure in its narrow sense shows
itself as deficient comprehension, inability to fix the
attention, forgetfulness, want of grasp,' imperfect
power of combination, inability to recognise fami¬
liar faces, defective acquaintance with the elemen¬
tary details of their own profession. Wherever
there is the slightest suspicion of commencing
paralysis, cautious inquiry from those connected
with the patient should never be delayed as to their
normal condition.

Psychotic symptoms in the narrower sense are
often absent at the early stage. The com¬
mencing paralytic at first does not give
the impression of being mentally affected
in the vulgar sense of insanity. The most
frequent commencing signs are groundless
fits of jealousy—an exaggerated sense of well¬
being, combined with a mania for planning and an
impulse to activity, which lead to undertakings
that, if carried out, would in an incredibly short
time lead to beggary. A similar danger threatens
the dementia paralytic through neglecting his busi¬
ness, and, above all, through lavish expenditure.

The graver paralytic psychoses (especially the
classic maniacal paralysis) generally belong to
later stages. The cases in which the paralysis
comes on without specific paralytic prodromata,
directly under symptoms of another psychosis, are
rare exceptions; they occur more frequently in
cases of old locomotor ataxy.

In spite of the review of the features here given,
in individual cases the differential diagnosis be¬
tween paralysis and neurasthenia cannot be made
at once, as paralysis may occur in a neurasthenic
just as it may in a healthy individual.

On the whole, however, the danger of a mistake
is not so great, and the diagnosis of neurasthenia
may be determined by exclusion on the basis of re¬
peated careful examination, and after the exclu¬
sion of organic mischief. Those cases must be ex¬
amined with special care—bearing in mind the
close connection between syphilis and paralysis—
in which a neurasthenic patient has previously been
infected with syphilis.

As regards the diagnosis of paralysis as opposed
to other organic diseases great caution is required,
especially in the case of alcoholics, and further, in
old ataxic cases, such a diagnosis can only be
deemed certain when unobjectionable cerebral
symptoms are present. The examining physician
must take care not to speak of the danger of a
serious psychosis in the presence of the patient; if
the diagnosis is correct it does not do him the least
good, if incorrect, incalculable mischief may have
been done.

Treatment.—Considering the close connection
with syphilis, the question of a course of mercurial
treatment first comes up. It has in general proved
useless; it is indicated only where specific changes
cannot be altogether excluded, and thus in all cases
where affection of individual basal nerves is pre¬
sent, small doses of iodides may be given for
lengthened periods (sod. iodid 1.0 to 1.5 grm. pro¬
die). From the disappearance of attacks, however,
specific disease need not be concluded, as these at¬
tacks also disappear spontaneously. The bromides
also in large doses, are not very effective in the
stages of excitement. In case of sleeplessness pro¬
longed baths at 35 deg. to 36 deg. (cent.) or hypno¬
tics in doses not too small (veronal 0.5 to 0.6 grm.
trional 1.0 to 1.5 grm.; paraldehyde 4. grm.;
amylhydrates 4. to 5 grm. in a 10 per cent.

34 ° The Medical Press.

OPERATING THEATRES.

Sept. 25, 1907.

aqueous solution, or by enema), and the most pro¬
longed rest in bed.

A special diet is not requisite. A glass of dinner
wine, smoking, and the accustomed cup of coffee
may be permitted without injury. On the other
hand, “ going out,” from the danger of excesses,
should be forbidden. Much more important is the
further care for the patient. First of all, when the
diagnosis is certain, the physician must draw the
attention to those belonging to him to the serious¬
ness of the condition, and with them see about his
admission into some institution for seclusion. Such
a course is, in almost all paralytics, as a protection,
both to the patient (danger of suicide) and his
family, absolutely indicated. Only the pure de¬
mented torpid forms may seem at first not to de¬
mand seclusion. In all cases business activity
must be given up at once; a lengthened period of
complete mental rest gives some prospect of tem¬
porary improvement; but the complete retirement
from business best arrests the dangers that the
patient, especially when he is in a responsible posi¬
tion, may prepare for himself or for others. Gene¬
rally the pure demented paralytic adapts himself to
the change of giving up business with great non¬
chalance—the nonchalance itself may afford a final
criterion in the differential diagnosis. Business
matters will be most safely kept away by putting
the patient into an asylum, or some sanatorium for
seclusion. Any special methods of treating the
basal disease are not possible ? even here, but a
warning must be given against any energetic
hydropathic or any similar procedures.

In the case of any undoubted paralytic who has
means or credit, it is advisable to have a trustee
appointed as soon as possible. The consequences
of insane behaviour may be properly annulled by
law, S. 1021, 7 B.G.B. (but this is, unfortunately,
frequently not practicable). In answer to the ques¬
tion whether the patient's condition of mental dis¬
turbance covered the time when something
improper was done, a specimen of the writing of
the time in question may be useful.

Regarding the validity of a marriage contracted
by a paralytic after the outbreak of the disease,
the claims for nullity can be raised according to
law, S. 1325, B.G.B. by the legal representative
(S. 1336). In the frequent criminal processes

against paralytics the application of S. 51 Str. G.B.
may be claimed. Very frequently the commission
of some illegal act will be the first indication of an
onset of the disease. Paralytics are not properly
liable to punishment in accordance with law S. 487,
Str. Pr. O. If after any condemnation it appears
probable, or only suspicious, that the act leading
to the punishment was the commencement of a
paralysis that only became evident afterwards, it
may be desirable, in the interests of the family, to
demand a fresh inquiry according to S. 399, 5 Str.
P.O. The number of cases in which paralytics are
condemned for wrong doings would diminish with
increased knowledge and attention to the early
stages of the disease.

OPERATING THEATRES.

KINGS’ COLLEGE HOSPITAL.

“ Haemorrhagic Necrosis ” of Cancellous Bone.—
Mr. Peyton Beale operated on a man set. about 35,
•who had been admitted with the following history: he
was by trade a leather dresser, and beyond a few falls
from a bicycle had suffered no previous illness or
accident of any moment. About five weeks before, he
began to complain of severe pain in the lumbar
region; the pain was deep-seated and only relieved
by the recumbent position ; there was no evidence to

show that it was in any way due to muscular
rheumatism or to his urinary organs, or indeed to any
other organs. The pain was soon succeeded by
retention of urine followed by incontinence, due to-
the overflow of the distended bladder; in a few days
this was followed by retention of faeces proved to be
due to paralysis of the lower bowel; later on incon¬
tinence of faeces came on, clearly due to paralysis of
the sphincters. He was losing flesh, but was able to
walk about until the time of his admission. Upon
admission he was found to have: 1. Anaesthesia
corresponding to the cutaneous distribution of the left
fourth sacral nerve ; this anaesthesia extended in some
degree down the back of the left thigh, probably
corresponding to some cutaneous branches of the
small sciatic nerve coming off from the third sacral.
2. Paralysis of the perineal muscles and sphincters
and some paresis of the glutei, and perhaps of the
hamstrings as well. Upon careful examination under
an anaesthetic, a marked swelling of the left erector
spinas in the lumbar region was observed, and on
inserting an exploring needle a very little blood¬
stained fluid was obtained, indicating that this
swelling was probably due to oedema of the erector
spinas itself and of the tissues beneath. On examining
the rectum a large fluid tumour was felt in front of
the sacrum and extending upwards beyond the reach
of the finger; this contained loose bodies thought to
be pieces of bone, and the case was looked upon as
probably one of advanced tuberculous caries of the
lower lumber vertebrae involving the lumbo-sacral
joint. It was decided to explore the sacrum by opera¬
tion, and an incision about nine inches long was
made over the spines of the lower lumbar vertebrae
and back of the sacrum. On separating the muscles from
these portions of bone and from part of the posterior
aspect of the iliac bones, the whole of the exposed
bone appeared dark grey in colour and denuded of
periosteum; on cutting through the external shell of
compact issue, practically the whole of the cancellous
bone was found to be replaced by dark fluid and
clotted blood; in many places there were several loose
pieces of what appeared to be necrosed cancellous
bone. On cutting through the posterior shell of the
sacrum there appeared to be nothing left of that bone,
and the cavity which had been felt per rectum was one
containing blood and many pieces of cancellous bone.
The membranes of the lower lumbar cord were
exposed and incised, and a large quantity (about two-
ounces) of slightly blood-stained cerebro-spinal fluid
escaped. The wound was then closed, a gauge drain
having been inserted. Mr. Beale said that until
further investigation had been carried out the case
could only be described as one of haemorrhagic
necrosis of cancellous bone. The man’s symptoms
improved for three days after operation, the pain
being very much relieved, but on the morning of the
fourth day he died very suddenly. A post mortem was
subsequently performed, and it was then found that
every bit of cancellous bone in connection with the
lower part of the spine and the pelvis exhibited the
same characteristics as those exposed at the time of
operation, viz., “haemorrhagic necrosis.” Professor
Dalton, who conducted the post mortem examination,
was of opinion that it was probably a case of very
extensive myeloma. It may be mentioned that the
man was found to have a tumour of the stomach close
to the pylorus, which appeared to be a carcinoma, and
also some enlarged cervical glands which looked like
secondary carcinomatous glands.

Thirty-five cases of bubonic plague have occurred 1
at San Francisco up to date, of which twenty have
ended fatally. Twenty suspected cases are under
observation.

zed by Google

D

Sept. 25, 1907.

CORRESPONDENCE.

The Medical Press. 34 1

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Pari*. Sept. 22 nd. W.

Diazo-reaction of Ehrlich in Eruptive Fevers.

To find the diazo-reaction one should proceed as
follows : Pour into a test tube two and a half cubic
centimetres of urine, to which is added an equal
quantity of the following solution : —

Hydrochloric acid, 50 grammes.

Water, 200 ditto.

Sulphanilic acid (to saturation).

And then two drops of

Nitrate of soda, o : 50 centigrs.

Water, 100 grammes.

That done, the tube is agitated, and ten drops of
ammonia are poured in slowly, when a red ring is seen
to form at tne point where the ammonia comes in
contact with the rest of the liquid. After mixing, the
red colour is communicated to the entire solution,
while the froth resulting from the agitation is of a
rose colour, and adheres to the walls of. the tube.
Such is the reaction in typical cases ; that is to say,
in eruptive fevers. In normal urine, when tested as
above, the colour remains unchanged.

However, certain medical substances, as guaiacol,
creosote, benzonaphtol, in being eliminated by the
urine, can give-a similar reaction. It has neverthe¬
less a certain value for diagnosing such affections as
tuberculosis, typhoid fever, and eruptive fevers.

In many cases of typhoid fever the reaction of
Ehrlich revealed at the very beginning the nature of
the affection, where a positive diagnosis was as yet
impossible.

In measles the reaction rarely failed, and before
the characteristic eruption had been observed. The
colour seems to deepen as the fever increases, and
becomes more clear as the temperature falls.

The duration of the reaction is five or six days on
an average.

In scarlatina, the reaction is generally negative, as
well as in diphtheria.

Sea-Water Treatment.

Injections of seawater, rendered isotonic by
dilution with sterilized water, have entered into daily
medical practice in France, and notably in Pans,
where Dr. Quinton, one of the most ardent
partisans of this treatment, has established a dis¬
pensary, largely attended by patients suffering from
eczema, and children more or less emaciated by
chronic gastro-enteritis or suffering from eczema.
Chronic constipation has been also treated with suc¬
cess by the saline injections. The doses vary from
one drachm to four ounces, and are repeated every
two days. The region selected for the injections is
generally the scapular, but the abdomen is sometimes
preferred.

Apoplexy.

A patient has lost consciousness, the treatment
differs according to the cause. Is it a case of coma
due to uremia or to diabetes? The diagnosis is not
always easy. The antecedents of the patient with
signs of diabetes or nephritis that he might have
presented, will clear up any doubt. Other affections
might be pre-supposed, meningitis, hysteria, syphilis
(in a young man), but if the diagnosis inclines to
cerebral hemorrhage, the treatment varies with the
condition of the patient. If he is pale, with rapid,
weak, and irregular pulse, injections of camphorated
oil or cafein, followed by a stimulating mixture, if
the patient can swallow, constitutes the first treat¬
ment, while mustard is applied to the legs and
thighs.

More frequently the practitioner will not have to
prescribe this treatment, for instead of being pale
with a weak pulse, the face of the patient will be
congested, and the pulse will be strong and bound¬
ing. Here blood letting will be necessary, either
directly or by means of ten or twelve leeches placed
behind the ears, and the ice-bag placed to the head.

A drastic purgative will be prescribed, or an enema,
while mustard is applied to the legs.

The following days the purgatives will be continued
and a blister applied to the back of the neck.

The consecutive paralysis will be treated towards
the tenth day by movements in the articulations, and
six weeks afterwards by electricity (galvanic currents).

The diet will be lacto-vegetarian, with suppression
of all spirituous liquors. As to iodide of potassium,
its action is problematic, and in any case it should be
prescribed in only small doses.

GERMANY.'

Berlin. Sept. 22 nd, IP07.

„At the Medizinische Gesellschaft, Hr. Graeffner
showed a patient with

Ochronosis,

the first case that had ever been shown in the living.
This affection, first described by Virchow, consisted in
a brown colouration of the cartilages and skin, occa¬
sionally with black patches on the mucous membranes
and cornea. Pick had propounded the theory that the
affection was the result of chronic carbolic poisoning.
In many cases the patients had suffered from chronic
ulcers of the legs, and had been treated by dressings
of carbolic acid. There were also cases with alkap¬
tonuria in which carbolic acid did not play a part.

Hr. v. Hansemann mentioned a case in which car¬
bolic acid certaiuly did not play a part. There must
therefore be at least two kinds of ochronosis.

Hr. Pick made a distinction between endogenous
and exogenous ochronosis. In the latter form car¬
bolic acid was the cause of the pigmentary deposit.

Hr. Orth read a paper on

The Immunization of Guinea-pigs Against Tuber¬
culosis.

He gave an account of his experiments for producing
immunization against tuberculosis in guinea-pigs by
means of the bacilli of turtle tuberculosis discovered
by Friedmann. The animals were first infected with
the bacilli of tuberculous turtles; they were then sup¬
posed to be in a position to resist tuberculosis from
any other source, whether human or any other warm¬
blooded source.

An animal inoculated with turtle tuberculosis might
become diseased, but recover and gain in weight. An
animal was so treated, and a year and 12 days after¬
wards was killed. Tuberculous changes were found
on the peritoneum ; they had implicated the testicles
in which were tuberculous nodules with giant cells ;
but no tubercle bacilli were discoverable, and even
cultures remained sterile. In a second animal, how¬
ever, into which some of this tuberculous mass was
injected subcutaneously, in’ spite of it appearing well
and increasing in weight, on being killed 10 months
afterwards, tuberculous changes were found on the
I peritoneum, and a few baccili were found in the
regionary and distant lymph glands which developed
sparingly in cultures.

This showed that the bacilli of turtle tuberculosis
really belonged to the group of tubercle bacilli; that
they were not killed off in the guinea-pigs, but set up
a slowly progressing tuberculous affection.

The other animals were infected with human and
bovine tuberculosis. All the animals were therefore
equally tuberculous, but those with the preparatory
! treatment lived somewhat longer than the control
I animals. The mistake was often made of killing the
1 control animals too early. Tuberculosis required
| time, and results free from objection were only to be
obtained if we waited until the animals died. He
only killed some of the animals in order to study their
condition after infection. In one of the animals that
had undergone the preliminary infection, he found a
j general tuberculous eruption everywhere on the
1 eighteenth day. He observed further that the animals
with the preliminary treatment did not get the usual
' general infection, but only typical pulmonary phthisis
i with cavities, although they had not lived a long time,
i The cause of this cavity formation, therefore, did not
I lie in a lengthened life, but rather in the preliminary
J treatment.

Digitized by GoOgle

34 2 The Medical Fees*.

CORRESPONDENCE.

Sept. 25, 1907.

As Baumgarten and Orth had previously pointed out,
these experiments again showed that the lung disease
commenced comparatively late. It seemed, therefore,
as if the preliminary treatment had a certain influence
on the infection with tuberculosis in guinea-pigs, but
the result was not great, and further investigations
should be made. How this effect, although only
slight, was produced, the speaker claimed that it was
not due to any weakening of virulence, but by the
action of typical antibodies, that acted on the body
cells, the action possihly being only explainable from
the standpoint of cellular pathology.

Hr. Friedmann believed that with a greater number
of animals undergoing the preliminary treatment the
results would have been better.

Hr. Wassermann doubted whether immunity could
here be spoken of ; it seemed more like a super-infection
rendered difficult. We knew that if a body had
tubercle about it, it was difficult to infect it afresh.

AUSTRIA.

Vienna, Sept. 22nd, 1907.

Swimmers and Albuminuria.

Kienbock has recently been watching the con¬
stituents of the urine in prize swimmers, and finds
that, out of eleven cases, seven of them had albu¬
minuria. The appearance of the albumin is in greatest
quantity immediately after a great effort, when an
abnormal quantity of waste product is found in the
muscles, which produces temporary toxic albuminuria.
He attributes this morbid appearance to the exhaustive
loss of oxygen in the muscular system that subse¬
quently deprives the kidneys of finally performing the
function of normal elimination. In two of these cases
there were quantities of sugar. In twelve cases
examined for cardiac trouble, seven of them were
found with enormously dilated hearts, having arhythmia
and murmurs. From these he argues that swimming
is an exercise that should be practised with caution,
as considerable damage may be done in a subject pre¬
disposed to cardiac affection.

Tubal Pregnancy with Melena.

behind the vagina on the left side, while a small
round swelling, about the size of an egg, was found
on the right in close contact with that on the left.
The pus was still present in the faeces, but the rectal
speculum gave negative results. The diagnosis was
speculative, having something to do with the abortion
and presence of pus in faeces. Stupes over abdomen with
rectal douches were continued, the temperature stand¬
ing 38.0 Cent, in the evening and 37.2 Cent, in the
morning. On October 20th temperature was normal
and patient much better, while the swelling or infiltra¬
tion seemed less.

On the night of October 27th she took suddenly
ill with pain in the bowel followed by a great rush
of blood. By the following morning she was white,
feeble, and pulseless. In one of the stools there was
a litre and a half of coagula.

It was resolved on the 28th to operate, and, making
an incision in the linea alba the small tumour in the
pelvis with serous contents was found firmly attached to
the peritoneum, the latter protruding into the bowel.
After enucleation the cyst was removed, and the second
hard tumour on the right side, about the size of a
goose's egg, was discovered and removed also. The
dilated portion of the tube had next to be removed.
A clamp centrally admitted of the external portion of
the tube being removed from the posterior attachment,
when an opening into a clot revealed a large
hematocele in communication with the bowel.

After securing the internal organs with catgut, a
counter opening was made in the pouch of Douglas,
the cavity filled with medicated gauze, after washing
with a salt solution the whole abdomen was closed.
The temperature immediately fell, but rose on the
fourth day to 38. Cent., which continued five days.
On the ninth day the gauze was removed, and the
temperature fell to normal, where it has continued ever
since. She was dismissed on the 17th of December
perfectly cured.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

Karczewski exhibited to his clinic the left adnexa
uteri, right tube with peripheral ends obliterated, and
hydatis Morgagni. The middle portion of the tube
was dilated, but had normal lumen at the uterine end.
The section of the dilated portion revealed a blood clot
with a shaggy chorion.

The left adnexa of the left side were dwarfed and
deformed. A section of the lumen exhibited ovules in
different stages of degeneration.

This was a tubal pregnancy with rupture forming a
secondary haematocele, which opened into the large
intestine. He considered this haematocele was the cause
of the withering of the right adnexa, the affection Of
the left being secondary.

The clinical history showed how different the
diagnosis becomes with these complications. The
woman was only 24 years of age; commenced to
menstruate when 14 years old ; married at 20; bore one
child, everything ending normally, as she had
always been healthy and strong. The second pregnancy
aborted about the sixth month, after which she lay
in bed six weeks. In July, 1905, she was quite well,
and . had been since her recovery.

On August 8th she complained of headache, pain in
right inguinal region, and went to bed. A week after
haemorrhage from the vagina commenced, followed by
fibrous masses on the 18th. After this the haemorrhage
continued three weeks, more profuse than ever, but no
pain was present.

On September 3rd colic pains suddenly appeared
with fainting. A day after she recovered, and was
able to move about till the end of September, when
she was again attacked with severe pains in the lumbar
region, followed by tenesmus alvi, fever, and a dis¬
charge of fasces mixed with pus. This continued till
she was removed to hospital on October 14th in a
critical condition, pulse 100, evening temperature 37.8
Cent., morning 37.2 Cent., abdomen nQt enlarged
but greatly emaciated. Just over the pubis a hard
resistance lost in the pelvis could be detected, and
with by-manual movement could be detected above and

BELFAST.

Public Health Posters.— The Public Health Com¬
mittee of the Corporation has ornamented the city with
huge posters, headed “Diarrhoea” in type almost
offensively observable. There follows a quantity of
good advice as regards the feeding of children, and
the special precautions needed in hot weather. The
advice is excellent, but it is to be feared that the last
persons to hang about the streets reading the litera¬
ture provided on advertisement hoardings will be the
mothers of the poorer classes. The same advice has
been given by the Ulster Hospital for Children and
women for some years past in a much more effective
form, as it is printed on a small fly-leaf, and given
to mothers in the extern department of the hospital,
and distributed through the maternity nurses. It can
then be read at home, and referred to in future.

The Workhouse Sanatorium for Consumption.—
The Abbey Sanatorium, situated about five miles from
Belfast, on a fine site overlooking the Lough from its
northern shore, was formally opened last week. The
house, once the residence of the late Sir Charles
Lanyon, F.R.I.B.A., and the beautiful grounds
surrounding it, were purchased by the Guardians for
the moderate sum of -£5,000, and with the house used
as an administration block, and new wards built
round it, accommodation has been provided for about
250 patients at a cost of ^32,000. Additional accom¬
modation can easily be provided in huts in the
grounds, which extend to 33 acres. There are at
present 120 patients in the sanatorium, and it is hoped
eventually to have all the consumptive cases from the
Belfast Workhouse removed there.

Queen’s College : Opening of New Laboratories.
—The work of nearly seven years at the Better
Equipment Fund saw its full fruition on Friday,
September 20th, when no fewer than seven new labora¬
tories were opened at once, an event, according to
Lord Kelvin, without precedent in the annals of
science.

ized by Google

Sept. 25, 1907.

OBITUARY.

The Medical Press. 343

LETTERS TO THE EDITOR.

THE INEBRIATES’ ACT AND THE PREVENTION
OF ALCOHOLISM.

To the Editor of The Medical Press and Circular.

Sir, —In the present state of our Parliamentary
machinery it seems evident that attempts at paternal
legislation are doomed to failure. The House of
“Commons occupied fully with high politics has not
the time or strength to master the minute details upon
the understanding of which the construction of effec¬
tive laws depends. We shall have to wait a long time
for the protection of simple people before the
fraudulent drink-cure quacks, about whom a corre¬
spondent writes in your issue of September nth, are
made amenable to the law; and we shall have to
wait perhaps as long before the vendor of fraudulent
•“ nerve tonics ” containing alcohol, as well as the
whole tribe of bogus cure-mongers of every class, are
brought within the reach of the law. Meanwhile the
drink traffic under the cloak of medicinal remedies is
assuming enormous proportions. The proprietors of
one of these baneful drinks are spending at least
j£io,ooo a year in newspaper advertisements alone;
and this affords a measure of the vast consumption of
these pernicious disguised intoxicants which is going
■on. The basis of most so-called wine tonics is simply
crude alcohol. It would require a clever palate to
distinguish the quality of the liquor contained in a
mixture of the character of these potions, and there
can be no doubt it is spirit of the cheapest kind their
vendors can procure. Vast numbers of innocent
people who would shrink from over-indulgence in
wine are thus led unknowingly to poison themselves
with raw spirit; and at least one death from this
cause was recently authenticated. Perhaps the greatest
evil arising out of this traffic lies in the facilities it
affords for secret drinking among women. Of this I
could relate many instances. It is very easy for a
woman, who would be unable or afraid to send for
drink from the usual sources, to order from her chemist
a supply of “tonic,” and without shame to indulge
lier craving to the top of her bent.

I am, Sir, yours truly,

Medical Temperance Reformer.

September 20th, 1907.

SPINAL ANALGESIA.

To the Editor of The Medical Press and Circular.

Sir,—I am much interested in Mr. Edred Corner’s
remarks on the subject of spinal analgesia. There
are several points which to my mind require comment
and criticism.

1. With regard to the drug used I would point out
that novocain is now recognised throughout Ger¬
many, and by all those who have had experience of
the two drugs (stovain and novocain) as infinitely the
"better of the two.

Mr. Canny Ryall has pointed out that with novocain
there are none of the complications mentioned by Mr.
Corner, except headache. After all, what is headache
compared to the usual after-effects of any general
anesthetic when given for a period exceeding half an
"hour?

2. The immense value of spinal analgesia lies in the
marvellous freedom from shock even after the severest
■operations. Mr. Comer does not emphasize this,
which is the greatest advantage of this method of
obtaining analgesia.

The pulse remains quiet and full throughout the
longest operation, and does not rise afterwards to any
extent.

3. The duration of the analgesia reported by Mr.
Corner is very small. It is quite possible, using the
proper method, to obtain an analgesia of two hours
duration or more.

Mr. Ryall, who is the pioneer of novocain in this
country and has used it extensively during the past
year, has had uniformly good results.

Dr. P. H. Parsons recently ansesthetised a patient
for me with to c.c of a 1 per cent, solution of
novocain to which had been added four drops of 1 in
1,000 synthetical supra-renin. This a very small and
perfectly safe dose. The patient was suffering from

intestinal obstruction, and on opening the abdomen I
found a condition of volvulus of the caecum with a
growth involving the posterior wall. I excised the
whole of the caecum and performed anastomosis. The
patient did perfectly well; the pulse during and after
the operation remained below 100, in fact during the
operation did not rise above 70. There was entire
absence of shock. Within two days the patient was
reading when I went in to see her.

I assisted recently in a Kraske’s operation of a
severe nature. Here again there was an entire absence
of shock. Recently a patient with a fractured
olecranon, and also a fractured patella was given
chloroform and also ether. Bv the time the olecranon
was wired the anesthetist decided it would be unwise
to prolong the anesthesia as the patient proved a bad
subject for both anesthetics. The patient was very
sick for two days, and was in a more or less delirious
state for an equal period. Later he was given an
injection of novocain for the patella operation, and
this proved most successful. The after effects were
practically nil.

In any operation where shock is a factor to be
considered this method should be adopted. Its draw¬
back is obviously that the patient knows what is
going on, which may be disconcerting to both patient
and surgeon, especially if the former is a nervous
subject. I maintain that this is the only real draw¬
back ; but since it can be prevented by preliminary'
injections of scopolamine and morphine there can be
no question as to the course to pursue in all opera¬
tions where shock is to be feared or a general
anesthetic is contra-indicated.

I am, Sir, yours truly,

H. Beckett-Overy.

Harley Street, W.,

September 21st, 1907.

OBITUARY.

OSIAH ROBERT JENKINS, M.D.Aber., J.P.
e regret to announce the death at Ruthin, on
September 16th, of Dr. Josiah Robert Jenkins, one of
the best-known medical practitioners in North Wales.
Dr. Jenkins, who had been ailing for some time, was
eighty years of age. Until recently he had been the
surgeon of Ruthin Prison, and was a justice of the
peace for Denbighshire. He also held several other
public appointments, and was an ex-Mayor of the
town. He leaves a widow, two sons and two daughters
to mourn his loss.

JOHN ST. SWITHIN WILDERS, J.P., M.R.C.S.,
L.S.A.

We regret to record the death of Dr. John St.
Swithin Wilders, at his residence, in Birmingham,
on September 20th. At one time he took a prominent
part in the public life of the city, but for the past
14 years he had been in indifferent health. He was for
many years a member of the City Council, a Justice
of the Peace, an ardent Conservative, and a pioneer of
the Volunteer movement in Birmingham. He studied
at Queen’s College, Birmingham, and at Paris, and
took his diploma as far back as 1858. At the time of
his death he was Emeritus Professor of Forensic
Medicine at the University of Birmingham, Consulting
Surgeon to the Queen’s Hospital, the Birmingham
Dental Hospital, and the Birmingham and Midland
Counties Ear and Throat Hospital.

ARNOLD F. BRADBURY, M.D.Durh., M.R.C.S.

We regret to record that Dr. Arnold Francis Brad¬
bury, of Halifax, died on September 19th from heart
disease, at the age of 45 years. As a boy the deceased
gentleman became seized with a strong desire to enter
the medical profession, and in spite of great obstacles
he ultimately succeeded in achieving the object of his
ambition. He was educated at Durham University,
where he eventually took his M.D. For about fifteen
years he practised at Halifax, retiring only a short
time since on account of health. He was an ardent
Nonconformist, and possessing a kindly nature he was
highly esteemed by a large number of friends and
acquaintances.

oogle

344 The Medical Press._ REVIEWS OF BOOKS. __Sept. 25, 1907.

REVIEWS OF BOOKS.

DICTIONARY OF MEDICAL DIAGNOSIS, (a)
In these days of bacteriological theories and patho¬
logical eccentricities, it is a comfort to turn to a book
of good, helpful, healthful clinical observation, well
arranged and well written by an experienced physician.
Such a book is “ A Dictionary of Medical Diagnosis ”
by Dr. H. L. McKisack, and we commend it without
reserve to those who wish either to attain bedside skill
or to strengthen their grasp on medicine. It is remark¬
able for its lucidity of description and its attention to
essential detail, no less than for its insistence on
guiding principles and its comprehensiveness. Ar¬
ranged in alphabetical order and supplied with a good
index, the work is possessed of such facility of re¬
ference as to make the task of handling it a pleasure
in itself. Any point can be looked up in a few seconds,
and all the needed information found in a reasonable
compass. The descriptions are, on the whole, well
managed and show the author to be possessed of
literary as well as medical skill, and if some are
rather bald and unsatisfying, the fact must be attri¬
buted to the copiousness of our knowledge of clinical
medicine and clinical methods. The article in the exa¬
mination of the blood is by Dr. Thomas Houston,
haematologist to the Royal Victoria Hospital, and
within the limits to which he is confined he has per¬
formed his task well. Similarly a short section on
“ X-rays in Diagnosis ” is from the pen of Dr. J. C.
Rankin, physician in charge of the electrical depart¬
ment, and one on " Examination of the Sputum,” from
that of Dr. J. E. Macllwaine, medical registrar to the
Royal Victoria Hospital. Both give a definite in¬
dication of the principles of their subjects, which is as
much as could be expected in the number of pages
allotted. The illustrations are well-chosen and fairly
numerous, the diagrams being especially clear and
useful. In every way, indeed, the book may be re¬
garded as one of the best of its kind, and its readers
will be amply rewarded by imbibing the enthusiastic
and painstaking spirit of the author if by nothing else.
Rather more than the proverbial “ word of praise ” is
due to the publishers, Messrs. Bailliere, Tindall and Cox,
for the get-up and printing of the book are uncom¬
monly good.

ON TREATMENT. ( b)

Dr. Harry Campbell in his book “ On Treatment ”
has construed the title in such a generous way that
everything from medical education to excessive eating,
from an account of Dr. Campbell’s day to his antics
in scaling a ’bus in the rain, are treated of, and a
great many other interesting things besides. There
was a very popular form of physical competition a few
years ago known as the ” Go-as-you-please ’’ race,
and we are of opinion that some such adjective would
aptly denote the nature of this treatise. Not that we
complain ; on the contrary, we find it unusually interest¬
ing and stimulating, but the title might lead people
to expect descriptions of new methods of passing the
stomach-tube or the most recent exploits of Teutonic
synthetic products. The medical use of the word
” treatment” it must be confessed is a specialised and
limited one, and the employment of the term in the
sense of “ discourse ” is quite legitimate. The most
important point is to discover whether the work is
intended for the practitioner, the student, or the public,
and here again we were for a time in something of a fix.
We thought at first it was for the student, as in the
chapter on “ Education of the Physician ” we seemed
to recognise our old friend, the introductory lecture;
but on reaching Chapters VII. and VIII., “ On Con-

la) "A Dictionary of Medical Diagnosis.” By Harry Lawrence
McKisack, M.D., M.R.C.P., Physician to the Royal Victoria Hospital,
Belfast. London: Bailliere, Tindall and Cox, 8 Henrietta Street,
Covent Garden. 1907.

(6) “ On Treatment.” By Harry Campbell, M.D., B.S., F.R.C.P.,
Physician to the North-West London Hospital and to the Hospital for
Diseases of the Nervous System. London : Bailliere, Tindall and Cox,
8 Henrietta Street. Covent Garden. 1907.

sulfation ” and ” Quackery,” we seemed to have
struck a popular harangue; this supposition was
supportable for some time, but Chapter XV., “The
Blood-Plasma Therapeutically Considered,” finally
shattered it, and we were finally reconciled to the
“go-as-you-please” theory. Emphasis should be laid
on the word “ please" for the general effect of the
perusal of the book is certainly pleasant. Dr. Camp¬
bell’s ideas and opinions are in the main sensible,
orthodox, and reasonable, and if he falls at times into
the literary trick of trying to “ make a platitude
plausible by making it pompous,” it is because he is
no more than human, and many of the remarks that
he makes on well-known subjects are those which he
has no choice but to make. Here and there some real
“ tips ” are to be found, and there is a great deal of
suggestive value throughout. We must protest,
however, in the name of the profession against the
doctrine, enunciated under the head of “ Humbug,’’
that a physician is ever justified in truckling to false¬
hood. The truth may be at times suppressed, that is,
the physician may say as little as possible on a subject,
in the interest of the patient, but the false should never
be suggested. Even at the risk of not becoming a
“ great physician,” the medical attendant should estab¬
lish a character for trustworthiness which nothing can
shake. There is a great deal of false sentiment about
“ breaking ” bad news to patients, but apart from any
principle, we have never known any real harm accrue
from the truth being tactfully put when necessary.
Medical men doubtless should always dwell on the
bright and hopeful features of a case, and give a
patient what heart they can ; but they should remem¬
ber that the distinction between them and the quack
is one of kind and not of degree. Save for this blemish
we can heartily commend Dr. Harry Campbell’s book
to the practitioner in his lighter moments ; it will
form a pleasant substitute for a siesta on a Sunday
afternoon.

THE DRINK PROBLEM, (a)

"The Drink Problem” belongs to Messrs.
Methuen’s New Library of Medicine, a series of books
on medico-sociological subjects by various authors. Dr.
Kelynack, who edits the volume before us, has secured
no fewer than fourteen collaborators, and it may be said
at once that the value of their contributions is markedly
unequal. Some of the sections are exceedingly good,
notably, perhaps, those by Dr. William C. Sullivan
on the “ Criminology of Alcoholism,” by Dr. Harry
Campbell on the “ Evolution of the Alcoholic," and
by Dr. Arthur Newsholme on “ Alcohol and Public
Health ” ; some are of average interest and merit,
and some—to put it mercifully—appear to have been
written in a hurry. On the whole, however, it may
be safely asserted that the standard is high ; quite a
respectable number of facts are given, theories and
remedies are presented very fairly, and the better
chapters are free from rant and special pleading. We
have to remember, however, that the book is one lor
the intelligent public, and it is certain that it may have
an excellent influence with those who are prepared
scientifically to study the subject for themselves, as
the dangers and allurements of alcohol are set forth in
such a way that a decided opinion may be formed on
the facts given. The scientific temperance reformer,
unfortunately, generally finds himself in a difficulty
when he comes to suggest a remedy—at any rate, any
remedy short of prohibition, which is, of course, the
logical cure for the evils of drink, and which he recog¬
nises to be impossible as the world is constituted at
present. The fact is that he does not like to admit
the real state of affairs, namely, that under modern
conditions of industrial und urban life alcoholic drink
is the practical soporific for man’s inhumanity to man.
and that prohibition would (if carried) create riots to
which the agitations of the Com Laws period would be

(a) “ The Drink Pr o b l em bv Fourteen Medical Authorities.” Edited
by T. N. Kelynack, M.D., M.fc.C.P., Honorary Secretary to the Society
for the Study of Inebriety. Two diagrams. London : Methuen and
Co. 7s. 6d. net.

Sept. 25, 1907.

REVIEWS OF BOOKS.

The Medical Press. 345

as nothing. It may be taken as axiomatic by all
temperance workers that alcohol will be the last evil
factor in social life to be removed by reform, and
that, hard as it may seem, all legislation and regula¬
tions and high licensing are mere momentary symp¬
tomatic expedients. Give every man his plot of
land, his decent house, his regular work, his games and
exercises, and perhaps he will be prepared to renounce
his drink; but till then alcohol is the only com¬
pensation he has for a life of semi-bondage, often of
semi-bestiality, and he will barricade the streets the
moment any Government tries to cut his beer off.
To pass to another subject, may we implore the editor
and his contributor. Mrs. Scharlieb, to abjure that
inexpressible vulgarism, the verb “ to overlay ” ?
The word, as well as the act it denotes, has come to
us from a class which habitually confounds “ to lie ”
with “ to lay,” in fact, supersedes the use of the former
by that of the latter. But that is no reason why we
should " paint our mother’s cheek,” as Professor
Clifford Allbutt has it. Still, as has been said, ” The
Drink Problem.” on the whole, is a wise and temperate
exposition of a great and many-sided evil; it may
safely be placed in the layman’s hands as having
both good sense, good feeling, and authority.

ALCOHOL AND MANKIND (a).

Abound the study of man’s relation and reaction to
alcohol cluster many problems of peculiar intricacy.
Many attempts have been made to determine the
precise etiology of the human craving for alcohol and
the exact action of this chemical agent on animal
tissues. The scientific study of alcohol and alcoholism
has too often been warped by prejudice or rendered
imperfect by the intrusion of moral and emotional or
economic and political influences. Since medical
writers and investigators have taken up this question
as a part of the great medico-sociological study erf
mankind, order has been brought into a subject where
confusion of thought and expression were conspicuous,
and rational suggestions for prophylaxis and treat¬
ment of alcoholism in its varied forms are now being
presented with a scientific precision and calmness
which augurs well for the future. Among recent
works dealing with the so-called drink problem the
monograph prepared by Sir Victor Horsley in colla¬
boration with Dr. Mary Sturge, merits a foremost
place. The authors claim to nave “put forward the
present state of knowledge of alcohol solely on the
basis of experimental, anatomical, and statisical
evidence,” and although they write as convinced
abstainers from alcohol their presentation is com¬
prehensive, judicious, and eminently scientific. While
no new facts or records erf original investigations are
noticeable in these pages, the most reliable results of
numerous trustworthy observers are conveniently
summarised, and the logical and practical conclusions
of recent researches clearly enunciated. Medical
practitioners will be particularly interested in the
opening chapters, which deal with the evolution of
medical opinion regarding the value of alcohol as a
drug. In a striking diagram it is shown that since
>852 “ alcohol and milk have practically changed places
as regards the extensiveness of their use.” After a
brief reference to the chemistry of alcohol and
alcoholic beverages and an all too short description
of the properties of cell life and the structure of the
nervous system, the authors pass to the most serious
and valuable sections of their work, a study of the
effects of alcohol on intellectual processes and on
the various parts of the nervous system. Here will be
found reference to the work of such investigators as
Kraepelin, Aschaffenburg. Ffirer, Kiirz, and others.
Even when dealing with the terrible effects of
alcohol-produced disease and degeneration of the
nervous structures, the authors still maintain a strictly
temperate and scientific presentation of the case, and

(a) “ Alcohol and the Human Bodv : An Introduction to the Study
of the Subject.” By Sir Victor Horsley, F.R.S., F.R.C.S., M.B., B.S.
Lond., Hon. M.D., Halle, Ac.; and Mary D. Sturge, M.D.Lond. With
a Chapter by Arthur Newsholme. M.D., F.R.C.P., D.P.H. Pp. xxv.
37 o. London: Macmillan and Co., Limited. 1907. Price 5s. net.

in evidence we may quote their concluding remarks in
regard to lhis matter—“alcohol tends to shorten life
both by causing widespread degeneration and also by
bringing on prematurely the special changes of old
age. These changes in the case of the nervous system
are, of course, especially to be dreaded because of the
accompanying mental deterioration—a deterioration
which frequently makes life a misery, and which, at
the very least, renders it useless and ineffective.”

The physiological and pathological action of
alcohol on the other systems of the body also receive
attention.

The work is excellently illustrated, and for the
coloured lithographs especially much praise is due.
In a measure rarely attained in so-called temperance
works, pictorial exaggeration has been excluded, and
accuracy in details obtained. In the minds of old-
fashioned practitioners trained in the ancient days of
what may be termed the alcoholic dispensation, and
amongst the prejudiced and ignorant in all classes of
society, many of the statements and some of the con¬
clusions found in this volume will doubtless be irri¬
tably denied or clamorously contended, but at least in
the main we have no hesitation in recommending
this book as a most reliable and valuable contribution
to the scientific study of a subject our attitude to
which must in the end be guided and governed by the
verdict of science.

The work throughout is written with a simple
directness and avoidance of obscurity and redundance
which will make it welcome to every intelligent lay¬
man. A glossary of technical terms is provided for
the non-medical reader.

We trust a copy of this admirable manual may find
its way to every medical practitioner and school
teacher throughout the land.

ST. THOMAS’S HOSPITAL REPORTS.

The present volume of St. Thomas’s Hospital
Reports ( a ) is a more bulky volume than any of its
recent predecessors, and the increase of size is chiefly
due to fuller details being given of the cases which
have been treated during the year. The tabulation of
cases in the various departments is excellent, and a
reader interested in any particular subject has no
difficulty in finding his way to the information he
desires. The use of the authorised nomenclature for
diseases and injuries is to be praised, and we hope to
see other hospitals follow in this particular the
example of St. Thomas’s.

All cases of special interest are detailed with fairly
full notes, quite adequately full as regards clinical
details. The pathological information is, however,
insufficient. This is most noticeable in that part
of the surgical report dealing with tumours, and in
the fost mortem records in the medical report. The
details given are so few as to be valueless, and one
is left in doubt as to the real nature of manv of the
cases. Obiter dicta, such as “carcinoma m some

portions distinctly squamous, in others spheroidal ”
(p. 208), do not elucidate a clinical history. Again,
the discovery of “a malignant growth ” (nature
unstated) in the liver ten years after the removal of
the patient’s eye for sarcoma, is not sufficient evidence
of “recurrence” (p. 91). We would have liked also
a little more information on the working of the clinical
laboratory. St. Thomas’s greatly prides itself on
having inaugurated one of the earliest clinical
laboratories, and those in charge of clinical labora¬
tories elsewhere are eagdr to leam from the experience
there acquired ; the present report devotes exactly one
age to the work of the laboratory. On the other
and, the descriptions of the specimens added to the
museum are admirably full, and should serve as an
example to curators generally. Individual papers on
various subjects are contributed by Messrs. Nitch
and Corner, and Drs. Dudgeon and Cassidy, while
Mr. Robinson writes a graceful memoir of the late
Mr. John Croft, who had been on the staff of the
hospital for over thirty-five years.

(a) “ St. Thomas's Hospital Reports.” New Series. Edited by Dr
H. G. Turney and Mr. W. H. Battle. Vol. XXXIV. Pp. xiv. 617
London: J. and A Churchill, 1906. Pricefla.6d.net.

34 ^ The Medical Press.

WEEKLY SUMMARY.

Sept. 25, 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT OBSTETRICAL LITERATURE.

Pyelo-nephritls In Pregnancy.— Fournier (Zentralbl.
fiir Gyndk., Nr. 38, 1907) in a paper on this subject
says there are two principal factors to be considered
in the causation of this complication of pregnancy.
Firstly, compression of the ureters; secondly, descend-
ing infection, e.g., bacterium coli and ascending
infection, e.g., gonococci, former renal disturbances,
and finally congenital malformations of the ureter and
pelvis of the kidney. The disease can be divided into
two groups:—(x) That produced by the bacterium
coli, in which one frequently finds the bacterium in
the urine; (2) that produced by the gonococcus, in
which the micro-organism is rarely found in the urine.
The former is much graver than the latter. The
presence of stone in the kidney makes the prognosis
more serious. As a rule the prognosis is seldom bad
for the mother, but always momentous for the chifd.
Under the influence of proper treatment from the first
the disease can improve. Disinfection of the intestinal
and urinary systems is the most satisfactory treatment.

Prematnre Detachment of the Normally Sitnated
Placenta. —The most important causes of this accord¬
ing to Gaston ( Zentralbl. fiir Gyndk. Nr. 38, 1907)
are albumenuria, injury, and endometritis. The most
characteristic symptoms are the sudden onset, intense
abdominal pain, great hardness of the uterus from
tetany, and the abnormal appearance of the uterus
which resembles a more advanced period of pregnancy.
The prognosis is very bad, both for mother and child.
The histological changes to be noted are: In the
uterus atrophy of the mucous membrane and degenera¬
tion, in the placenta hypertrophy of the decidua, blood
clots, alveolar endometritis, which extends over the
whole decidual tissue and atelectasis of a great number
of villi. When the symptoms are not severe the patient
should be kept attest in bed, labour then usually comes
on spontaneously. If the cervix is dilated the mem¬
branes must be ruptured and the uterus emptied as
soon as possible. If the cervix is not dilated the
Champetier bag or Bossi must be employed, or the
vaginal caesarean section if tetany of the cervix be
present. G.

Version for Placenta Praevla.— Jolly (Miinchener
med. Wochensch., 1906, Nr. 25) says in opposition to
the more surgical methods of treatment that this
remains always the most important means of treating
the placenta praevia. The high foetal mortality is not
so much due to the version as to the frequency of
debility of the infants since the labour is very often
premature. Version may be performed when it is
possible to introduce one or two fingers through the
cervix. As much liquor amnii as possible should be
allowed to escape. The diminution in the uterine
contents excites labour, and thus a rapid delivery of
the child. G.

The Complications of Septic Abortions, their
'^Etiology, Treatment, and Prognosis.— Seegert (Med.
Klinik, 1906, Nr. 31) divides the causes into internal
and external. The internal causes being those which
by producing intoxication terminate the pregnancy.
The external causes are regarded by the author
especially as the manifold injuries to which women
of the working class are liable during the early
months of pregnancy. In cases of feverish abortion,
when the cause of the fever is only a decomposition
of the uterine contents, the proper treatment is to
remove the source of the sapriemia as soon and as
carefully as possible, that is, the uterus must be
emptied without a sharp spoon or a sharp curette or
an ovum forceps. If the internal os is not dilated,
laminaria tents or an iodoform gauze tampon in the

cervix act quickly and well without producing much
injury. If the digital removal of the uterine contents
does not produce a cure, and if the bacteria have
already extended into the blood or the lymphatic
system of the mother, the treatment and prognosis
depend on the nature and the virulence of the
bacteria, on the action of their products of metabolism,
and on the resisting power of the mother. When
there is a lymphatic infection a parametritic exudate
may arise, or it may result in a phlegmasia alba
dolens. With such treatment as opium, heart tonics,
cold packing, etc., the prognosis is favourable unless
the rare “erysipelas malignum internum” (Virchow)
should arise, in which the cellulitis extends into the
connective tissue of the trunk. If in cases of infec¬
tion by the blood stream there should be a rapid
invasion of the entire body by pathogenic micro¬
organisms, this “ foudroyant ” sepsis has a fatal result
in a few days or even hours after the abortion with
the symptoms of cardiac paralysis. In cases of septic
endocarditis, in which an injury of any sort is not
to be discovered in the genital tract, the prognosis
remains very doubtful even after complete emptying
of the uterus. If the hematogenic infection in septic
abortion produces a localisation of the bacteria in
the ovarian and pelvic veins, the thrombophlebitic
form of sepsis or “pyemia” is the result. Pulmonary
embolisms, joint abscesses, infarctions or abscess
formation in the kidney (recognised by the bloody
urine) show how serious the prognosis is. If the
abscesses should be subcutaneous, intramuscular, or
periarticular the prognosis is relatively favourable.

Cystic Enlargement of the Ovaries la Cases •<
Hydatldiform Mole .—Goullioud (Rev. de gyn. el de chir.
abdom., 1907, No. 1) records the case of a patient, at-
25, Ilpara, who began to bleed about the fifth month
of her third pregnancy. On examination two cystic
tumours as large as a child’s head could be felt, one
on either side of the uterus, and both quite mobile.
Soon afterwards a hydatidiform mole was bom. The
convalescence was complicated by phlebitis. Except
for some uterine douching and treatment of the
phlebitis nothing was done. During this time the
tumours began to diminish in size till they gradually
returned to the size of normal ovaries. Two years
later the woman again became pregnant. The preg¬
nancy advanced normally till the fourth month when
abortion occurred. There were no ovarian tumours
to be felt. Six months after this she again became
pregnant, and went normally to full term without any
sign of an ovarian tumour. There was, therefore, in
this case a cystic degeneration of the ovaries com¬
plicating hydatidiform mole, which would be better
called a cystic tumefaction, since the process dis¬
appeared and the ovaries returned to their normal
size, and were capable of exercising their functions in
regard to menstruation and ovulation. Removal of
the ovaries therefore in those cases is quite false.

Carcinoma of the Ovaries in Cases of Care in* su •<
the Stomach, of the Intestine, and of the BUe Dsctx.—

Goullioud (Rev. de gyn. et de chir. abdom., i 9 ° 7 -
No. 2) in a paper on this subject says that malignant
tumours of the ovaries frequently complicate cancer
of the stomach, intestine, and bile ducts, and are
generally bilateral. On the other hand, epithelioma
of the ovary may cause metastases in the intestine
which resemble primary tumours of the intestine. One
must, as a rule, consider malignant tumours of the
ovaries as metastases. Therefore in cases of cancer ot
the pylorus, one must always look for metastases in
the ovaries before one decides on operation, and
during the operation itself one must never forget to

Digitized by GOOglC

Sept. 25, 1907.

WEEKLY SUMMARY.

The Medical Pkess. 347

examine the ovaries. In the same manner, when
malignant tumours of the ovaries are present the
intestines and stomach must be very carefully examined,
especially when vomiting and ascites are present.
When ovarian tumours are complicated with metastases
in the intestines and stomach, although operation
should never be shirked, the prognosis must always be
regarded as being very doubtful. G.

Fatty Degeneration of the Uterus in Pregnancy.—

Ciulla ( Zentralbl. fur Gynak., 1907, Nr. 37) in a paper
on this subject comes to the following conclusions.
From the beginning of the second last month of preg¬
nancy a true fatty degeneration of the uterus exists.
This degenerative process falls upon the hyperplastic
muscle fibres only. It destroys them, and then pro¬
duces a fatty infiltration process in the hypertrophic
fibres, which in this manner are reduced in bulk so
that they may return to their normal shape and size.
This fatty degeneration at the end of pregnancy has a
moderating effect on the extraordinary irritability of
the uterine muscle during pregnancy and also during
labour, and we can thus explain in cases of exaggerated
degeneration the uterine inertia, and in cases of incom¬
pleteness or absence of degeneration the excessive and
cramplike contractions which occur during labour. In
the same manner we can explain subinvolution and
hyperinvolution during the puerperium. We may
consider excessive and premature fatty degeneration to
be the principal cause of prolonged pregnancy, just as
in premature labour there may be an absolute failure
of this degenerative process. The fat which is thus
derived from the uterine muscle fibres can help to
nourish the foetus during the last two months, and
passing into the maternal blood prepares the way for
lactation. The fat obtained during active involution
is made use of for the milk secretion. G.

RECENT SURGICAL LITERATURE.

The Separation ot the Urine of the Two Kidney*.—

Luys (Med. Record, August 3rd, 1907), the inventor of
the Luys’ separator, points out the frequent necessity
in renal surgery for obtaining the urine of the two
kidneys separate. This may be done by ureteral com¬
pression, ureteral catheterization or intravesical separa¬
tion of the urine. Ureteral catheterization has many
objections. There is considerable risk of infecting a
healthy kidney. It is often untrustworthy as the
ureteral sound may not be of proper size, and may
slip out; or the ureter may be injured, causing a mis¬
taken diagnosis of haematuria, and the kidney may
secrete abnormally, due to abnormal excitation. Also
the difficulties in ureteral catheterization require con¬
siderable experience to overcome them. Endovesical
separation of the urine has the following advantages
over ureteral catheterization: (x) It is more simple';
(a) it may be applied in more cases than ureteral
catheterization; it is devoid of danger; the information
given by the separator, when properly applied, if
possibly not better is at least as exact as that furnished
by ureteral catheterization. S.

Perforation of the Gall-Bladder In Typhoid Fever.—

Brandon (Canadian Practitioner and Review, August,
1907) reports the following case. The patient, female,
®t. 18, was being treated for enteric fever which ran a
typical course for over three weeks, when one night
she was seized with severe pain in the right
hypochondiac region. There was considerable tender¬
ness and slight rigidity of the abdominal muscles.
Temperature 102 0 , pulse 120. Perforation was
suspected. Fluids were stopped by the mouth, and a
hypodermic of morphia relieved the pain. Next morn¬
ing the abdomen was slightly tympanitic. The pain
had descended, and was directly over McBurney’s
point, and was associated with considerable dulness
on percussion, simulating appendical trouble. There
were no signs of collapse save the gradual dropping of
the temperature and a slight change in the character
of the pulse. A diagnosis of perforation in some form
was made, either of the caecum colon or appendix.
Operation was decided on, but the patient suddenly
collapsed, became pulseless, and soon expired. Post¬
mortem showed the peritoneal cavity filled with

greenish yellow bile. The appendix was small and
perfectly normal. The gall-bladder showed two per¬
forations, one the size of the tip of the index finger,
and the other that of the little finger. There were also
two or three ulcerated patches. In all the literature
on this subject there are only thirty-five cases of per¬
foration of the gall-bladder due to enteric fever. Five
were operated on, and three of these survived. All the
cases not operated on proved fatal. S.

The Treatment of Surgical Tuberculosis by Hyper-

aemla (Bier—Schmieden, of Bonn Med. Record,
August 17th, 1907.) points out that Bier’s treatment
of inflammatory processes increases the normal re¬
action of the parts, artificially increasing redness,
swelling, and heat. It is difficult to arrive at the
proper degree of hyperaemia, and it is absolutely wrong
to think that if little is good, more is better. A
broad (6 c.m.) soft rubber bandage is applied slowly
and evenly round the extremity, proximally to, but
not too close to the tuberculous joint. Tuberculosis
of the wrist joint, for instance, is treated regularly
with a bandage above the elbow. Each turn of the
bandage overlaps the preceding one. These bandages
must not cause pain either at the place of application
or in the diseased joint. The extremity below the
bandage soon begins to swell in a moderate degree
and assumes a bluish red colour. It remains warm,
and the pulse remains entirely unchanged. The
hyperaemia bandage in tuberculosis is applied only for a
few hours per day, and during this time all other
bandages are removed, sterilized gauze being placed
over discharging fistulae. The joint is not kept in
fixation. The tuberculous joint must be movable
after the disease has healed to fulfil the purpose of
this treatment. The first result of this treatment is
abeyance o; pain. Inflammatory contractures also
soon disappear, and active as well as passive movements
are again possible. Every excessive use of the joint
should be avoided. In the further course of the treat¬
ment the swelling subsides, large fungous masses are
converted into hard connective tissue, which latter,
by further treatment, is also absorbed. The contour
of the bones becomes visible, tuberculous fistula
even extending to the joints or bones close. Some¬
times with less perfect technique cold abscesses develop.
These are never injected with antiseptics, but opened
“and treated with cupping glasses. Treatment by
hyperaemia requires much time, nine months or more in
bad joint affections. The treatment is very simple
amd can soon be applied by the patient himself or by
any one who is in the house with him. Almost ail
cases of joint tuberculosis in Bier's clinic are treated
by hyperaemia. It is to be regretted that tuberculosis
of the hip joint cannot be treated in the same way.
Hyperaemia of the shoulder-joint, however, is practic¬
able. Especially favourable results occur in the
ankle, elbow, and wrist. In severe knee-joint disease,
where ankylosis has already occurred, resection is
practised to shorten the time of treatment. In less
severe cases extension and splints are required when
the patient is not in bed. The exutative form (hydrops)
is never treated by hyperaemia; aspiration, and injec¬
tion of iodoform emulsion being used. In combination
with the elastic bandage cupping glasses are frequently
used. They are employed in all cases of beginning
softening amd of abscesses, which may or may
not have fistulous openings. The rarefaction of
air is accomplished in smaller cups by a hollow
ball, in larger ones by a pump. They are applied
intermittently for three-quarters of an hour, being
five minutes in situ, and three minutes off. A red
not a blue hyperaemia is aimed at. By use of the
cupping glasses all detritus is evacuated daily
through the fistula and hyperaemia of its walls and
of the abscess cavity is induced. Hyperaemia is
also applicable in tuberculous diseases of the
testes, in tendon sheaths, serous membranes, &c.
Bier, in the fifth edition of his book, " Hypenrmie
ads Hielmittel,” says: " Formerly I considered the
hyperaemic treatment of tuberculosis as good ; now I
consider it the best.” S.

348 The Medical Press.

MEDICAL NEWS IN BRIEF.

Sept. 25, 1907.

Medical News in Brief.

Maternity Hospital Case,

Ada Charlotte Chowne, who wore a nurse’s uni¬
form, was indicted at Newington Sessions on September
20th for neglecting three children, named Lena Rivi
Murio, Ena Pratt, and Una Edwards, in a manner
likely to cause them unnecessary suffering and injury
to health.

Counsel said the accused was the matron of. an
institution described as the Stockwell Maternity
Hospital and School of Midwifery, and she had been
in the habit of receiving young children to nurse. With
regard to the first child the facts were that a young
Italian woman, becoming pregnant, her mistress sent
her to this institution. The baby was left there, the
mistress undertaking to pay 7s. per week. After a
time it was proposed to remove the institution to
Brixton, and the prisoner asked the mother to take the
child away. When the mother did so she found it in
a deplorable conditibn, and her mistress communicated
with the Society for the Prevention of Cruelty to
Children. An officer of the Society called at the
institution and found six children there, although none
had been registered under the Infant Life Protection
Act. Defendant declared that some of the children
belonged to probationer nurses at the hospital. In
the case of Ena Pratt, the mother, who had been
addicted to drink, had paid the prisoner 19 guineas
to be trained as a midwife, but she left the hospital on
June 29. Little Ena Pratt was in a dying condition,
and the child Edwards was in a state similar to that
of Murio.

For the defence it was said the prisoner was a
respectable professional woman, who came in for a
fortune of £30,000 to £40,000. She married a man
who ran through all her money, but she kept to him
for the last years of his life. She then associated
herself with this “home,” which was not a public
institution, but a maternity home—a means of earning
a livelihood by helping women.

Mrs. Chowne went into the witness-box and em¬
phatically denied the allegations of cruelty. She said
that she was fond of children, or she would not have
carried on the institution.

Mr. Campbell: But you carried it on for profit?—
There was no profit—I only just got a living. Con¬
tinuing, she said she did not know that under the
circumstances she had to register the children.

Evidence was also given that the condition of the
children was not due to carelessness or neglect, but
the state of their health.

The jury found the prisoner guilty of neglecting the
Italian child and Ena Pratt.

Mr. Loveland postponed sentence.

Death Under Anesthetic.

At an inquest on September 18th on the body of
Reginald Gregory Lund, 46, late of Belmont Mansions,
Chelsea, Dr. Stephen Fenwick gave details of an
operation which was performed on the deceased, who
was suffering from a growth on his tongue. About
six weeks previously, at the Charing Cross Hospital,
half of the deceased’s tongue was removed, together
with some glands in the neck. The operation wa3
quite successful, but on September 15th the deceased
had again to be operated upon for lockjaw, and he
expired while under an anaesthetic. Dr. Fenwick
said the deceased had a weak heart, a complaint which
was aggravated perhaps by the distress of the opera¬
tion. Mr. Waterhouse, who performed the operations,
said they were successful. The immediate cause of
death was heart failure, and the jury returned a
verdict to that effect.

Metropolitan Asylum* Beard.

An ordinary meeting was held on the 14th inst. at
the office of the board, Mr. J. T. Helby, the chairman,
presiding. Letters were read from the Local Govern¬
ment Board stating—(a) that they were advised that
the estimated cost of the proposed additional storage
accommodation for coal at the Eastern Hospital was
unnecessarily high, and asking the managers to re¬
consider their proposals with a view to a reduction in
the expenditure; and (A) that they were prepared to

issue an order authorising the proposed expenditure on
the goods reception station and porters’ lodge at
Joyce Green Hospital, but that they were not prepared
to sanction so heavy an expenditure as £3,042 on the
erection and drainage on tne block of eight cottages,
and asking the managers to reconsider the matter
with a view to a reduction in the cost of that portion
of the scheme. Mr. Lower said he was not surprised
that the Local Government Board had objected to the
proposed expenditure of nearly £400 on each of the
cottages. The largest rooms in most of the cottages
were less than lift, square, and in his opinion they
were not worth anything like the proposed amount.
The board had been charged by newspaper writers
and others with extravagance, and there seemed to be
reason for it, because the Local Government Board had
constantly to object to their estimates for proposed
works. After further discussion, the letters were
referred to the Works Committee. The Local Govern¬
ment Board wrote stating that they were prepared to
assent to the provision of a central laboratory for the
preparation of anti-toxin serum and for bacteriological
work, but they would not be prepared to authorise a
total expenditure on the works of more than £6,500;
and also that they were advised that a saving of not
less than £1,000 might be effected by the erection of
the laboratory on the Belmont site instead of at
Peckham, and they asked the managers to reconsider
their proposals in accordance with these views.
QM*n'i College. Belfast.

The new laboratories of the Queen’s College were
opened on Friday last. Considerable disappointment
was felt owing to the fact that Lord Kelvin, who had
promised to perform the inaugural ceremony, was
unable to be present. The laboratories were there¬
fore opened by Sir Otto Jaffe, the chairman of
the Better Equipment Fund, and a munificent bene¬
factor to the College, and the address prepared by
Lord Kelvin for the occasion was read by his nephew,
Mr. James Thompson, himself the son of a former
professor in the College. In this address Lord Kelvin
traced the evolution of the College from the old Royal
Academical Institution, and pointed out plainly that
the natural goal is the establishment of an autonomous
University in Belfast. Two of the subsequent speakers
were in cordial agreement with this weighty opinion,
and pressed it home—Sir Christopher Nixon, Vice-
Chancellor of the Royal University of Ireland, and
Professor Letts, the senior of the science professors in
Queen’s College. The new buildings may be briefly
described as follows : —A series of buildings in the
north wing of the College, called the Harland Labora¬
tories, after the late Sir Edward Harland, whose
widow contributed largely to their cost, are devoted
to physics and engineering. The chemical or Donald
Currie Laboratories complete the chemical department
of the College, and give every facility, not only for
the ordinary practical classes for medical and other
students, but also for research work and advanced
technical chemistry. The pathological or Musgrave
Laboratories have been enlarged by the addition of
several new rooms, including one 43 by 28 feet, which
forms the professor’s private laboratory. In it Pro¬
fessor Symmers rejoices in what he confidently believes
is the largest private laboratory in the world, as far
as pathology is concerned. There is also a
bacteriology room 27 feet square, and a demonstrator's
room 22 by 15 feet. The additions to the physio¬
logical or Jaffe Laboratories include a practical class¬
room, fitted with benches having pulleys, shafting,
and Kershaw drums for experimental purposes, a
practical experimental room, a histology room, a
galvanometer room, and a lecture room. To the old
medical rooms have been added a large new surgical
lecture theatre, with operating table, lift to the base¬
ment, preparation room, and many other conveniences
for work. The natural history department has also
been provided with large biology laboratory, pro¬
fessor’s room, photographic room, and botanical glass-
house on the roof.

t

Women Doctor* In Austria.

Feminine ambition has now achieved in Austria a
success which is all the more valuable as it has been
the object of their aspiration for several years. The
Minister of Public Instruction has declared that

Sept. 25, 190 7 .

MEDICAL NEWS IN BRIEF.

The Medical P ress. 349

henceforward girls and women may enter the uni¬
versities under precisely the same conditions as men,
they can give private lectures in clinical hospitals,
and be appointed assistants by the professors. The
Minister at once granted the first petition of a lady to
act as private lecturer and instructor at Vienna Uni¬
versity. This lady, Fraulein Dr. Elise Richter, forty
years of age, has for the last four years petitioned the
professors of the university for permission to lecture
upon Roumanian philology. The professors were
willing, but the then Minister refused his ratification.
The female medical doctors also demanded to be
allowed appointments as assistants, and the Ministry
caused an inquiry to be made in all the Austrian
universities and clinical hospitals. The result of the
investigation was that only a few professors opposed
the admission of women as private lecturers and
assistants, hence the inquiry culminated in to-day’s
decree by the Minister.

5t Bartholomew’s Hospital and Mad I cal School.

During the past year the following changes have
taken place in the teaching staff: —

Dr. Christopher Addison, who was formerly Dean of
Charing Cross Medical School, and Professor of
Anatomy at the University College, Sheffield, has been
appointed Lecturer and Senior Demonstrator of
Anatomy.

Mr. W. D. Harmer has resigned the Assistant Sur¬
geoncy, and has been appointed Surgeon in charge of
the Department for Diseases of the Throat and Nose.
Mr. F. A. Rose has been appointed Assistant Surgeon
for Diseases of the Throat and Nose. Mr. G. E.
Gask has been appointed Assistant Surgeon and
Teacher of Clinical Surgery.

Dr. W. S. A. Griffith has been elected Physician
Accoucheur with charge of outpatients, and will give
part of the Clinical Lectures on Diseases of Women.
D. H. Williamson has been elected Assistant Physician
Accoucheur and Clinical Lecturer in Midwifery.

Dr. J. A. Willett has been appointed Demonstrator
of Midwifery. Mr. C. E. West has been elected
Assistant Aural Surgeon. Mr. C. Gordon Watson has
Been appointed Surgical Registrar, and has resigned
the Demonstratorship of Anatomy.

Mr. L. B. Rawling has been appointed Demon¬
strator of Operative Surgery. Mr. R. C. Ackland has
been appointed Dental Surgeon, and Mr. F. Coleman
Assistant Dental Surgeon. Mr. R. C. Elmslie has been
appointed Demonstrator of Pathology and Dr. H.
Pritchard and Mr. H. G. Ball have been elected Junior
Demonstrators of Pathology. Dr. H. G. Adamson
has been appointed Chief Assistant in the Department
for Diseases of the Skin.

Dr. C. M. H. Howell has been elected Junior
Demonstrator of Physiology, and Mr. T. S. Lukis and
Mr. C. T. Neve have been appointed Assistant Demon¬
strators of Biology.

The following awards of scholarships and prizes
have been made during the year 1906-7: —

Lawrence Scholarship.—G. T. Burke, J. C. Meade
(equal). Brackenbury Medical Scholarship.— E. A.
Cockayne. Brackenbury Surgical Scholarship.—P. L.
Guiseppi. Matthews Duncan Prize.—R. B. S. Sewell.
Kirkes Scholarship and Gold Medal.—G. T. Burke.
Walsham Prize.— P. L. Guiseppi. Bentley Prize.—
H. J. Cates. Hichens Prize.—S. Dixon. Wix Prize.—
A. W. J. Cunningham. Senior Scholarship.—A. P.
Fry. Junior Scholarship.—R. G. Hill, C. D. Kerr,
J. W. Trevan (equal). Sir George Burrows’ Prize.—
A. W. G. Woodforde. Skynner Prize.—P. L. Guiseppi.
Harvey Prize. —K. Bremer. Treasurer’s Prize.—R. G.
Hill. Foster Prize.—W. C. Dale. Shuter Scholar¬
ship.—R. R. Armstrong.

The Report of the Queen’* Coder*, Cork.

The annual report of the president of the Queen’s
College, Cork, for the past year, which has just been
issued, refers at some length to the generous offer
which was made by Mr. William O’Brien, M.P., of
the whole of his own and his wife’s fortune, at their
death, for the foundation of a local university or for
the support of a truly autonomous college, which
offer was accompanied by a further suggestion that
on certain conditions a sum of ^50,000 might be
immediately available.

Dr. Windie goes on to say that this generous offer
must have great weight with those whose duty it is
to consider the proposals which will be made for the
modification ana improvement of university education
in Ireland. He goes on to point out that the ex¬
pressions of local opinion which he appends proves
conclusively the four points which he enunciated
in his previous report, and which he now again
emphasises :—

(1) That the relations of the college to the district
which it is intended to serve have never been satis¬
factory, and still remain in an unsatisfactory condition.

(2) That until these relations are placed on a satis¬
factory footing the college cannot expect to have
that number of students which, under normal con
ditions, it would undoubtedly attract.

(3) That such alterations in the constitution of the
college as would place it on a satisfactory footing
might be made without any difficulty and without
any danger to its academic position by alterations
in the charter and without direct legislation should
His Majesty issue letters making such alterations
in the charter.

(4) That there is a great and general desire through¬
out the whole of Munster that the college should be
made available for the people of the province.

Referring to the work of the College during the
past session, Dr. Windle says it is more than twenty
years since the College has had so many students
in attendance, the number being 261, of whom 77 were
new students. He records with satisfaction the
establishment of a students’ club, the work of which
has been an unqualified success. A considerable
number of other improvements are also mentioned,
notably the erection of an operating surgery theatre
which in its design imitates the most modem type
of operation theatre in a hospital. Many further
improvements are, however, needed, and chief among
these Dr. Windle puts forward accommodation for
the teaching of chemistry and physics.

Medical Sickness and Accident Society.

The usual monthly meeting of the Executive Com¬
mittee of the Medical Sickness, Annuity, and Life
Assurance Society was held at 6, Catherine Street,
Strand, London, W.C. There were present: Dr. de
Havilland-Hall (in the chair), Dr. F. S. Palmer, Dr.
H. A. Sansom, Dr. J. W. Hunt, Dr. M. Greenwood,
Dr. W. Knowsley Sibley, Dr. F. J. Allan, Dr. St.
Clair B. Shadwell, Mr. H. P. Symonds, Dr. J.
Brindley James, and Dr. J. B. Ball. The accounts
presented showed that during the first eight months of
this year the operations of the Society had been greater
than in any similar period of its working. Since
January 1st last, nearly nine thousand pounds has been
distributed to the members in the shape of weekly
sick pay, and good cash bonuses have been given to
those who reached the limiting age of 65; yet the
funds, which now amount to over ,£200,000, have
received a substantial increase, as the annual income of
the Society is considerably larger than its outgo.
Prospectuses and all particulars on application to Mr.
F. Addiscott, Secretary, Medical Sickness and Accident
Society, 33, Chancery Lane, London, W.C.

An important concert in the series of twenty Odeon
Concerts in aid of the Lord Mayor's Cripples’ Fund,
and under the Lord Mayor’s patronage, was given at
Hammersmith Town Hall on Friday, September 20th.
Sir John Kirk, the Secretary of the Ragged School
Union, again presided, and opened the proceedings
with a short speech, pleading very earnestly for the
cripples and the cause which the Odeon Company has
taken up. The record specially made for these con¬
certs by the Lord Mayor was recited, and could be
heard clearly all over the hall.

A scare has been caused at Cleethorpes by a number
of people who have eaten potted meat suddenly develop¬
ing symptoms of irritant poisoning. They are now
undergoing treatment. No fatal consequences are
anticipated. The whole of one family has been ill,
two of the daughters dangerously.

oogle

D

350 Thk Medi cal Press. NOTICES TO CORRESPONDENTS.

Sept. 25, 190 7 -

NOTICES TO
CORRESPONDENTS,

(Pc.

Correspondents requiring a reply in this oolumn are par¬
ticularly requested to matte use of a Distinctive Signature or
Initial, and to avoid the practioe of signing themselves
•' Reader,” ” Subscriber," " Old Subscriber,” etc. Muoh oon-
fusion will be spared by attention to this rule.

Reprints.—R eprints of artiolea appearing in this Journal can
be had at a reduoed rate, providing authors give notioe to the
Publisher or Printer before the type has been distributed. This
should be done when returning proofs.

Original Abticles ob Letters intended for publication
should be written on one side of the paper only and must be
authenticated with the name and address of the writer, not
necessary for publication but as evidenoe of identity.

R. M. P.—The names of the two medical men belonging to
the Liverpool School of Tropical Medicine who lost their lives
in. pursuing scientific work abroad are Dr. Walter Myers and
Dr. J. E. Dutton. Dr. Myers died at Para of yellow fever,
and Dr. Dutton on the Congo.

Omnibus.—I t is not correct to say that the medical officer* in
question was oensured. His abilities were recognised and the
smallness of his salary mentioned in such a way that it was
clear no extensive duties could have been expected of him. It
is unreasonable to suppose that a man, however talented, can do
work for which he is not paid, and the more talented men
will naturally find freer eoope for their abilities in other fields.

Vkbmin.—T here are several preparations of the kind on the
market, and we believe they are all of bacteriological origin.
They seem all to be harmless, but we are not in a position to.
sav anything positive of our own knowledge; they all have good
credentials. You had better write direct to the makers for
what they euphemistically term “ literature.”

Febbib.—’T here is normally a rise in “ fever ” at this time of
year but the curve for 1907 oertainly is higher than for some
vears past. For the week ending September 7th the number of
'cases of soarlet fever admitted to hospitals in London rose to 687,
as compared with 430, 440, and 557 for the preceding three weeks.
Diphtheria and enteric fever showed rather smaller rises.

G P I.—The pathology of general paralysis is by no means
settled. The theories of Dr. Ford Robertson are by no means
accepted by the general body of psychologists. The observations
of this gentleman point to there being constantly present
certain diphtheroid bacilli in the vessels and affeoted nervous
tissues. He has carried hit work to the point of inoculation.

The invention of spectacles has been attributed to Roger Bacon
in the thirteenth century, and also to Alexandre di Spina and
Salvino degli Armati, distinguished Italians of the early four-
teenth century. These ophthalmio aids, however, are probably of
a muoh older date. Magnifying glasses, at least, must have
been in use among the ancients, for it is difflcqlj to believe that
the perfection of gem-cutting whioh they attained could have
been acquired without their assistance. The OhineSe, too, claim
credit for having used them before the Christian era, and the
passage in Holy Writ, " Now we see through a glass" is con¬
sidered by some commentators to be a mis-translation, and
should read " through glasses.”

W. 8 . H.—The dates of the various developments are as
follows for the infant:—Tears, about the second month; sweat,
about the same time; saliva—in any quantity—about the fourth
month; appreciation of sights and sounds, about the raid of the
first week; ability to raise the head, about two months; to rat
up, seven months; to stand, twelve months.

r. G. I.—The returns of the Registrar-General for Ireland
9 how a disturbing prevalence of consumption. There were in
1906, 74,427 deaths registered in the country, and of those 11,758—
a number equal to 15.8 per oent. of the total—are attributed to
tuberculosis. In this respect Interest will be found in the
comparisons between the death rate from tuberculosis in the
three kingdoms between 1864 and 1906. In England and Scotland
the returns show decreases from 3.3 to 1.6, and from 3.6 to 2.1
per thousand respectively, but in Ireland there is an inorease
from 2.4 to 2.7. ,

Senility.— There are a good many authentic cases of centen¬
arians in this country. 8 ome time ago the case of an old lady
who had died in the department of the Haute Garonne, Franoe,
at the well-nigh incredible age of 150, who had lived the
best part of her life on goat's milk and cheese, was reported.
There is also the case of James Grieve, of Ardkinglass, Argyll¬
shire, who is now 107 years of age, and who repudiates what he
calls dietetlo fads, declaring that he has always been in the
habit of eating anything he fanoied. At Horncastle, the Rev.
Thomas Lord, now in his hundredth year, still occupies the
pulpit of his church on Sundays; at Cleeve, Somerset, a well-
known resident, Mrs. Honor Coleman, is in her 107th year.
Many other instances might be given of centenarians of
England, to say nothing of well-known personages like Sir
Andrew Lusk and Sir Henry Pitman, whose ages are very little
short of five soore. Ireland has, in proportion to population, the
largest number of aged people. In 1905, the last year for which
we have complete returns, seventeen centenarians died in that
country in the workhouses alone. The oldest of these, a
Limerick man, was no less than 113 years of age.

Anon. —(Imprisonment for Debt.)—Many thanks for the cut¬
tings. We cordially endorse the sentiments.

iBeethtga of the Soci et ies, lectures, &c.

Wednesday, October 2nd.

St. Mart's Hospital Medical 8chool.— 3.30 p.m.: Annual
Presentation of Prixes and Introductory Address by Professor
Osier, M.D., LL.D., F.R. 8 . 7 p.m.: Annual Dinner of Past and
Present Students at the Whitehall Rooms.

WEDNE8DAT, SEPTEMBER 25TH.

Medical Graduates' College and Polyclinic (22 Chenier

8 treet, W.C.).—4 p.m.: Mr. L. Mummery: Clinique. (Surgical.).

Thursday, September 26th.

Medical Graduates’ College and Polyclinic (22 Chenie*

Street, W.C.).—4 p.m.: Mr. Hutchinson: Clinique. (8urgical.)

Friday, September 27th.

Medical Graduates’ College and Polyclinic (22 Chenies.

8 treet, W.C.).—4 p.m.: Mr. S. Stephenson: Clinique. (Eye).

fteomaes.

University of Manchester.—8enior Demonstrator in Physiology.
Salary, £150 per annum. Applications to the Registrar.

The Hospital for Sick Children, Great Ormond Street, London,
W.C.—House Physioian. Salary, £20, washing allowance
£2 10s., with board and residence in the Hospital. Applica¬
tions to the Secretary. (See Advt.)

The Hospital for Sick Children, Great Ormond Street, Londou,
W.C.—House Surgeon. Salary, £20, washing allowance
£2 10s. with board and reaidenoe in the Hospital. Applica¬
tions to the Secretary. (See Advt.)

The Hospital for Sick Children, Great Ormond Street, London,
W.C.—Assistant Casualty Medical Officer. 8alary, £20, wash¬
ing allowance £2 10 s., with board and residence in the
Hospital. Applications to the Secretary. (See Advt.)

Manchester Royal Infirmary.—Resident Surgical Officer. Salary,
£150 per annum, with board and residence. Applications to
Walter G. Caret, General Superintendent and Secretary.

Farringdon General Dispenaary, 17 Bartlett’s Buildings, Ho'lborn.
Circus, E.C.—Resident Medical Officer. Salaiy, £120 per
annum, with apartments, coals, gas, and attendance. Appli¬
cations to the Honorary Secretary.

Kent County Asylum, MaidBtone.—Fourth Assistant Medical
Officer. 8alary, £175 per annum, with furnished quarters,
attendance, coals, gas, garden produce, milk, and washing.
Applications to the Medical Superintendent.

Metropolitan Borough of 8t. Marylebone.—Medical Officer of
Health. Salary, £900 per annum. Applications to James
Wilson, Town Clerk, Town Hall, Marylebone Lane, Oxford
Street, W.

Durham County Hospital.—House Surgeon. Salary, £120 per
annum, with board and lodging. Applications to Wm. B.
Wilson, Secretary, 684, Sadeler Street, Durham.

Jersey Dispensary.—Resident Medical Offloer. 8alary, £120 per
annum, with furnished quarters and attendance. Applica¬
tions to the Secretary.

City of London Hospital for Diseases of the Chest, Victoria
Park, E.—Pathologist. Salary, £105 per annum. Applica¬
tions to H. Dudley Ryder, Secretary.

Royal London Ophthalmic Hospital (Moorflelds Eye Hospital).
City Road, E.C.—Senior House Surgeon. Salary, £100 a
year, with board and residence. Applications to the
Secretary.

General Hospital, Birmingham.—Two Receiving-Room Officer*.
Salary, £150 per annum. Applications to Howard J. Col¬
lins, House Governor.

SppomtmentB.

De Selva, E. M. J., L.R.O.P. and B.Edin., L.F.P.S.Glasg., Cer¬
tifying Surgeon under the Factory and Workshop Aot for the
8 calloway District of the oounty of Shetland.

Foley, Cornells, L.R.C.P. and 8... L.M.Irel., District Medical
Offloer by the Ross (Herefordshire) Board of Guardians.

Grandaoe, William B., M.B., B.C.Cantab., M.R.C.S., L.R.CP.
Lend., Assistant Resident Medioal Offloer to Queen Char¬
lotte’s Lying-in Hospital.

Harvey, Fbane, M.R.C.8., L.8.A., District Medical Officer by
the St. Columb Major (Cornwall) Board of Guardians.

Henderson, G., M.D.Edin., Certifying Surgeon under the Faotory
and Workshop Aot for the Coldstream District of the county
of Berwiok. . .

Imbik, G. J., M.B., M.S.Glasg.,' Certifying 8urgeon under the
Faotory and Workshop Act for the Levenwick Distriot of the
oounty of Shetland.

Lavers, Norman, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Physi¬
cian Superintendent of Bailbrook House, Bath.

Richards, John Barrow Osborne, L.R.C.P. and S.Edin.,
L.F.P.S.Glasg., Medioal Offloer of Health for the Wade-
bridge (Cornwall) Urban District.

Sharp, P. J., M.B., M.S.Edin., Certifying Surgeon under the
Faotory and Workshop Act for the Ollaberry District of the
oounty of Shetland.

Shnneb, D., L.R.C.P. and S.Edin., Certifying Surgeon under
the Factory and Workshop Aot for the’ Lauder District of
the county of Berwick.

Calet.—O n Sept. 19th, at 24 Upper Berkeley Street, London,
the wife of H. A. Caley, M.D., F.R.C.P., of a son.

4&arnaat0.

Chater—Arnaud. —On Sept. 18th, at the Church of St. Thomas
& Becket, Portsmouth, Staff-Suigeon Harold John Chster,
R.N., seoond son of William Chater, Esq., of Godalming.
Surrey, to Winifred, youngest daughter of Franois Henry
Arnaud, Esq., of Southsea, Hants.

Cowie—Roberts. —On Sept. 19th, at 8t. Stephen's, Bourne¬
mouth, Charles George Cowie, M.A., M.D., of Bon-Accord.
Branksome Park, eon of the late Alexander Cowie, of Ellon.
Aberdeen, to Evelyn Gertrude, second daughter of Fred »-
Roberta, of Wyuna, Branksome Park, formerly of Melbourne.
Australia.

zed by G00gle

The Medical Press and Circular.

“SALUS POPULI SUPREMA LEX.*

Vol. CXXXV. WEDNESDAY, OCT. 2, 1907. No. 14

Notes and Comments.

If anyone doubts that temperature
Climate and rainfall are intimately related

and with mortality, at any rate at this

Diarrhoea, time of the year, the returns for last
month as they come in should go a
good way towards carrying conviction. The death-
rate for this cold, showery summer has been
noticeably low, the last two weeks of August only
showing 11.5 and 11.8 per thousand as the annual
rate of mortality for England, and London for the
first eleven weeks of the quarter averaged but
12.0. But with the burst of warm, dry weather
that the last three weeks of September have seen,
the death-rates have begun to mount again. The
great saving, of course, has been in the diarrhoeal
mortality in young children, which has been
almost phenomenally low; certainly so as com¬
pared with last year’s returns. Now, it is a
matter for very serious reflection whether, know¬
ing the outstanding facts, it is not possible from
them to construct some working theory. The
knowledge that the 4-foot earth thermometer is
beginning to rise, and that in due course that rise
will be followed by a slaughter of the innocents
by diarrhoea, is useless pedantry unless it tends in
some way to guide useful action in preventing
this lamentable result. It may be argued that
temperature and climate are “ acts of God,” arid
therefore beyond the scope of preventive medicine,
but there is no sense in pursuing the paths of pre¬
ventive medicine unless attempts are made to cir¬
cumvent the “acts of God.” The factors most
needed in the situation at the moment are imagi¬
nation, and the solid wish to confirm or refute the
results of imagination.

Starting with the facts that dry
The heat in summer conduces to diar-
Shortcomlngi rhcea. and that cool showery weather
of the Fly. prevents it, and taking it for
granted that the cause of diarrhoea
is bacterial, it seems necessarily to follow that hot,
dry weather conduces to the growth and distribu¬
tion of the particular bacterial agent or agents
at work. Now, the only obvious distributing
agencies are the movements of the air carrying
particles to a distance, and insects. It is quite a
plausible explanation that the rain, falling on suc¬
cessive days during a wet season, lays the dust,
and that the dissemination of bacteria is thereby
restricted; but it is quite as plausible to argue
that cold, wet summers are poor in flies, and that
it is to flies we ought to look for an explanation.
Probably both factors operate to some extent, but
which is the more important, is there not enough
evidence to decide? This summer has been
markedly poor in house-flies, and we feel our
suspicions against them much aroused. That
flies can carry infection has been demonstrated,

and that they do feed on faecal matter and on food
prepared for human consumption indiscriminately,
with, perhaps, a slight preference for the former,
is a fact of common observation. We have, then,
the following links in the chain of evidence
That flies can carry infection, that they revel in
diarrhoeal dejecta, that they frequent food stores,
that when they are abundant diarrhoea is abundant,
and that when they are absent diarrhoea is infre¬
quent. Moreover, in places where middens exist
and sewage disposal is slack, diarrhoea and enteric
diseases are generally rife. These facts surely
would justify a campaign against flies as vigo¬
rous as that against mosquitoes.

The homoeopaths, or as we see them
frequently styled now the homce-
nomoeopainic pa thists, have been disporting
themselves at Harrogate- A Con¬
gress was held at that town to¬
wards the end of last month, and the dele¬
gates were refreshed by an address from
the President on “Spas I have seen.” The
“ allopathic ” infidel is perplexed as to the
need for spas in the Hahnemann system, but
any qualms that might disturb a doubting brother
were speedily put to rest by the president’s com¬
forting words. “ At first sight,” said he, “ it might
not seem that hydro-therapeutic treatment, either
at the spas of Great Britain or on the Continent,
have much, if anything, to say to homoeopathy.
To that he emphatically demurred, because he
was of opinion that in the highly varied and
luxurious healing founts which nature had caused
to flow gently forth from some of the fairest spots
on the face of the globe, the alchemy which was
connected with the dogma, 4 similia similibus
curantur,’ was distinctly in evidence.” “ Here’s
richness,” as Mr. Squeers said when he tasted his
pupils’ milk-and-water. The evidence which sup¬
ported the alchemy of this dogma was not, as far
as we can see, produced; but, then, it is not such
an easy task to demonstrate the alchemy con¬
nected with a dogma.

But as we read on, we come to
Silica in even more startling news. “The
Infinitesimal permanently curative effects of
Doses. many of these waters, he believed,
lay, not so much in the massive
doses of the more ordinary salts which they con¬
tained, as in the almost infinitesimal quantities of
deeply-acting drugs, like bromine, iodine, silica,
and arsenic, which also existed in some of them,
and very small doses of which we knew perfectly
well had a potent and lasting action on the con¬
stitution when administered in the dilutions pre¬
pared by the chemist. The knowledge of how to
use these healing streams was a valuable addition

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35 2 The Medical Press

LEADING ARTICLE.

Oct, a, 1907.

to their armamentarium." The point raised here
by Dr. W. T. P. Wolston, in his address, is a
valuable one, and may have missed many men’s
attention. The opinion he gives amounts to this :
that things are not what they seem, and that if a
patient goes to a spa after a course of free
living, and returns home permanently set up, we
must not attribute this restoration to massive
doses of magnesium and sodium sulphate, but to
the cheering and invigorating effect of the infini¬
tesimal quantities of such “deeply-acting” drugs
as silica. In the midst of the material world of
medicine, how refreshing it is to have these
idealistic conceptions to counteract the hard facts
of science and experience!

A subsequent speaker at the same
The “ Art Congress made the apposite state-
end ment that “ homoeopathy was like
Mystery.*' Christianity in one respect—it con¬
tained both truth and mystery.
That there was truth in it they all knew, and the
mystery that attached to it was the mystery that
led to everlasting discussion.” We do not re¬
member to have heard the homoeopathic position
stated with quite so much candour before. The
great difference between Christianity and homoe¬
opathy, we should think, would be that Christianity
contained a great deal of truth to a little mystery,
while homoeopathy contains very little truth to a
great deal of mystery—resembles, indeed,

Falstaff’s hotel bill in containing but “one half¬
pennyworth of bread to this intolerable deal of sack.”
But, as the Congress speaker said, it is this
mystery which leads to everlasting discussion, and
we might add that it is just this “mystery ” which
attracts a certain class of mind which has not the
openness to prefer demonstration to speculation.
The beauty of the everlasting discussion that
ranges about homoeopathy is that, like the disputes
of the old schoolman, it can lead to no useful result,
and the point at issue remains as obscure and
mysterious after the argument is over as when it
began.

The firm known as “Boots, Cash
The Boot Chemists, Ltd.,” which combines
on the the useful art of pharmacy with
Other Foot. the vending of trinkets and the

circulation of literature, were
considerably perturbed the other day by being sum¬
moned for the offence of selling tablets containing
strychnine without the precautions enjoined by the
Pharmacy Act. The offence was proved by the
Pharmaceutical Society, who initiated the prosecu¬
tion, and the defendants fined. By way of justi¬
fying themselves, Messrs. Boots proceeded to sum¬
mons a qualified pharmacist, trading as W. Walter
Madden and Madden and Co., for a similar fault,
and at Westminster Police Court, on September
23rd, they succeeded in getting a conviction. To
the medical man this occurrence suggests several
lessons. In the first place, everyone must regret
the decline of the old-fashioned pharmaceutical
chemist who was in business for himself, had one
shop, and personally supervised and was respon¬
sible for everything that went on therein. In the
second place, there must be equal regret for the
unhappy habit that is springing up of indiscrimi¬
nately selling to the public any drug that is asked
for. And, thirdly, it seems that the restric¬
tions of the Pharmacy Acts, little effective as they
are, can be easily neglected. Happily, it is
still possible for medical men, by recommendation
and patronage, to support those pharmaceutical
chemists who give their personal attention to their
business, and conduct it with a due sense of its
grave obligations.

LEADING ARTICLE.

PLURALITY OF HOSPITAL
APPOINTMENTS.

The honorary medical staff of the Bristol
Infirmary have found themselves suddenly plunged
into the throes of a controversy with their Board
on questions connected with the terms of their
appointment. The issues involved are of the
deepest interest to the medical profession generally,
and on that ground claim an amount of attention
not usually accorded to a local hospital dispute.
The crux of the matter may be readily gathered
from the two following rules which were last week
passed at the half-yearly meeting of the Royal
Infirmary Board by about twenty out of seventy-
two governors. The new rules provide that: “No
member of the honorary staff shall hold any union
or club appointment. No member of the full staff
shall hold any other professional public appoint¬
ments other than a 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. ” The new rules,
therefore, involve two points—namely, plurality of
appointments and the ethics of consultant and
specialist practice. With regard to the first, it is
not easy to understand why, in a provincial town
like Bristol, the Committee of the Infirmary should
take so sudden a stand against plurality. There
is a large general hospital, but the posts there are
never held in common with those at the infirmary.
There are the usual number of small medical chari¬
ties, general and special, that we would expect to
find in a population of some 320,000. Within a
generation the ancient city of Bristol has greatly
increased in size, probably by one-third. The
medical school is one of old standing, and many
famous medical men have been connected with
the Royal Infirmary at Bristol. Of late years the
local school has entered on a new phase of exist¬
ence by its absorption in the Medical Faculty of the
Bristol University. It may be that these altered
conditions may demand the framing of fresh
ethical rules on the part of the profession and of
alterations in the tenure of appointments on the
part of the executive boards of the medical
charities. The new rules were energetically upheld
by the President of the Infirmary, Sir George
White, who quoted a series of rules against plural
appointments in force at hospitals and infirmaries
in Birmingham, Leeds, Liverpool, and Manchester.
The populations, and consequently the number of
medical charities, however, of those towns vary
from 450,000 in Leeds to 650,000 in Manchester,
and they can hardly be regarded, therefore, as
parallel instances. As regards the general ques¬
tion of multiplicity of hospital appointments, it
may be pointed out that there is pluralism and
pluralism. There is the tenure of two, or in some
cases three, posts that are well within the capacity
of a single individual, with work that extends the
experience and strengthens the capacity of the
holder. Especially true is this of the holding of

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Oct. 2 , 1907.

CURRENT TOPICS.

The Medical Peess. 353

an appointment in some special branch in addition
to a general post as physician or surgeon. In
Bristol there seems little chance of any man hold¬
ing so many posts as to be incompatible with the
proper discharge of his duties. Were there any
such risk, it would be easier to understand the
sudden reversal in the policy of the infirmary,
which has hitherto given a free hand to its medical
staff to hold what outside posts they wished, and
to do consultant, general, or special practice as
they chose. As regards the holding of multiple
posts by one man who is obviously unable to do his
duty in all of them, we hold that kind of pluralist
as an anachronism and a hindrance to his profes¬
sion. His existence handicaps most unfairly the
career of many a promising young man, who is
thereby prevented from entering the lists. So far as
the restricted and wholesome plurality that is likely
to obtain in Bristol is concerned, we are absolutely
in agreement with the local medical men, who re¬
gard the matter as one that concerns themselves
alone. We venture to hope that the new rules will
be reconsidered by the whole body of governors of
the infirmary. At the same time, we suggest that
the resolution to restrict the private medical prac¬
tice with certain conditions should also be recon¬
sidered. During a long and not undistinguished
history, the Royal Infirmary has been well and ably
served by men who were for the most part frankly
engaged in general practice. There is much to be
said for a system of that kind, which reduces the
doctrines of advanced science to the test of daily
and sustained application. In the past, at any
rate, Bristol has had no reason to regret the service
of her medical charities by medical men engaged
in general practice. Whatever the upshot of this
new departure on the part of the Royal Infirmary,
we trust that the decision will be submitted to the
whole body of the governors, and that the views of
the local medical profession will be duly considered.

CURRENT TOPICS.

The Beatitude of Bowls.

The twentieth century has been ushered into
existence in the midst of a kind of athletic renais¬
sance among the nations of the earth. Cricket,
football, rowing, tennis, cycling, golf, all have
their devotees; while recreations demanding
varying degrees of strength, skill, and activity are
hardly less popular. One of the most recent
revivals is the ancient game of bowls, which now
bids fair to take once again a leading place among
the sports of Merrie England. As a matter of fact,
it is just as good a game to-day as it was in the
time of Raleigh or in the remote Anglo-Saxon
times. While it provides good, easy exercise for
the whole body, it requires a moderate amount of
skill, without laying too great a strain upon the
mind. The whole environment of bowls is restful;
its green sward a delight; its battles one long,
enthralling beatitude. Not least of all, it is within
the power of man, woman, and child to play a
fairly good game, although the higher flights
demand a level of achievement that is undreamed of
save in the house of the serious player. So that it
may pretty safely be assumed that bowls will once
again take a foremost place amongst our national

games. From a medical point of view, we have
nothing but praise for this most excellent of
recreations. It provides open-air exercise and
amusement for old and young, it is admirably
fitted for many invalids, and, above all, it is one of
the best of what may be called natural opiates.

Scarlet Fever and Sanitary Science.

Scari.et fever still presents an unbroken front to
the attacks of the sanitarian. In spite of many
years of notification and the enormous sums that
have been expended in the hospital isolation of the
malady, there is no sign of decrease in its annual
incidence upon the nation. Nor is it at all hopeful
under present conditions that scarlatina will ever
be exterminated by sanitary measures alone. Its
short incubation, its high degree of infectiveness,
and its proneness to attack infancy and childhood,
render it one of the most difficult of all the specific
fevers to bring under control. Indeed, the pre¬
valence of scarlet fever in most of our great towns
at the present moment is such as to constitute ah
admitted failure of the measures of public health
hitherto organised with a view of controlling and
ultimately eradicating the disease. Some day the
key to the position may be placed In the hand of
medical science, which has solved many problems
of no less apparent hopelessness. Take the case of
cholera and of small-pox, for instance; one has
been banished altogether from our shores, and the
other has been reduced to a fractional and feeble
existence. On the whole, it seems possible that
the future control of scarlet fever may be in the
direction of some preventive vaccine or serum.
Why should not the Government find the money
to carry out an authoritative scientific investigation
upon this point? At any rate, it seems clear that
our present public health methods in dealing with
scarlet fever stand in need of revision.

School Hygiene.

An important divergence of views has taken
place with regard to Dr. George Newman’s
appointment as Chief Medical Officer to the Educa¬
tion Board. It is held that the post should have
gone to Dr. Kerr, of the London County Council.
As both these gentlemen are of high position and
ability, the matter might seem to be merely
a personal one, but this is not the case. The
question at issue is really the vitally important
one as to whether the administration of hygiene
in schools shall take place through the ordinary
sanitary machinery of local authorities, or whether
school hygiene shall be totally separated from
ordinary public health work and managed by a
distinct staff. The decision on this point was
practically made by the late Government when it
did away with school boards and made county
councils and municipal authorities responsible for
education. Had the old school boards remained,
no doubt it would have been comparatively easy to
make each authority responsible for the respective
interests; but the matter is so complicated now by
the fusion of education with municipal affairs, that
the distinction of sanitary administration from
school hygiene administration would be difficult to
maintain. Sir Robert Morant, Permanent Secre¬
tary to the Education Board, had apparently
decided that the medical inspection of schools
should take place through the channels of the

i>

D

CURRENT TOPICS.

Oct. 2 , 1907.

354 The Medical Press.

departments of the medical officer of health, and
therefore the appointment of a medical officer of
health, pure and simple, to be head of the medical
department of the Education Board was natural,
and a sound and well-known man was selected for
the post. Whether this policy is the right one is a
weighty question which deserves full discussion.

Mental Condition of Rayner.

The view expressed in the Medical Press and
Circular at the time of the trial of Horace G.
Rayner for the murder of Mr. Whiteley—namely,
that the man was not mentally responsible at the
time of the crime—has been strikingly confirmed
by the latest news from Parkhurst Prison, where
he is now incarcerated. It is reported that Rayner
is now recognised as being in a hopeless mental
condition. His suicidal intention shows no ten¬
dency to diminish, and after a probationary period
of “observation” he has been classified by the
medical staff of the prison as permanently weak-
minded. It is no longer considered safe to confine
him in a separate cell, even under close observation.
He has accordingly been transferred into an
“association ward,” where a warder and an orderly
are in constant attendance. Ever since Rayner’s
reception at Parkhurst he has been in hospital, and
he is likely to remain there until released by death
or transferred on certificate to a criminal lunatic
asylum.

The Anti-Vivisection iHospital and the
Sunday Fund.

That curious product of modern medical evolu¬
tion, the National Anti-Vivisectionist Hospital at
Battersea, is clearly not going to take “lying
down ” the refusal of the Metropolitan Hospital
Sunday Fund to make a grant. Their secretary
has been engaged in a fulminating correspondence
with Sir E. H. Currie. The latter gentleman has
been indiscreet enough to state in reply that the
governing body of the Battersea Institution
imposes restrictions on its medical staff. The
Hospital Sunday Fund, he adds, can in no case
assist institutions whose governing body dictates
the form of treatment to be used by the medical
staff. To that statement the secretary promptly
replied, pointing out that, whereas the Homoeo¬
pathic and the Temperance Hospitals imposed
special forms of treatment upon their medical staff,
both of them received grants from the Sunday
I'und. Logically, . the position appears to be
unanswerable. A fundamental rule of administra¬
tion, the first we remember to have heard from
the Hospital Sunday Fund, is laid down by a
responsible official, but is at once shown to be
unequally applied. We have no sympathy with the
supporters of the Anti-Vivisectionist Hospital
authorities ; on the contrary, we regard their views
as narrow, illogical, and ludicrously disingenuous,
but nevertheless we think that institution is en-’
titled to fair treatment. If they are excluded from
a grant by a law that is only applied in particular
instances, then they are unjustly dealt with. The
weak point seems to be the want of a declared policy
by the Metropolitan Hospital Sunday Fund, which
is now enabled to inflict a serious injury upon a
medical charity by withholding a grant on grounds
that are, as a rule, autocratic and absolutely secret.

The “ Fainting Fit ” in Criminal Assault.

Of all classes of criminal inquiry, there is none
that should be approached with more caution and
calm judicial alertness than that which deals with
sexual charges. The very fact that such cases are
generally heard in camerd renders paramount the
necessity of an absolutely impartial administration
of justice. The criminal assault, by the very
circumstances of the case, furnishes a readily
available instrument to the hand of the black¬
mailer. Short of that, it suggests itself automatic¬
ally, as it were, to the disturbed imagination of the
hysterical or the epileptic woman, who often
believes implicitly in the reality of her imaginings.
Again and again the apparent sincerity of her
evidence may convince a seasoned court of justice.
Members of the medical profession are always
specially open to the charges of blackmailers or of
hysterical women. Only last week a medical prac¬
titioner in the East of London was tried at the
Central Criminal Court on a charge of assault on
a young married woman. In her evidence she
stated that, being subject to fainting fits, she went
into one of them, and on coming to found herself
on a sofa and prisoner assaulting her. A “ fainting
fit ” of this kind is of so peculiar a type as to be
in the highest degree unlikely and suspicious. As
a matter of fact, the judge, acting on the opinion
of the jury, very properly dismissed the case.

Medical Officers of Health and
Security of Tenure.

The last thing that is likely to be learnt with
regard to the origin of many public disputes is the
truth of the matter. As regards Southend it has
been more than hinted in some quarters that Dr.
Nash has been deprived of his post as Medical
Officer of Health because of his zeal in public sani¬
tary administration. Whatever may have happened
in his particular case, there can be little doubt that
the general question as to the permanency of
health appointments of that kind is in urgent need
of authoritative discussion. Under the present
system, as we have for many years past pointed
out in the pages of the Medical Press and
Circular, the annual election, or the power to dis¬
miss a Medical Officer of Health without the sanc¬
tion of the Local Government Board, opens the
road to many abuses. A competent and zealous
official in that capacity must necessarily come
more or less into collision with members of the
Council which he serves. At every turn he finds
himself called upon to criticise his own masters,
who as tradesmen, landlords, and so on, are con¬
tinually brought into contact with the Public
Health Acts. A man cannot act satisfactorily as
servant and judge upon the councillors; even if he
have the will the councillors will take good care
that he has not the way—at any rate after the next
succeeding election.

Sheffield Infirmary Trouble.

At present the position at Sheffield, from the
spectacular point of view at all events, is one of
marking time- The Hospital Committee are pre¬
paring a scheme for presentation by the Board of
Guardians at their next meeting, and the medical
men of the district have met and passed resolutions
to the effect that they consider the arrangements

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Oct. 2, 1907.

PERSONAL.

The Medical Press. 355

at present in force unworkable, and that they do
not see that they are called upon to take any active
steps in the matter. By a curious coincidence,
however, two Local Government Board inspectors.
Dr. Fuller and Mr. Bagenal, have visited the
town and held a consultation with the Hospital
Committee. In an inspired paragraph in the
Sheffield Daily Telegraph, it is stated that this
visit had no connection with the dispute in hand,
but was connected with a suggested amendment of,
the Hospital Separation Order, which, it is naively
asserted, does “ indirectly” affect the issue. More¬
over, the Hospital Committee, says the paragraph,
incidentally informed the inspectors of the new
scheme. From the line the Local Government
Board has always hitherto taken in matters of this
sort, we have little doubt that proper advice was
given to the Hospital Committee, and though per¬
haps the inspectors could not take official cog¬
nisance of the embryo proposals, our forecast would
be that a deft finger was laid on any objectionable
points. If the matter is satisfactorily adjusted, we
cannot grumble, perhaps, at the Guardians wishing
to save their face.

Register! Register ! Register !

The usual appeal has been made by the General
Medical Council to members of the medical pro¬
fession to notify any change of address to the
official headquarters at 299, Oxford Street, Lon¬
don, \V. In view of the somewhat unbusinesslike
character that is often attributed to the profession
in question, it may be well to remind any of our
readers who may have changed their residence
during the year that the omission to notify the
same may possibly lead to a removal of that in¬
dividual’s name from the ‘'Register,” with the
consequent inconvenience and annoyance of such a
position. The Registrar also adds, significantly,
that much trouble will be saved if the names are
written clearly, and the full names, or, at least,
the full initials, be also given.

PERSONAL.

Dr. James Craig will deliver an address at the
opening meeting of the medical session at the Meath
Hospital, Dublin.

A fountain, in memory of Dr. James Wilson, of
Govan, was unveiled in that town last week by Mr.
Robert Duncan, M.P.

Mr. K. F. Tobin, F.R.C.S., delivered on Tuesday
last an address introductory to the medical session at
St. Vincent's Hospital, Dublin.

Dr. Reginald Stilwf.li. will entertain the members
of the South-Eastern Division of the Medico-Psycho¬
logical Society for their autumn meeting at Hillingdon.

Wf. beg to congratulate Dr. French of the White
Star liner. Majestic, on his providential delivery from
a murderous attack by a lunatic on the ship.

The International Congress of Hygiene and Demo¬
graphy was opened on the 23rd ult. at Berlin by
the President, Prince von Schoenaich-Carolath.

Dr. M. Grabham, representing the Royal College of
Physicians of London, gave an address at the centen¬
ary of the Geological Society on September 26th.

Dr. F. M. Sandwith, Gresham professor of
Medicine, will give the first Hunterian lecture of the
Hunterian Society on October 9th, at 8.30 p.m., on
“Dysentery.”

Dr. A. E. Garrod will open the winter session at
the Hospital for Sick Children, Great Ormond Street,
London, by a lecture on October 10th on “ Diabetes
in Children.”

Mr. T. Neville, L.R.C.P. and S.I., of Goelen, co.
Cork, has been the recipient of a handsome suite of
hall furniture on the occasion of his wedding, pre¬
sented by the inhabitants of Goleen.

Dr. James Rutherford has resigned his post as
Medical Superintendent of the Crichton Royal Institu¬
tion, Dumfries, on the ground of ill-health. Dr.
Rutherford has held the post for twenty-four years.

Sir Lauder Brunton has been compelled to undergo
an operation in the Royal Victoria Hospital, Montreal,
but we are pleased to hear that his homeward journey
is not likely to be delayed for more than ten days
or so.

Mr. James Carroll, surgeon in the United States
Army, has recently died after prolonged suffering,
as the result of contracting yellow fever from the
bite of a mosquito, which he allowed to bite him for
experimental purposes when investigating the disease.

The British delegates to the Berlin Congress for
Hygiene included Dr. Whitelegge, C.B., His Majesty's
Chief Inspector of Factories and Workshops, and
representatives of the War Office, the Admiralty, the
Local Government Boards of England and Scotland,
and the Board of Education.

Mr. Charles Sissmore Tomes, M.A., F.R.S.,
F.R.C.S., who delivered the inaugural address of the
Manchester Medical School on the 1st of October, is
Treasurer of the General Medical Council and Vice-
President of the Zoological Society. His subject was
“ Medicine and its Specialities and the State: a Re¬
trospect and a Prospect.”

Dr. W. Hale White will deliver the opening lec¬
ture of the winter session of the North-East London
Post-Graduate College and of the North-East London
Clinical Society to-morrow (Thursday), at 4 p.m., at
the Prince of Wales's General Hospital, Tottenham,
the subject being “ The Various Conditions Causing
Enlargement of the Liver.” All qualified medical
practitioners are invited.

Ir is stated that the selection committee of the
Unionist majority in the Liverpool City Council has
unanimously recommended Dr. Richard Caton for
election to the position of Lord Mayor of the city for
next year. He is a member of the Liverpool University
Council and of the General Medical Council.

We are glad to announce that on September 26th
Dr. J. M. Rhodes was honoured by a presentation at
Didsbury. The presentation took the form of a cheque
and an illuminated address, to which there were 250
signatories, and the subscribers to the testimonial
included all classes of the community.

The following gentlemen have lately been the re¬
cipients of presentations from patients, friends, and
institutions they have served for long periods of time.
Mr. William Annesley Eden, L.R.C.P. I.ond.,
M.R.C.S.Eng., on the occasion of his leaving Wade-
bridge (Cornwall) ; Mr. Frederick Weatherby,
M.R.C.S.Eng., L.S.A., J.P., after more than twenty-
five years’ service to local public institutions at Long
Ashton (Somerset! : and Mr. Eleazar Davies, L.R.C.P.
and S.Kd., at Pantvwaun, near Dowlais.

Digitized by Google

35 ^ The Medical Press.

CLINICAL LECTURE.

Oct. 2, 1907.

A Clinical Lecture

ON

CONGENITAL ANOMALIES OF THE EYE. (a)

By SYDNEY STEPHENSON. M.R, FJLGS.E4,

Ophthalmic Surgeon'to the Kenalngton General Hospital, the Evelina Hospital, the North-Eastern

Hospital lor Children, etc.

(Concluded.i

III.— Anomalies Due to Intra-Uterink Inflam¬
mation.

Considerable attention has recently been paid,
especially on the Continent, to intra-uteiine inflamma¬
tion and infection as factors in the causation of cer¬
tain anomalies of the eye. It is, indeed, difficult to
account for some conditions, as congenital ophthalmia
and congenital staphyloma, on any other grounds.

In the first case, a few words may be said with
regard to so-called “congenital ophthalmia,” as to the
existence of which there can be no shadow of doubt.
That babies might be born with ophthalmia is a fact
that has been known, although perhaps not generally
recognised, for many years. The existence of such
cases was alluded to by Quellmalz in 1750. In 1902
Dr. Queirel, a Marseilles obstetrician, whose work
apparently has been overlooked by ophthalmic sur¬
geons, reported 15 cases of the kind that he had
observed in the course of his work (Lefons dc Clinique
Obstitricale, 1902). I have recently collected from the
literature 71 cases of ante-partum ophthalmia, and to
that number have been able to add 19 others met
v/ith in the course of my own work. The material at
hand, therefore, amounts to 105 cases, a number that
shows pretty conclusively that this form of disease
is nothing like so rare as has been assumed.

In explanation of the cases it has been very generally
assumed that the liquor amnii had been discharged
long enough before the completion of the second stage
of labour to allow of inoculation of the infant’s eyes
by gonococci or other organisms present in the
maternal passages. Assuming that the fluid was really
liquor amnii, and not liquid such as is known to
be now and then present between amnion and chorion,
this premature escape doubtless accounts for a moiety
of the cases. It may actually have taken place in
26 of the 71 cases where the time of rupture of the
membranes was mentioned. There still remain, how¬
ever, 63.38 per cent, of the cases in which this view,
known as Haussmann’s, does not apply. The bacteiio-
scopic examination of the discharge from the eye gives
us no help, since the results do not differ markedly
from those obtained from ordinary cases of ophthalmia
neonatorum. Thus, among my 19 cases, gonococci
were present in 52 per cent., pneumococci in 10 per
cent., bacterium coli in 5 per cent., B. pyocyaneus in
5 per cent., and the results were negative in 26 per
cent. Thanks to the work of Kiihne, Haussmann,
and recently of Hellendahl (Beilrage tur Geburtshilfe
u. Gynak., Band X., Heft 2), there is now experimental
evidence to show that penetration of the intact amnion
by bacteria is possible. It is known that organisms,
especially the gonococcus, may lurk in the recesses of
the uterine mucosa, and it seems likely that they may
pass through the chorion and amnion, and thus reach
the liquor amnii, where they infect the conjunctival
sac during the last weeks of pregnancy—that is to
say, at a time when the eyelids are no longer closed,
as at an earlier period in foetal life. What is true
of the gonococcus is true also of the other micro¬
organisms found in association with ophthalmia
neonatorum. The bacteriological permeability of the
membranes once granted, organisms may reach the
uterine cavity either from the mother’s anus or from
the peritoneum vid the Fallopian tubes.

The etiological analogy of ante-partum ophthalmia
with the condition in which the liquor amnii is occa¬
sionally found to be brownish in colour, muddy in
consistence, and peculiarly offensive to the sense of

(«' A Clinic*! Lecture delivered July 19th, 1907. in the Poet-
Gradual e Course of Ophthalmology in the Unlrerelty of Oxford.

smell, is somewhat striking. The fluid in these cases
may be likened to an ordinary typhoid stool. Indeed,
the two conditions—ophthalmia and offensive liquor
amnii—have been known to co-exist, as in oases re¬
ported by Chavanne (Rev. Giniralt d'Ophtalmologie,
1X99, p. 70), and by Armaignac (Annales d'Oculistique,
1902, T. 128, p. 241). Dr. Handfield-Jones has recently
published (Journ. of Obslel. and Gyn of the British
Empire , April, 1907, p. 305) five of these cases observed
among 3,300 deliveries at the British Lying-In Hos¬
pital, London. In one case, examined bacteriologically,
the stinking liquor amnii was found to contain staphy¬
lococci and coliform bacilli. Handfield-Jones thinks
that if infection with the coliform bacillus occurred
after rupture of the membranes, then the putrefactive
changes must have supervened with preternatural
rapidity. In one of his cases, however, the amniotic
fluid was noted to be muddy and offensive at the
time the membranes ruptured.

The etiology of ante-partum ophthalmia has been
discussed at some length, because it forms an authentic
and comparatively simple instance of intra-uterine in¬
fection, and renders it more easy to understand what
may occur in other cases believed to be due to the
same cause, such as congenital adherent leucoma and
staphyloma, and dacryocystitis, and opacities of the
cornea, and the rare and curious conditions called
“ cryptophthalmia ” and “buphthalmia.”

Congenital Staphyloma. —This rare condition, of
which only about twenty cases have yet been pub¬
lished, is almost certainly due to perforation of the
foetal cornea, as the result of intra-uterine inflamma¬
tion. This view has been strongly urged in an im¬
portant communication on the subject by Mr. J. H.
Parsons (Trans. Ophthalmologieal Society, Vol. XXIV.,
I 9 ° 4 > P- 47 )» who bases his opinion to a large extent
upon the histological appearances presented by such
an eyeball removed from a child aged three days.
As Parsons points out, “All these cases of anterior
staphyloma show exactly the same features as those
found when the condition develops in the usual
manner after birth.” “A priori, therefore,” he con¬
tinues, “we should naturally be inclined to attribute
them to the same cause.” The considerations that
apply to congenital staphyloma apply equally to an
even rarer condition—namely, congenital leucoma
adherens —that is to say, a corneal cicatrix to the hinder
surface of which the iris is adherent.

Congenital Dacrocystitis. —Although, as explained
before, the essential cause of this condition is un¬
doubtedly of a developmental nature, yet when a
baby is born suffering from a suppurating or distended
lacrymal sac—from a lacrymal abscess, in fact—the
infection must have taken place prior to birth. The
organisms present in such cases are the pneumo¬
coccus, the bacillus coli, the common pyococci, and
the xerosis bacilli, of which all, with the possible
exception of the xerosis bacillus, have been found in the
genital tract of parturient and puerperal women. It is
probable that in these cases, as in many of congenital
ophthalmia, the micro-organisms gain access to the
epithelial dibris of the lacrymal passages by passing
through the unbroken foetal membranes, and that they
reach the cavity of the uterus either by ascending
from the pudenda or by descending by the Fallopian
tubes.

Congenital Opacities of the Cornea. —In rare cases a
child is born with a more or less cloudy cornea.
These cases must be carefully differentiated from these
of buphthalmia, or infantile glaucoma, concerning
which something will be said later. The main points
of distinction are—first, that the intra-ocular tension

CLINICAL LECTURE.

The Medical Pr ess. 357

Oct. 2 , 1907.

is raised in buphthalmia, and, secondly, that the
cornea in that disease is not only cloudy, but more
strongly curved and larger than normal. Congenital
opacities of the cornea may be total or partial, and
the opacity may be complete or incomplete. The

sclerophthalmia ” is applied to cases where there
«xists no sharp boundary line between the sclera and
the cornea, which ran almost imperceptibly into one
another. The “arcus juvenilis” of Wilde is a con¬
dition closely resembling the arcus senilis, but of con¬
genital origin. A good example of this condition has
been described by Mr. R. W. Doyne and myself in
the twenty-fourth volume of the Transactions of the
Ophthalmological Society (1904). It should be added
that many authorities still believe that corneal opaci¬
ties are the result, not of intra-uterine inflammation,
but of incomplete development. The fact that they
tend to clear after birth does not tell strongly in either
direction. Opacities due to injury at birth, so care¬
fully described by Drs. Ernest Thomson and Leslie
Buchanan, belong, of coarse, to quite a different
category.

Cryptophthalmia. —This exceedingly rare malforma¬
tion, of which about a dozen cases only have been
reported, is marked by the absence of eyelids, so that
the integument stretches uninterruptedly from the fore¬
head over the rudimentary eyeball to the cheek. Indi¬
cations of the palpebral fissure may be wholly absent,
or may manifest themselves by a horizontal furrow or
by an anus-like opening. The eyebrows may be
absent. The globe, which is always deformed, can
be felt under its cutaneous investment as a rounded
mass, varying in size from a pea to a cherry. The
rudimentary eyeball, however, has reacted to light in
some of the reported cases. Thus, in one of bilateral
cryptophthalmia recently published by Goldzieher
(Centralbl. f. prak. Augenheilkunde, Aug., 1903), twitch¬
ing was noticed when a strong ray of light was allowed
to fall on the bridge of skin which covered the eyes.
The condition is generally bilateral. Associated ocular
defects are the rule. Goldzieher (loco citato )
believes that intra-uterine inflammation must lie at the
root of the changes in the eyeball in cryptophthalmia,
inasmuch as no arrest of development could account
for the cicatricial tissue and adhesions that have been
found in these cases. He supposes that when the con¬
junctival sac is forming, say, before the third month
of foetal life, an ulcerative process destroys the super¬
ficial tissues of the eyeball, whereby a considerable
loss of substance ensues, which leads to adhesion
between the raw surfaces and the skin coveriig them.
In consequence of these adhesions, the formation of
the conjunctival sac ceases. Inasmuch as the cornea
has, so to speak, come to grief, the organs of the lid
fail to develop, such as tarsus, glands, and cilia.
Moreover, the embryological impetus to the separation
of the adherent lids is wanting. This view, according
to Goldzieher, fully explains not only the absence of
lids, but also the undifferentiated condition of the
skin-covering in cases of cryptophthalmia (for
abstract of Goldzieher’s important communication see
Ophthalmoscope, Vol. II., 1904, p. 135). On the other
hand, Van Duyse adopts the theory of amniotic adhe¬
sions to explain the production of cryptophthalmia.
Lastly, defective development has been invoked by
some authors as the cause of this rare malformation.

Buphthalmia , or Infantile Glaucoma. —The last but
by no means the least important condition to be
described is that curious and rare affection variously
known as buphthalmia, hydrophthalmia, megalo-
cornea, and infantile or congenital glaucoma. In a
pronounced case the appearances are so characteristic
?hat once seen they can never be forgotten. Thus,
one—or more commonly* both—eyeballs are much
larger than usual in babies, the corne® are generally
more or les 3 opaque (milky-looking), and obviously
globular, and the intra-ocular tension is notably
raised. The anterior chamber is deep, the iris and
the lens may be tremulous, and a glaucomatous ex¬
cavation of the optic disc may be found if ophthal¬
moscopic examination be possible. A degree of
photophobia is commonly present. The eyes, as a
rule, are myopic. In all the early cases I have myself
seen, more or less sight was present. But if the disease
cannot be checked by treatment, it is apt to entail

blindness. A few instances of spontaneous cure, how¬
ever, may be found in the literature. The progressive
enlargement of the eyeball may lead to the production
of rents, resembling supplementary pupils, in the iris,
as in one of my cases, to clefts in Descemet’s mem¬
brane, as in another, to dislocation of the crystalline
lens, and to intra-ocular haemorrhages.

With regard to the etiology of buphthalmia, there
exists considerable divergence of opinion. Everybody
agrees that enlargement of the affected eyeball is the
direct result of intra-ocular pressure acting upon parts
which are as yet extensile and yielding. It is further
admitted that the pathological feature cf these cases
is to be found in the existence of adhesions between
the periphery of the iris and of the cornea, which
impede the exit of fluid from the eye, and thereby lead
to heightened intra-ocular pressure (Cross). The point
at issue is with regard to the cause of these anterior
synechiae, for that is what they really are. In the year
1889 Horner expressed the view that they represented
developmental anomalies. It is held by Mr. E. T.
Collins (Norris and Oliver’s System of Diseases of the
Eye, 1897, Vol. I., p. 424) that they result from “a
failure in the separation of the anterior fibro-vascular
sheath from the back of the cornea.” It is clear that
such adhesions would prevent the passage of the intra¬
ocular fluids into the spaces of Fontana, and also
that as the eyeball enlarged, the adhesions might yield,
thus accounting for the cases of spontaneous cure of
buphthalmia. On the other hand, as I have pointed
out elsewhere ( British Journal of Children's Diseases,
1905), most of the cases of buphthalmia that have
come under my care have very obviously been the sub¬
jects of congenital syphilis. This observation has led
me to suggest that the synechiae, so far fr:>m being a
developmental anomaly, are attributable to an intra¬
uterine irido-cyclitis of specific origin. As a point
telling in favour of my view, I may say that I have
on several occasions seen cases yield to prolonged
treatment with mercury and chalk. The histological
appearances of buphthalmic eyes are, to my mind,
more characteristic of inflammation than of develop¬
mental defects. For example, th3 iris is fibrotic, and
the ciliary body often shows evidences of former in¬
flammation ; the peripheral parts of the cornea, besides
being attenuated, may be infiltrated with cells and per¬
meated by fine vessels. These changes, I admit, might
possibly be of secondary production, but I believe the
evidence points rather in the direction of their being
primary and the essential cause of infantile glaucoma.
In my experience, the fact that buphthalmia is seldom
associated with other anomalies, unless it be with
plexiform neuroma, tells in the same direction. Reis
(v. Graefe's Archiv fur Ophthalmologic, LX., Heft i.,
1005) and others have attached importance to the fact
that in these cases the canal of Schlemm is more or
less obstructed, if not actually absent, as a congenital
defect. Obliteration of the venous channels, how¬
ever, could come about as the result of anterior
synechiae, much as it is known to supervene in old
cases of glaucoma in the adult (Parsons).

Microphthalmia and Anophthalmia. —The two con¬
ditions of microphthalmia—that is, an abnormally
small eyeball—and anophthalmia—that is, an absence
of the eyeball—have been placed in a separate cate¬
gory because of the divergence of opinion as to their
causation among those most competent to express an
opinion. There are some, as Hess, who adopt the
developmental theory, and others, as Deutschmann,
who voice the inflammatory theory. It is sometimes
difficult or impossible to say where microphthalmia
ends and anophthalmia begins. We shall do well,
I think, to adopt the view enunciated by Messrs.
Collins and Parsons (Trans. Ophthalmological Society,
Vol. XXIII., 1903, p. 244), which is to the effect that
no case should be classed as one of anophthalmia if on
microscopical examination the least trace can be found
in the orbit of retina, optic nerve, or, indeed, of any
part of the nervous apparatus of the eye. All other
cases, no matter bow insignificant and functionally
useless the eyeball may be, are examples of micro¬
phthalmia. It is a little unfortunate, from a practical
point of view, that this scientific distinction between
the two conditions can be established with certainty
only by a more or less difficult microscopical investi¬
gation.

itized by G00gle

358 The Medical Press.

Of anophthalmia, as defined above, I have never seen
a case. When the defect does occur, which must be
very rarely, it seems always to be associated with
grave developmental deficiencies in the central nervous
system, such as absence of cranial nerves, of olfactory
lobes, of optic chiasm or tract, or of the external
geniculate body. On the other hand, microphthalmia ,
especially in its slighter forms, is tolerably common.
A difficulty in diagnosis can arise only in pronounced
cases. Under such circumstances the palpebral fissure
is unusually short, and no trace of an eyeball is to be
seen on superficial examination. At most, a gloDular
body, of hard consistence, perhaps no bigger than a
pea, is to be felt at the back of the orbit on deep
palpation through the upper eyelid. Such an examina¬
tion in the case of a young child is best made under
the influence of a general anaesthetic. Even then,
when the little finger is introduced into the con¬
junctival sac, it may be difficult to affirm the absence
of a rudimentary eyeball, owing to the smallness of
the palpebral aperture. In another and very interest¬
ing class of case, the apparent absence of eyeball is
associated with a fluctuating cyst in the lower or (much
more rarely) in the upper eyelid. Such cases are
spoken of as “microphthalmia with orbital cyst.” The
cystic growth is then by far the most prominent feature
of the case. It has been shown by Ewetzky, Lang,
Collins, and others that the cyst, in the walls of which
retinal elements can often be recognised with the
microscope, communicates with a rudimentary eyeball
at the back of the orbit by means of a tubular process,
also lined with retinal elements. In explanation of
this curious condition, it is supposed that the foetal
ocular cleft is closed by adventitious tissue, which
eventually bulges out into a cyst, one effect of which
is to retard seriously the proper development of the
eyeball. Into other theories of causation, such as
those which are associated with the names of Kundrat
and Ginsberg respectively, we need not enter here.

Conclusion.

In conclusion, let me say that I am painfully aware
of the shortcomings of this lecture, in which a few
only of the congenital anomalies of the eye and its
appendages have been described. Several other con¬
ditions of at least equal interest, such as albinism,
cataract, and anomalies of the fundus oculi, have
been omitted. For an account of these and of other
anomalies I feel I cannot do better than to refer you
to some of the larger text-books on the eye, among
which I would signal out for special mention Fuchs’
Ophthalmology and Parsons’ Pathology. For anomalies
of the fundus it is impossible to praise too highly
Frost’s Ophthalmoscopic Atlas (1896).

NOT *.—A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture for
next week will be by Robert Saundbu, M.D.Edin., Hon.
LL.D., Hon. M.Sc., F.R.C.P.Lond., Professor of Medicine
in the University, and Senior Physician to the General
Hospital, Birmingham. Subject: “ The Sphygmomano¬
meter in Medicine .”

ORIGINAL PAPERS.

“Res Medica, Res Publica.”

THE PROFESSION OF MEDICINE—
ITS FUTURE WORK AND WAGE, (*)

By WILLIAM EWART, M.D., Cantab, F.R.C.P.

Senior Physician to St. George's Hospital, and to the Belgrave
Hospital for Children.

The Profession and its Twentieth Century Crisis.

I may put to you briefly as general propositions the
views I have to express. Although the laity has much
to discover in this constellation of ours, we are being
a little better focussed and better understood. The
sign of the profession is in the ascendant, and every¬
thing points to its gravitating into the orbit of the

(a) An Inangnral Addrea* delivered .at St. George's Hospital on
October 1st, 1907.

Oct. 2 , 1907.

State. At the same time strange perturbations are
noticeable within it, and to these I have to call your
attention under the name of our twentieth century
crisis.

Looking back, there is no profession of greater
antiquity, yet none so truly young. The history of
humanity is our history, and its future our future.
Their joint record can be but beginning. Are we not
still fighting for dear life against deadly foes? Ages
ago it was the mammoth. Now the microbe only
remains ; but its days are numbered, and the era of
health with its peaceful developments is in sight. The
profession is only just cutting its back teeth, in the
weirdness of puberty.

Had a man stepped forth in ancient Greece or Rome
equal in wonders to the youngest of our qualified men
he would have been accounted a demigod. We have
thirty thousand such in the kingdom, and they pass
unnoticed, as a negligible quantity. But a body
controlling so much power cannot remain a cipher.
We need only look back little more than a century,
as the whole change has occurred in that time. Its
wage, its status, and alas! its routine, have remained
what they were. But a transformation has been
silently accomplished within it. It held the shadow
of knowledge; it now bolds the substance. It had
laboured long in hopeless efforts to be of use ; it now
waits upon humanity with the most brilliant service.
Yet it ingloriously remains “Cinderella,” the humble
maid of all work.

The Profession—What is it? What ought it to be?
What is it going to be? —The question has been asked
before ; but never with so much point or greater un¬
certainty. As the moulding of its future is to be
partly within your own hands, you must bear in mind
its attributes. The famous motto, Liberty, Equality,
Fraternity, which has proved elsewhere not at all a
good fit, would almost seem to have been borrowed
from us, for we truly own those characteristics.

Fraternity ranks first: the telling title of “confreres”
will identify us anywhere as members of the pro¬
fession. It implies our essential independence and
equality, and the absence of any hierarchy among us
beyond that of elder brotherhood ; and it also suggests
the reciprocity without which the profession cannot
subsist.

Freedom must ever remain our boast. But complete
independence from the State is no longer for us a
condition of existence as in darker ages. Independence
was then vital to the progress of science. Our need
is now no longer for the liberty but for the means of
research.

Equality and its Duties. —Our equality is not a mere
sentiment: it has its responsibilities. We are not so
narrow-minded as to be intolerant of superiority, or
anxious to level down the taller heads. We would
rather be illogical, and put up with inequalities such
as a Harvey, or a Laennec, or a Lister. But for the body
■ of the profession we stand for equality;—Equality in
education, equality in qualification, equality in
status, and equality in wage. Only this carries with
it serious obligations: henceforth but one set of
standards, the highest. Our equality is that of an
education which levels us all up, and of a qualifica¬
tion which confers upon us a high status; and there
should never be any falling back in respect of outward
dignity or of that within from that high level
reached during our fellow studentship, which our life’s
labour should only further raise.

Altruism. —But there is another attribute, quite
unique, which no one has ever been tempted to steal
from us. Call it a fault or call it a virtue, we must
agree to live with it because it is constitutional but
very awkward to bear and delicate to touch upon ; a
thing to be proud of like an honourable scar, yet
carefully concealed; and the disguise invented as a
veil is that puzzle of the laity—“professional etiquette.”
We cannot quarrel with our altruism, which is our
chief distinction. But as it is at the bottom of our
crisis, and as we cannot subsist on hard work and a
proud title, plain common sense must be brought to
bear.

The Crisis in its Two Aspects—Economical and
Professional.

We are in the throes of a double crisis: an

ORIGINAL PAPERS.

Digitized by LjOOQLe

Oct. 2, 1907.

ORIGINAL PAPERS.

The Medical Press. 359

economical crisis which affects a large majority of our
numbers, and a professional crisis which threatens
a previously compact profession in its corporate
capacity. The situation itself and its great
factors are entirely new. The earliest symptoms
were overlooked and subsequently misunderstood.
They were treated symptomatically without any refer¬
ence to their cause ; and the same symptomatic treat¬
ment runs risk of being repeated, as fresh symptoms
continue to break out in connection with the individual
and with the profession. As both crises have identical
and reciprocating causes no separate remedy can
exist for either, and any drastic measures would be
dangerous if one-sided.

Before we can attempt to legislate for the future we
must grasp the inevitably progressive nature of our
changes. The chief cause of the economic crisis is our
immensely growing success in reducing the prevalence
of disease. That which mainly constitutes our pro¬
fessional crisis is the unlimited growth of specialism
as the penalty of our progress:. we have got in some
way to fit it in, or we must fit in with it. The third,
which takes effect in both directions, is the headlong
change in the times, with which our old routine is
quite out of touch. But we also have to take a clear
view of the conditions as they now exist within the
profession itself.

The Present State of the Profession. —What is the
profession? And where is it? It is becoming increas¬
ingly difficult to be definite in speaking of the pro¬
fession as a whole ; and hardly any general remarks
can apply with equal point all round. Yet, as the
laity look upon us as a definite entity, we must shape
the argument upon their concrete view, and use the
word as a conventional formula for that which to us
is really a huge abstraction. What are the facts?

“Pure medicine” and “pure surgery” are both
dwindling by chronic cleavage. The great section of
“pure surgery” rejoices in exceptional activity and
in the absence of any grudge, whether from the body
of the profession or the public. Moreover, thanks to
the ever-increasing risks to life and limb from the
harnessing of the forces of nature, it will continue to
be in some request apart from the prevalence of disease.
But “pure medicine” is left as severely alone as
possible by both. In like manner most of "the surgical
sub-specialities are in work ; but the medical preserves
are shot over from every quarter without much regard
for any genuine title to the ground. It thus happens
that, though the long and gratuitous labour of research
is mainly borne by the medical section, they are not
as welcome as the quack to a meagre retribution for
its fruits: whilst the surgeons are allowed by a public
eager to be operated a fair acknowledgment for the
time and skill they more largely devote to practice.

There remains the vast body of general practitioners,
the bone and sinew of the profession, more homo¬
geneous through the pervading similarity of their
avocations, but more isolated by their exacting duties
from professional intercourse even in towns. But
within recent years a great and hopeful beginning has
been made, thanks to the energy of a select few in
their number, and to the devoted efforts of the officials
representing the British Medical Association through¬
out the Empire, which should end eventually in the
personal participation of all or of a large majority
in the organisation which has been elaborated for
them. Within that body the disparities are consider¬
able, the great changes which have been gradually
worked upon the profession having told unevenly in
the direction of increased labour, technical, pro¬
fessional, and charitable, and of diminished emolu¬
ment. But an adequate living wage is the exception ;
whilst the worst predicaments are too serious to be
further endured.

This complex and strained machine of our pro¬
fession needs expert handling to save it from being
wrecked. None of our specialities, even the most
scientific, can be taken as fair exponents of the require¬
ments of the whole. On the other hand, even a com¬
plete combination of all general practitioners could
hardly be expected to negotiate the affairs and fight
the battles of a profession in which specialism is
taking, in respect of remunerated practice, but
particularly of study and of discovery, so considerable

and increasing a part. Moreover, all groups alike
have had practically to resign the technicalities of
“research”—that latest and tallest of our branches
which alone can give our full height when it comes to
“sizing up” the profession.

Thus, whilst general practice offers the least of
limitations, we look in vain for “ the profession ” as
a concrete and complete working unit. Yet that unit
is not altogether a myth. I had almost left out our
better part, our students. In our fragmentation the
great bond of union remains for us our joint study of
man, and in this they are our living link. Perish the
thought of any “specialisations” within their curri¬
culum, which, when combined with an equally com¬
plete general education, alone now reflects the com¬
prehensive nature of that study, and is the only stage
at which there is any complete integration of the pro¬
fession and of its objects, without difference or dis¬
tinction between the workers.

The Professional Crisis. —The extensive field of
specialism must continue to grow. Does this read
practical dismemberment through divided interests,
and the end of our influence as a great fighting unit?
Is it with us “ Finis Polonia ” ? That prospect is
before us unless we can provide some timely
cementation, for the safety of the profession and of
specialism itself. Some of the risks of the latter are
obvious enough. They have not hitherto included
the struggle for existence, though this might easily
eventuate in some of them.

The Economic Crisis.—The field of general practice
has been for many years contracting, and is bound
further to contract. The doctors are too many, the
patients too few. In short, there are not enough cases
“to go round.” At the present accelerated rate of
prevention there will soon be little left of preventible
disease to attend. And no royalty can be raised on
the independent employment of any device of such
startling simplicity as the free use of water and
boracic powder to fresh wounds to prevent inflamma¬
tion, or “open air” in a tent with plenty of good food
for the treatment of consumption, for that is the kind
of ridiculus mus for which mountains of research had
laboured so long without any compensation.

The altered conditions of life must tell upon local
practice whether in town or countrv. Sentiment still
pleads for the devoted family practitioner. But these
days are “matter-of-fact”: and no man can in the
future regard the personal allegiance of those who
consult him as a reliable source of income. Never¬
theless, in the wealthy districts there must always
remain in spite of all drawbacks a fair opening for
local practitioners if only their number could be
limited.

Less precarious perhaps is the practitioner’s hold
on the humbler class of practice, particularly under
the provident system. But this has given rise to crying
abuses under which he is still the sufferer.

Owing to the increasing size of our great towns
entire districts are tenanted by a population little
removed from destitution, in the service of which his
ministrations, not less valuable, not less faithful, not
less honourable than elsewhere, lead neither to honour
nor to a compensation compatible with the dignity of
the profession. That is our sorrow.

What is the upshot? Let me quote from the
British Medical Journal for September 7th and
14th : —

“The average income of the British practitioner has
been variously estimated at ^200 to ^250 a year. . . .
The chances of being able to save even to the extent
of the return of the capital expended in education are
in a large proportion of cases slight; while reason¬
able provision for old age, after family expenses are
met, is difficult and too often impossible.” Is this
the wage of lifelong self-sacrifice and of the highest
skill?

The odium of so great a reproach has not been truly
our own; bnt we should make it ours were we to
fail to concentrate upon its cure the entire strength
of our united body, and for that purpose alone, if for
no other, we need a compact profession.

Thje Causes ok the Crisis.

To dispel any doubt as to the permanent character
of the changes it is enough to enumerate their causes.

Google

3 t >0 The Medical Press.

ORIGINAL PAPERS.

Oct. 2 , 1907.

The prime cause is the spread of that old tree of
knowledge of good and evil. The immediate causes
are its fruits, chiefly of 19th century growth. First on
the side of the laity:—

1. The vulgarisation of facts and fallacies by our
irresponsible Press.

a. The genuine growth of education, particularly in
science.

3. The resulting free thinking and liberty of con -
science in matters medical.

4. The independent individual inquiry for specialism
on the one hand: and on the other—

5. The recrudescence of the innate fascination for
home treatment —no longer with simples, but with com¬
pressed remedies.

6- The emancipation of the patient which sums up
these tendencies.

7. The reversion to Nomadism or a wandering life
—with all its good and all its evil—a taste fostered
by the enormous growth of rapid locomotion.

8 . Nomadic restlessness and instability, as it affects
the conditions of practice.

9. The decline of invalidism, as a result of “open
air ” and of an active life.

10. The promotion of health by the remarkable
spread of physical hygiene, particularly among
women.

11. The salutary influence of the growing modera¬
tion in the use of alcohol.

Much of all this is the harvest which we have sown.
Much more remains which can only be described as
the direct handiwork of the profession: —

1. The increasing knowledge of the nature of
disease ; of its treatment; and of its prevention.

2. The suppression of many decimating infectious
diseases.

3. The surgical cure of many intractable chronic
ailments;

4. The inevitable specialisation of the study of
disease;

5. The progressive growth of specialism in practice :
and

6. The attractions exercised by the success of
specialists, which tends to swell and overcrowd our
ranks.

All these are new facts in the history of the world.
C^n we pretend to arrest their progressive develop¬
ment? If not, is it likely that the new situation can
be met by anything short of a new departure on our
part?

The Harvard “Policy of Perfection.”

What is the forecast? Is our crisis the herald of
recovery—and not the beginning of a natural death
for want of anything more to cure? If any doubt
should exist we need only look where coming events
cast strong shadows before. Twelve months ago this
school was represented at Boston by your delegate, at
the inauguration of the new Harvard Medical College by
the illustrious President, C. W. Eliot; a climax to
similar achievements at New York, Baltimore, Chicago,
and other great cities in the United States, as well as
at the Universities of Toronto, Montreal, and Winni¬
peg in the Dominion of Canada. They all proclaim
what the New World thinks of the prospects of
medicine.

The new 0 Temple of Science ”—for no other word
could express its magnificence—stands as a sign of the
times and a symbol of a principle with which the
name of Harvard may deservedly be connected: “To
science the highest place in medicine; to medicine the
highest place in science.”

The Harvard policy of high standards , not less con¬
sistently pursued for the preliminary than for the pro¬
fessional education, bears witness that medicine is
still young, its advance only beginning, and its efficient
function marked out among the institutions of the
younger countries as of supreme concern to the com¬
munity. This will be more clearly seen as we inquire
into the public aspect of our calling and of our work.
The State and the Profession.

(a) The Value of the Profession in the State.

(1) The Conservative Function. —What is the profes¬
sion in the State? Not, as the Tiers Etat claimed to
be, “ Everything ”—the last of its conceivable errors
would be Socialism—but much more than is commonly

suspected. Above all conservative, and above all pro¬
gressive, its antiquity and stability are not merely orna¬
mental, but columns of support for our institutions.
Its conservatism, copied from the teachings of Nature,
spreads as a lesson which our time is least fitted to
supply. Our own unbalting progress is equally safe
from the spirit of reaction, and from that of revolu¬
tion. Even under mob rule we could feel secure;
for it is something to be so poor as not to invite
spoliation; it is much more to be so skilled as to be
indispensable. In reality we stand as the political
body whose fabric shows least signs of “rocking,”
and of which can confidently be said in sight of
impending changes, impavidam ferient.

(2) The Function of Progress. —No less precious than
this staying function is our perpetual youth with its
immense working power. When humanity shall have
passed through its era of disease our function of pro¬
gress will stand better revealed, in the promotion of
its highest physical, intellectual and moral develop¬
ment. Potentially it is so now, to the knowledge of
the better informed.

(3) The Educational Function. —Faust could not
have lived within the last 150 years, or he would not
have included medicine in his catalogue of barren
studies.

Our students and their labours are a wealth in the
State. Their arduous curriculum has often proved a
stepping stone to distinction in other careers. Its
wide and practical training is worth taking for its
own sake, apart from any idea of practice ; and it
may be begun quite early without any fear of eventual
waste of the labour bestowed in this direction. For the
community the educational value of the profession
will continue to rise with the growth of its higher
specialities of research.

(4) The Advisory Function. —There are few questions
relating to the welfare of the race, besides the social
question itself, in which its deliberate opinion would
not be the most important of all opinions to ascertain.
There is none within its immediate competence greater
than that of national education. Where else can be
found the expert knowledge of cerebral physiology
and pathology to adjust the increasing intellectual
burden to the growth of the physical capabilities of
the child? A service hitherto uninvited, which the
profession will in the future be required to render to
the State.

(5) The Political Function. —For the exercise of this
function it has no longing. Intolerant only of error,
it can never surrender its conscience to party, and
must remain above the arena. But in any future
political redistribution its integrity of purpose and
disinterested benevolence may count; and duties will
attach to the power which it owes to knowledge and
to highly trained aptitudes. Its legislative fitness is
displayed in the important growing sphere of medical
politics. Lastly, the contingent of able and highly
educated women which has of late years joined its
ranks is an accession of consultative efficiency, as this
completes its practical representation of the entire
interests of humanity, man, woman, and child.

(b) The Value Contributed to the State.

(1) Do ut des. —In all ages the profession had con¬
tributed service for which it had earned various
recognition, as priests of Hygieia at Cos, and as Greek
slaves at Rome. But never before Jenner had it con¬
tributed actual value. The fact is startling, yet true,
that whilst there is no profession but this handing to
the State immense treasure year by year, if this be
merely computed as wage earning value on the human
life saved, all other professions have State subvention,
establishment or endowment, to say nothing of other
rewards that fall to their lot. Alone, the profession
of medicine, the all-giving, is not assisted, not even
with the education for the supply of that wealth.

In India, 5,000,000 of our fellow subjects have
perished of the plague in the last seven years, in spite
of the labour lavished by our profession upon the
study of its treatment and prevention. The day will
come when we shall succeed in abolishing forever that
ghastly toll. What reward will this profession receive
for the labour of its sons?

In the light of past experience shall we call it
again “nothing,” as in the other big transactions

Oct, a, 1907.

ORIGINAL PAPERS.

The Medical Press.

beaded smallpox, typhus and cholera, diphtheria and
phthisis, and tropical malaria? “Nothing,” not even
the out-of-pocket expenses for the means of research.
The profession labours and gives; the State takes—
where is the “ do ui des ”?

Again, the incalculable value of the disablement from
work now largely saved by preventive hygiene is an
unacknowledged gift, not of any surplus of wealth,
but of the actual means of livelihood of the giver.

But this is not all. Preventive pathology is
becoming a definite speciality; and the profession will
consist soon of two uneven sections, that of “ practice ”
and that of “research.” The latter works for the gain
of the State and against that of the profession. To
suggest that its support should be charged to the pro¬
fession would be neither common sense nor common
justice. As a branch of national defence it contri¬
butes immense value, and has a higher claim to
national subvention than the King’s forces, which con¬
tribute nothing and cost so much. All this makes up
a heavy debt, with but meagre instalments on the
ether side of the account.

(2) The Nation's Vicarious Charity. —Not less
gigantic is the contribution received by the State from
the great branch of practice, in the shape of un¬
requited or ill-requited service to the community.
The “ Nation’s almoners ” is the only title which could
express the mission of many of our number in the
poorer districts. If anything could be more pathetic
than the rags of the apothecary in Romeo and Juliet
it is that quiet devotion of the surgeon of twentieth
century attainments, as he toils under his heavy
burden either totally unpaid, or at a wage not present¬
able. Innocent of causing the poverty which he at¬
tends, a heavy toll of overwork with underpay is
systematically levied upon him, which, strange to
say, does not relieve him of the poor-tax or of calls
for the support of many charities.

Our profession never did admit, and the State never
dare admit,- that there should be any distinction
between the treatment of the poor and the treatment
of the rich. Justice then would claim not less but better
pay for the appalling labour of ministering to the
poor. It was Locock, so says tradition, who replied
to the august visitor who summoned him to the bed¬
side of the great Queen, “ Her Majesty shall be treated
as well as the most humble of her subjects.” That
great lesson has passed unheeded. The humblest have
continued to be treated as queens, but for what
honorarium! From the purely moral standpoint of
“virtue its own reward ” a double wage might be said
to have been won, as humility and self-humiliation
have been as conspicuous as charity. But these are
virtues for individuals to practise apart from their
profession. Upon the profession itself their exercise
is deleterious and demoralising.

The State which ignores sentiment or pure charity
as motives has to answer for the health of the masses ;
it cannot escape from that law. As regards the pauper
class, the liability has been acknowledged; and for
that section of its health insurance the public pays
the whole because the pauper can pay nothing ; but
for the vaster insurance of millions who can afford
only totally inadequate compensation it pays nothing
at all. An immense burden belonging to the State is
shifted on to the shoulders of its hard-ground
almoners. But no record is kept of the transfer, nor
any voucher given to show that business has been
transacted for the State.

For the unofficial press the whole transaction goes
under the simple heading, “Charity and Charitable
\Vork.” From society more of contempt is earned
than of pity bv the toiler of the slums. It is not
perceived that charity is being done for the Nation—
vicarious charity —and therefore done unto the Nation
itself.

(c) The Duty of the State.

Sanitas Sanitatum et Omnia Sanitas.

The profession have hardly realised, much less the 1
laity, that, with the acknowledgment by statesmen i
that the health of the people is the primary care of
the State, a turning point was reached. That
principle places the profession in an entirely different
position, as on examination a great deal of its work
is work done for the State ; and it is inevitable that the I

profession should become more and more its servant.
As the organisation of the public health service has
brought the new principle into operation, the system
cannot remain limited, but must ultimately reach its
normal development. This involves definite con¬
sequences—under the general headings of the duties
of the State, and of the rights of the profession. The
functions of the latter, its status, and its pay must
tend to be regarded more and more as matters of
public utility.

It is manifest then that the quality of our pro¬
fessional work is not a matter of indifference to the
State which absorbs it so freely. Good work is said
never to be wasted—a comforting view, as the less our
labours have profited us, the more certainly must they
have been of some use elsewhere—but, as it is bad
economy to spoil the quality of good work by breaking
the spirit of the worker, our legitimate requirements
are not foreign to public utility. They will be
appreciably furthered by the fulfilment of the duties
to which the State is pledged by its own policy: —
(1) The organisation of the prevention of disease and
of the cultivation of health; and (2) the organisation
of research for both those objects. The nature of the
measures required is not open to question : a State
examination to ensure the highest efficiency; and a
ministry of public health to undertake vast responsi¬
bilities too long officially ignored.

Our Remedies and Practical Ideals.

Quality versus Quantity .—Relief cannot be obtained
from any source immediately, but would come with
least delay and with coupled honour and efficiency
from restricting our numbers by adding to the labour
of our apprenticeship, and to the quality of our work.
These are not features of trade unionism—a policy
with which we have little in common. They are prin¬
ciples of duty and of progress, and practical appli¬
cations of the rules of political economy, for the
profit of the employer as well as the employed.

The problem of the attendance on the poorer classes
and of its proper remuneration is difficult. But why
should it be insolvable, with the co-operation of our
employers and of the State? In this matter the word
impossible should have no application, for of all un¬
practical suggestions, the worst were to submit to a
continuance of the present plight of a noble profession.

Our Future Work and Wage.

I believe that in fairy tales the fairy rarely gets
any thanks. For the fairy “Medicine” the chief
thanks has been the request for further wonders—a
business-like view of our raison d’etre , and of the
value as an insurance of any support given to the
profession, which only calls for the comment that the
increased labours in prevention which are demanded
must further victimise us. President Eliot eloquently
urges all medical schools “to supply the twentieth
century physician who shall prevent the access of
epidemics, limit them when they arrive, defend society
against bad food and drink, and reduce to their
lowest term the manifold evils which result from the
congestion of population.” But these utilitarian
claims will extend far beyond the safeguards against
mortal disease and economic losses incidental to
sickness. There are other needs, less familiar to lay
thinkers, and consciously reasoned out only by a
minority of the profession, but voiced by the logic of
facts. In addition to “the teaching” and “the study”
of prevention, guidance will be needed in wider fields
for the cultivation of health. The State looks to us
for the supply of a vigorous as well as sound race of
workers and warriors. But there remains another
great department, that of the mind. We are still
struggling with the elementary stage of the cure of
mental disease; and the study of its prevention is
hardly begun. But the cultivation of mental health,
with all its physical, intellectual, moral, social and
political consequences, is a vast duty for our future
occupation. Who else can undertake it?

The unhallowed perpetuation of sinister heredities,
and other elementary failures in eugenics, call for a
remedy. Wider still is the task of strengthening men¬
tal and moral health in the growing generation by a
judicious interaction of the physical and of the mental
factors ; and of encouraging among adults that physio-

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362 The Medical Press. ORI GINAL PAPERS.

Oct, a, 1907

logical rectitude without which there can be neither
longevity for the individual nor increase for the race.
In all these directions there is ample scope for the
study, the teaching, and the individual service of the
profession, but for the success of its ministrations it
will need the support of the State.

The future earning power of the profession is not
easy to estimate, but we may infer that as emoluments
for private services decrease, there will be a slight
tendency towards an increase in remunerated public
work.

We have seen our busiest days in the treatment of
Disease, henceforth our livelihood must be increas¬
ingly derived from the Care and Culture of Health.
The greater part of that remuneration must ultimately
be derived from the State. The long delayed medical
inspection at schools is a first instalment in that
direction ; but much larger work should follow, which
would employ larger numbers. The registration of
each individual health, with a view to prevention, is
not a Utopian view, but a measure suggested by
common sense. Each growing leaf in tobacco planta¬
tions is registered and watched. Our own Excise
appoints a special officer to watch the still. We shall
not succeed in stamping out tuberculosis until a
health watch is kept over each life, that by timely
treatment it may be made germ proof. The highest
skill is essential for this class of work, and will call
for adequate remuneration. Personal certificates of
health could be paid for by the smallest number of
taxpayers. For the majority, any difference unpaid
by the individual would be charged to the public
funds. What applies to certificates would a fortiori
apply to the attendance on actual disease, which could
no longer be charged as a private tax on the
practitioner.

Conclusions.

This imperfect sketch can only suggest outlines, not
any of the details: —

(1) As a profession we can advise and we can act:
but the business of health is of the State. State
organisation and subvention for increasing labours
undertaken in its service are unavoidable, even at the
cost of public treasure, and for us of a nominal loss
of independence.

(2) A ministry of public health and a State examina¬
tion are the definite steps for immediate contemplation.

(3) Our practical policy is to be “prepared for any
fate ” by an unlimited adaptability for the coming
changes, of which we only know that they will exceed
the record of the past. And this means raising the
preliminary educational standard to its highest pitch,
which can never be too high for the possibilities
ahead. This is also our only plank of safety from
the dangers of over-crowding and of disorganisation.

(4) Indispensable to teachers and to rulers, our co¬
operation should be worthy to command its own terms.

(5) The fundamental reform in the status and
remuneration of the profession demanded by its vast
labours and service can only be won by high standards
of self-improvement, and by the combined efforts of
the highest and most influential with the rank and file.

(6) The details of reorganisation are beyond the wit
of individual man, but would evolve from the opera¬
tion of the four principles which are essential:—(1)
Exclusion from our portals of any but the highest
preliminary educations; (2) uniformity of the pro¬
fessional State qualification ; (3) recognition of the
equality in claim to adequate remuneration ; and (4)
assumption by the State of those responsibilities which
are not ours but of the State.

Our future wage should not fall sort of that com¬
petency which allows scope for the best work. Wealth
it never will be. As of old it must remain largely a
consciousness of doing our best as healers and helpers,
as students and teachers, and as a moral and
intellectual elite ; with the added satisfaction of
belonging to a profession not only honourable but
honoured.

Dr. Peter Fraser, medical offioer of health for the
Carnarvonshire Joint Sanitary Authority, is surrender¬
ing his post in order to take up the position of
a medical missionary in India.

THE GOVERNMENT'S SCHEME TO
PROMOTE THE UNQUALIFIED
PRACTICE OF MEDICINE.

By J. C. McWALTER, M.A., D.P.H., M.D.Brux.,
F.F.P. and S.Glas.

Of the King's Inn, Bnrrlster-at-Law.

Let us clear our minds from cant. What is
the genesis of this Notification of Births Bill? and
what must be its effects—on the population and
on the practitioner?

To start with, we must remember that it is not
merely futile to discuss the matter even now, for,
although the Bill has passed, the Act is an adop¬
tive one, and if strong objection can be shown to
its effects, it simply will not meet with any large
measure of acceptance by local authorities.

Huddersfield is a very progressive town, with a
population under 100,000. It was blessed with a
most intelligent and philanthropic mayor, Mr.
Broadbent, and a most active and forceful Medical
Officer of Health, Dr. Moore. They devised a plan
whereby prizes were offered to mothers who kept
their offspring alive to a certain age, and who noti¬
fied the authorities immediately of the occurrence
of a birth. On this notification nurses were sent
to instruct the mothers in the care of the infant*.
&c. Apparently, as a result of these efforts, the
infantile death-rate in Huddersfield went down
greatly—although in 1906 it seems to have been
only about 7 per cent, below the average, and
Mayor Broaabent and Dr. Moore naturally rejoiced,
and proclaimed in every congress and from every
hill-top their success. So thoroughly did they suc¬
ceed in influencing the public mind to believe that
they had discovered an important weapon in deal¬
ing with infant mortality, that a Bill has been
brought in and passed by the Government requir¬
ing doctors, under pain of a penalty, to give early
notification of births.

I happen to have got myself into considerable
trouble by questioning the wisdom of the Hudders¬
field scheme, but I am still unconverted, and do not
think it wise that ill-digested legislation, based,
practically, on a few ill-considered instances, should
be thrust on the whole country. I contend that the
effect of the Notification of Births Bill is to open
wide the door for the unqualified practice of an
important department of medicine by midwives or
by persons of still less skill.

If Huddersfield is to be set before us as the
Great Example of municipal righteousness in the
production of a healthy population, and if laws,
based on its example, are to be thrust down our
throats, it cannot complain if we examine its claims
to excellence more closely.

Obviously, it is idle to consider the death-rate of
a small section of the population. You must look
on the whole to gain any idea of the facts. The
last statistics of Huddersfield show, I believe, a
birth-rate of 22, and a death-rate of 19. It
is a fundamental principle of vital statistics that an
infantile death-rate is only an indication of im¬
portance as to the health of a locality when it is
compared with the infantile birth-rate. Now, 19 is
rather a small death-rate; it seems to compare very
favourabjy with Dublin, where it is 25. But the
Dublin birth-rate is 33, and hence the population of
Dublin continues to increase two and a half times
as quickly as that of Huddersfield. That is, under
Dublin conditions—such as they are—the number
of persons who survive to the service of the State
is two and a half times as great as in Huddersfield.

These questions can only be studied profitably
when we examine millions of examples. We have
them in France. Practically every point of im¬
portance in the Huddersfield system is copied from
French methods—but the population of France was

Du

Oct. 2. loo?. ORIGINAL PAPERS. The Medical Press. 363

forty millions thirty years ago, and is practically
the same to-day.

I submit, therefore, that Huddersfield is a very
bad, in fact, a fatal, model by which to regulate
the families of the nation. Of course, I know that
Mayor Broadbent and Dr. Moore would both insist
that they were only anxious to check an apparent
wastage in infant life, and had not the slightest
desire to see the number of births checked. But
1 would point out, whilst giving them ample credit
and praise for their endeavours, that we are bound
to examine the facts as they work out—with all
their attendant circumstances. If, therefore, we find
that the difference between the actual birth-rate
and total death-rate in Huddersfield is so small that
it would mean ruin to the nation if the same
figures prevailed in every other town, I submit
that Huddersfield is not an example to be followed,
or to be made the groundwork for general legis¬
lation.

I am open to conviction and correction on this
point, but I believe that in every place—or certainly
in the vast majority of places—where there is a
low infantile death-rate, there is also a low in¬
fantile birth-rate. The question for us, as scien¬
tific men, to decide is, whether it is post hoc or
propter hoc. The question is not only of the
greatest importance to the British Empire, but
also to the whole white race. If all white peoples
continued to increase in numbers only at the Hud¬
dersfield rate, in thirty years’ time the Japanese,
with their high birth-rate, would overrun the
world. Moreover, it is abundantly proved that
where the infantile death-rate is kept small, a vastly
larger proportion die in the third, fourth, fifth,
and sixth years of life, and a vastly larger pro¬
portion of the survivors are afflicted with some
bodily or mental defect and become burdens to
society.

But what is the early notification of births for?
It is to send an unqualified person to occupy the
place of the doctor in superintending the care of
the mother and child. She directs all that per¬
tains to the hygiene of the child—its food, cloth¬
ing, air-space, time of outing, and even,' detail of
its life. Now, the sanitary inspector charged with
these duties—this illegal medical practice—may,
in a sense, never have seen a child before; she
need never have been in a hospital, or seen a case
of contagious disease; she simply holds the certi¬
ficate of a sanitary inspector. Nothing is more
certain than that the major part of her work will be
to diagnose infantile ailments, and to prescribe for
measles, scarlet fever, gastric or bronchial troubles,
meningitis, &c. Of course, she will be ordered to
do no such thing by the sanitary authorities, but
from the nature of her avocations she will be con¬
sulted constantly about these things. The effect,
therefore, of the Notification of Births Act, where
adopted, will be to create a trade of unqualified
practitioners. I happened to glance at the pro¬
ceedings of the General Medical Council for 1898,
and I find a practitioner, of unblemished reputa¬
tion, haled before the Council to answer a charge
—of what?—that, having a case of confinement
under his care, he sent a woman to attend it
during the interval between two visits! And we,
at the public charge, propose to send out ignorant
women to attend mothers and their babes, and to
give instruction as to their care, where no doctor
may see the child first or last.

The essential object, then, of the Notification of
Births Act, is to send an unqualified person to
direct the care of an infant, and at the public
cost; though if a practitioner should do the same
thing with his private patients, and with the most
ssfeilful nurse under his own observation, he would
be struck off the register for it.

A WORD FOR TRYPSIN.

By A. K. MATTHEWS, M.R.C.S., L.R.C.P.

The utter powerlessness of medicine or surgery
to relieve patients is frequently experienced by
medical men, but never more poignantly than in
the last stages of cancer. One therefore welcomes
any success in this almost hopeless warfare, and
it is with much pleasure I quote my experience
of trypsin in a case of inoperable cancer of the
tongue.

Briefly, the notes of the case are the follow¬
ing :—T.H., a boatman, aet. £8, no family history
of cancer no history of syphilis, and urine normal.
When I first saw him he was suffering from large
fungoid ulceration of the left side of the tongue,
which had been slowly extending for seven or
eight months. The tongue on the side of the
growth was fixed, causing difficulty in speech and
deglutition, and he was unable to take solid food.
The salivation was excessive, and the haemorrhage
on three occasions severe, the loss each time being
three or four pints. The submaxillary and cer¬
vical glands were greatly enlarged, causing stiff
neck, and the pain in the growth and the glands
was at times very severe.

There can be no doubt about the diagnosis, as
he had been sent to Guv’s Hospital, where he was
advised that the case was too far gone for opera¬
tion. Considering the extent of the disease, it
was almost without hope that I recommended the
trypsin treatment, and before commencing the in¬
jections I told T.H. they might give him con¬
siderable pain and not much benefit. He, how¬
ever, welcomed any chance of relief, and I began
the hypodermic injections of inj. tryp. co. (Allen
and Hanbury), and liq. tryp. co. by the mouth.

Without exaggeration, I can describe the result
as marvellous. After three daily injections (15
min.) he expressed himself as feeling “ twice the
man,” his tongue was freer, and I could under¬
stand all he said. After a week’s daily injections
I increased the dose to 30 min., using it every
other day with liq. tryp. co. t.d.s. He continued
to improve rapidly. The glands entirely disap¬
peared, the growth was reduced to half its size,
no further pain, salivation greatly reduced, no re¬
currence of haemorrhage, and speech and degluti¬
tion markedly improved. The effect constitu¬
tionally may be summed up in the man’s own
words : “ I feel a different man altogether,” and
he began to look forward hopefully to tackle his
work again.

I continued the treatment for a little over two
months, always injecting the left buttock or flank.
He experienced no pain, nor was there ever any
sign of inflammation—in fact, nothing but the best
results.

I left the case in the hands of another medical
man (I was at the time doing locum whilst the
practice was passing from one medical man to
another), and I regret that my successor w had no
faith in trypsin.” The treatment was discontinued,
and the man died six months afterwards.

Dr. H. writes to me that he saw no indication
to continue trypsin, as there was “ no pain or
haemorrhage,” and death was due to exhaustion.
Dr. H., however, includes a very important state¬
ment in his letter, in which he says : “ I have now
a case of pyloric cancer, and am going to give
trypsin a good trial." Verb. sap.

The first meeting of the Obstetrical and Gynaecolo¬
gical Section of the Royal Society of Medicine will
be held on October 10th at 7.45 p.m. Professor W. E.
Dixon and Dr. F. E. Taylor will Tead a paper on
“The Physiological Action of the Placenta.”

Digitized by boogie

Oct, a, iqoy.

364 The Medical Press. _OPERATING THEATRES.

THE OUT-PATIENTS’ ROOM.

CHILDREN’S HOSPITAL, PADDINGTON GREEN.

Habitual Dislocation of the Thumb.

By Arthur Edmunds, M.S., F.R.C.S.

Among the patients was a boy, »t. six, who had
fallen down when a year and eight months old, and
dislocated the terminal phalanx of the right thumb.
Ever since the accident the thumb had been continually
liable to a repetition of the dislocation, althoxwh at
the time it was reduced in the usual way and efficient
suitable after-treatment adopted. On examination one
found that the terminal phalanx was acutely flexed
upon the next bone with a marked rotation, so that
its palmar surface looked almost directly backwards.
There was very considerable impairment of the useful¬
ness of the hand as the thumb was kept flexed into
the palm. The dislocation could be reduced quite
readily, and indeed the boy was able to do this for
himself, but after reduction the slightest attempt at
flexion of the joint reproduced the deformity. A
skiagram was taken which showed that the end of the
proximal phalanx was smaller and more pointed than
normal, and it seemed reasonable to assume that this
was the cause of the recurring deformity. In view of
the extreme disability it was necessary to perfofth
some operation which would render the joint more
stable, or at least so stiffen the junction between the
two bones that the thumb could be used. Habitual
dislocations are by no means uncommon, and they
are usually due to disproportion in the articulating
surfaces of the bones which form the joint; as a
secondary result of this, the ligaments which form the
joint’s capsule are often extremely lax. The
strength of a joint depends upon two factors, in the
hip joint, for example, the articulating surfaces are
extensive and accurately fitting, so that dislocation is
prevented even if the capsule were a little lax, in
other cases, for example, the knee joint, although the
articular surfaces are not very accurately opposed to
each other, yet the ligaments and muscular structures
which surround the joint combine to form one of the
firmest articulations in the body. In the present case
the deformity was, as Mr. Edmunds pointed out, due to
the deformed condition of the proximal phalanx,
which was pulled out of position by the tendons of
the long flexor which are inserted into the base of the
terminal phalanx. In order to rectify the condition
it was obvious that the pointed end of the proximal
phalanx must be removed with a liberal amount of
the shaft of the bone so as to give an increased surface
to articulate with the terminal phalanx. Fortunately
so far as muscular insertions are concerned this piece
of bone is unimportant, and the bone increases in
length almost entirely from the other end. An incision
of about an inch was made along the inner border of
the thumb, the structures around the head of the bone
separated from it until the last half inch was satis¬
factorily exposed, this was then removed with cutting
forceps, and the wound sutured and dressed. As
regards the ultimate success of the operation,
Mr. Edmunds remarked, it is, of course, im¬
possible to say, but there was no tendency
for the terminal phalanx to fall into its previous
faulty position, and there was no tendency to flexion
of the thumb into the palm of the hand, so that it is
probable that after the stiffness which is fairly certain
to follow has worn off an excellent result will be
ultimately obtained.

OPERATING THEATRES.

ROYAL FREE HOSPITAL
Pirogoff’s Amputation.—Mr. Wii.lmott Evans
operated on a man, aet. about 60, who had been
admitted for gangrene of the foot. About a month
before, after a slight injury, several of the toes had
become black with complete loss of sensation. After
a longer or shorter time the toes had sloughed away,

leaving exposed the four outer metatarsal bones, while
of the great toe a portion of the proximal phalanx
still remained. No extension of gangrene occurred,
though the patient was kept under observation for
several days. His general health seemed good; the
arteries were not much hardened. Pulsation could be
felt in the popliteal and slightly in the anterior tibial
at the bend of the ankle. Some slight pulsation was
palpable in the posterior tibial behind the internal
malleolus. It was decided to remove the foot. The
exposed bones were carefully covered with a dressing
so as to lessen the chances of infecting the operation
wound. The skin around the ankle having been
cleansed, Mr. Evans entered a Syme’s amputation
knife at the tip of the external malleolus and carried
it downwards and forwards at an angle of about 6o°
to the sole of the foot; it was then carried straight
across the sole and then upwards and backwards to a
point on the inner side about three-quarters of an inch
below and behind the tip of the internal malleolus;
this incision was deepened down to the bone. A
straight cut was then made across the front of the
ankle joining the extremities of the original incision.
This was deepened, all structures being cut through
until, the anterior ligament of the ankle being divided,
the joint was opened. During this incision the
anterior tibial vessels were divided, they were seized
with Spencer Wells’ forceps, though they bled but
slightly. The bleeding also from the plantar incision
was but slight and easily controlled. With the point
of the knife the lateral ligaments of the ankle joint
were divided. The foot was fully extended, and the
posterior ligament was cut through and the tendo
Achillis exposed. A saw was then introduced behind
the astragalus and the os calcis was sawn downwards
and forwards in the plane of the original incision and
the foot removed. The skin and structures around
the malleoli were carefully turned upwards for about
an inch and a half; the tibia and fibula were then
sawn from before backwards and slightly upwards,
the plane of section forming an angle of about twenty
degrees with the horizontal, the whole of the articular
surface of the joint being removed. All discoverable
blood vessels were tied whether bleeding or not, and
the remains of the os calcis with the heel flap turned
up so as to meet the sawn surfaces of the tibia and
fibula. A silk stitch was then introduced uniting the
periosteum of the tibia to the periosteum of the
calcaneum. Skin sutures were put in, no drainage
being employed. A light dressing of sterilised gauze
was put on and very loosely bandaged. The patient
was put back to bed with the leg lying on a pillow and
gently held in place by sandbags, no splint being
employed. Mr. Evans said this case was one of senile
gangrene, and even at the present time there is con¬
siderable divergence of opinion as to the best treat¬
ment to be followed ; in his own opinion the treat¬
ment may have to vary very much according to the
individual case. The chief difference in treatment is
as to the site of amputation ; some surgeons are in
favour of amputation limited to the affected part,
while others urge that if amputation be done low
down in these cases recurrence of gangrene is almost
certain because of the thrombosed condition of the
anterior and posterior tibial arteries. Therefore, they
advise an amputation high up, say, the lower third
of the thigh, as much more likely to be followed by
recovery. There is certainly in these cases, Mr. Evans
pointed out, a very great tendency to recurrence of
gangrene after amputation, but the thrombosis of the
vessels is not the only factor in the production of this
gangrene; sepsis is almost equally important, and if
sepsis can be avoided the risk of the recurrence of
gangrene is much diminished. The chief points in
determining the site of amputation to be adopted in
senile gangrene are, he considered, the following:—

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Oct, a, 1907.

CORRESPONDENCE.

The Medical Press. 3^5

(1) The state of the vessels: if all the arteries supply¬
ing the foot are completely thrombosed the chance of
a satisfactory result of an amputation low down is
small, but if even one of the tibial arteries can be
felt pulsating that in itself is in favour of the lower
operation; (2) the character of the progress of the
gangrene: if it stops completely and shows no
tendency to reappear higher up, the less the risk of the
lower operation, but if it is spreading, however
slowly, there is always a large element of risk in any
amputation low down. In this patient there was no
evidence of any immediate extension of the gangrene,
and there was definite pulsation in, at least, one of
the tibial arteries; therefore he thought it justifiable
to limit himself to amputation of the foot. When that
decision was arrived at the question arose as to what
amputation should be done: from the extent of the
tissues already destroyed it was obvious that only two
alternatives were possible: Syme’s amputation or
Pirogoff’s. In deciding between these two operations
we had, he said, to take into account the reason of
the amputation, the condition of the patient, and the
nature of the stump produced. For cases of disease
of the bones of the foot such as tuberculosis there
could be no doubt that Syme’s operation was prefer¬
able, but when the cause is traumatic or strictly
limited to the anterior part of the foot Pirogoff's
method is the better. As to the condition of the
patient the heel flap in the Pirogoff is much less likely to
slough than the heel flap in the Syme, for the latter
flap cannot but be more damaged in being formed.
In a case like the present where the vitality of the heel
flap was gravely compromised by the condition of the
arteries the small amount of disturbance of the tissues
in the Pirogoff operation was a decided gain. The
value of the stump produced depended, in his opinion,
greatly on the manner in which the operation was
performed ; when, as in Pirogoff’s original operation,
the os calcis is sawn vertically and the tibia and fibula
are sawn horizontally, the treading part of the stump
is formed by the soft skin just behind the ankle since
the heel flap has to be rotated through 90°; such a
stump is not well adapted for walking; this objection
can be entirely done away with if the os calcis is sawn
downwards and forwards and the leg bones backwards
and upwards, for the rotation required of the heel flap
is then only about 20 0 or 30 0 . A well-made Pirogoff
stump is admirably adapted for bearing pressure, and
he had known of a case of a double Pirogoff in which
the patient could nm freely on his bare stumps. It
would have been noticed, he pointed out, that no
tourniquet was employed. This was done intentionally,
for he felt sure that a tourniquet favoured thrombosis
and so prejudiced the vitality of the stump; and in
these cases no tourniquet was needed, for the
haemorrhage was always easily controlled It had been
seen in this case how very little blood was lost.
Another point of importance was, he considered, the
advisability of bandaging the stump as lightly as
possible; just sufficient dressing was employed and a
few turns of a bandage to hold it in position. It was
hardly necessary to point out the intense importance
of asepsis in dealing with tissues whose vitality was
already greatly lowered. One other matter he might
mention; it is always advisable to stitch the piece of
os calcis to the tibia, either with silk or wire. In the
present case he was content to stitch the periosteum
as less likely to do harm.

The further progress of the case was satisfactory.
Except for a little moisture at one portion of the skin
wound the healing was by first intention ; the skin
stitches were removed at the end of a week ; the wound
was soundly healed in three weeks from the date of
operation.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Parts. Sept. 29th, ip®7.

Drainage in Gynaecology.

The history of drainage of the abdominal cavity
does not go beyond 1850, says Prof. Pozzi.

Peasley, in 1855, was the first to have recourse to
drainage of the abdominal cavity in every case where
he feared the exudation of a liquid (pus, blood, etc.)
into the abdomen, by placing in the vagina an elastic
catheter, which penetrated in to the cul de sac of
Douglas.

In 1867 Kceberle recommended the drainage of the
abdomen directly through the wound by means of a
glass perforated wound ; this practice was adopted
with slight modifications by Spencer Wells, Keilt, etc.

Later, in 1872, the eminent gynaecologist, Sims, pro¬
posed draining systematically all cases of laparotomy,
on the grounds that the death of every patient after
the operation of laparotomy was due to septicaemia
and that exudation was found in the abdomen at the
autopsy.

The ideas of Sims were adopted by Nussbaum
(1874) and Olshausen (1876).

In order to have a correct idea of the utility of
drainage, it is necessary to understand the function of
the peritoneum, in normal and pathological conditions.

In the healthy state, the peritoneum absorbs easily
liquids of slight density (water, semen, blood).

Wagner demonstrated in 1876 that the serous mem¬
brane could absorb from two to six quarts of salt
liquid in the twenty-four hours, and that a relatively
large quantity of infectious substances could be
eliminated by the peritoneum or encapsulated by
means of exudations, without danger to the patient.
But for this the membrane must be intact.

In every case, on the other hand, where the peri¬
toneum is infiltrated and poisoned, its physiological
properties are destroyed. It ceases consequently to
be absorbent when it is macerated by ascites co¬
existing with a tumour, its epithelium being thus
destroyed.

Drainage is indicated when there is positive or
imminent infection of the seat of operation, and to
ensure the evacuation of the liquids, and above all to
avoid possible accumulation of blood.

In operations for salpingitis, some of the pus might
fall into the seat of operation. If it were aseptic no
harm would be done, but generally the wound is
infected. By closing completely the incision, the
microbes contained in the pus would produce
peritonitis. If, on the contrary, drainage was
practised, the infection is limited and the liquids
secreted by the peritoneum against the microbes are
evacuated at the same time as the microbes.

Drainage allows also sequestration of the infected
spot, for around the drain plastic peritonitis develops;
an artificial membranous canal is formed, protecting
the neighbouring parts. 6

Each time, in laparotomy, the presence of a liquid,
ascites or other, drainage must be practised and con¬
tinued three or four days.

When an effusion of blood is produced, the drain
should be used not only to evacuate the clots which
would be absorbed with difficulty but also to produce
haemostasis, for, when capillary haemorrhage meets
with the rough surface of a drain or plug, it
coagulates and the drain becomes thus an haemostatic
centre.

In great oozing of blood as in the decortication
of a large tumour a drainage practised according to the
method of Mikulicz becomes an agent of compression.

The drainage can also be done per vaginam, and
many foreign surgeons give it the preference. In
l 1 ranee, Richelot believes vaginal drainage superior to
abdominal drainage.

M. Pozzi drains through the vagina only when it is
completely opened at the end, that is to say, after
vaginal hysterectomy.

Google

Digitizi

366 The Medical Press.

CORRESPONDENCE.

Oct. 2, 1907.

Hegard drained by means of an enormous india-
rubber tube, fenestrated, into which he introduced
antiseptic plugs which were changed when they were
completely infiltrated.

At present, in France, drainage is done by elastic
tubes (tube of Chassaignac), supple but resisting , they
are always fenestrated.

Another method, abandoned for a long time, after
enjoying great favour, consists in the use of plugs.

It was Kehrer, in 1882, who brought this method
back to public favour. Bands of aseptic or antiseptic
gauze replaced the cotton hitherto in use. These
plugs act like a drain; but thanks to their capillarity,
they aspire all liquids and are consequently superior
to the indiarubber tube, at least in the first few days
following the operation.

In 1884 Mikulicz published an important pamphlet
in which he recommended the method employed to-day
by a large number of surgeons.

His method is not only a drainage of the abdomen,
but also a plugging of a portion of the abdominal
cavity.

Where there is a large denuded surface to be
drained, two, three, or four plugs have to be placed
together. When at the end of a certain time it
becomes necessary to remove these plugs they are all
stuck together, and to the edges of the wound ; to
withdraw them, a considerable effort is necessary and
suffering is caused to the patient.

Mikulicz conceived the idea of placing these plugs
in a bag. The bag, empty, is placed in the centre of
the incision and pushed gently to the bottom of the
wound. To this bag is fixed a long and strong silk
cord of which the end is fastened outside on the wall
of the abdomen by an adhesive plaster ; the bag is
filled with the plugs and then closed. At the end
of a few days the plugs are withdrawn quite easily,
one after the other, and finally the bag is removed
by drawing on the silk thread, without causing the
slightest suffering to the patient.

Coryza in Infants.

Coryza in infants is, as all know, a very troublesome
affection, preventing the development of the child.
Two or three drops of glycerine three or four times a
day bring about a speedy cure.

Mushroom Poisoning.

A few tablespoonsful of powdered charcoal or
animal black in milk or water are sufficient to arrest
the most acute symptoms.

GERMANY.

Berlin. Sept. 29th. 1907 .

At the Medizinische Gesellschaft Hr. Goldscheider
communicated a note on

Percussion of the Lungs.

He first described the method in general use, and
drew attention to the methods of Ziemssen, Gerhardt,
and Kronig, and observed that they were capable of
improvement, as they were not based on exact patho¬
logical knowledge of the anatomical relations of the apex
of the lungs. These relations the speaker showed by
drawings, and came to the conclusion that the apex was
best percussed between the two heads of the sterno-
cleido-mastoid. In percussing the apex of the lung
from the back he did not percuss over the supras¬
pinous fossa, as there was no lung tissue there, but
recommended percussion over the two first ribs after
the attitude proper for the examination had been
assumed (sitting with the arms slung round a chair
back 1. By this the shoulders were drawn widely
apart on both sides, and the ribs exposed. Percussion
performed in this way was of more value than auscul¬
tation. It should be performed lightly.

Herr Kwald did not think much of the importance
of percussion based on anatomical position ; it was a
matter of the projection of the sounds of the lung
into the neck, rather than of determining changes.
The previous speaker had not mentioned a good kind
of physical examination of the apices of the lungs,
namely, direct clavicular percussion. He was in the
habit of using a method that seemed useful to him,
namely, percussion of the apex from behind.

Hr. Westenhoeffer observed that, with percussion be¬

tween the heads of the sterno-cleido-mastoid, glands in
that position might easily be percussed that might be
enlarged in incipient tuberculosis.

At the Verein fur innere Medizin Hr. Westenhoeffer
demonstrated the organs from a case of
Plethora Vera.

A telegraph worker was admitted into the Moabit
Hospital with symptoms of meningitis, and died in
ten days. In the fluid obtained by lumbar puncture,
and which flowed out under great pressure, leucocytes
were found, and on puncture a second time lympho¬
cytes. The autopsy revealed as the direct cause of
death meningeal haemorrhage into the left lateral ven¬
tricle ; but besides this quite peculiar features were
observed. All the organs were overfilled with blood
(heart, liver spleen, kidneys, stomach, pancreas, and
bones). The organs preserved in formol still showed
a dark blue-red colouration. The case was one ot
plethora vera. The etiology of the affection was
completely dark. The watery constituent of the
blood-serum was not diminished, as shown by
Weintraub, but somewhat increased; there was no
thickening of the blood therefore. The disease in the
bone marrow was characteristic ; this was dark red,
and it looked just as it did in little children, in a
state of infantilism. The patient did not suffer from
cyanosis, but the face was very red. He had never
had any signs of circulatory disturbance, and had
been of a quiet temperament. The spleen was not
greatly enlarged, and its tissue showed no changes.
The blood did not differ from the normal, and in
particular it contained no nucleated red blood cor¬
puscles. The heart was not enlarged, and showed no
deviations from the normal. It was the same with
the aorta. The kidneys were slightly enlarged, but
not changed. The lungs were over-filled with blood.
Only five cases had been published.

Hr. Hirschfeld remarked on the case that the
lymph glands were normal. The spleen showed
diminution of the follicles, with hyperplasia of the
pulp; normoblasts and myelocytes were present in
the blood of the spleen. The bone marrow was red
through engorgement; the quantity of normoblasts
was not greatly increased. Hyperplasia of leucocytes.
The chief feature was the change in the bone marrow.

Hr. Max Michaelis was of opinion that not five but
many cases of plethora vera had been published, but
only five with autopsies. Possibly the disease had
some connection with impeded respiration.

Hr. Mohr had seen eight cases in three months. The
patients were not cyanotic but flushed ; there was no
swelling of either spleen or liver. In three the
patients had had to do with carbon monoxide. The
number of red blood corpuscles in his cases oscillated
between seven and eleven millions.

Hr. Westenhoeffer observed that the discussion
showed the confusion that reigned as regarded the
views on the subject. The cases related by the
speakers did not belong to the category of those re¬
ported. In those there was absolutely nothing of im¬
peded respiration, of carbon monoxide poisoning, or
of concomitant disease. The sole cause of the
plethora was the change in the bone marrow. They
were cases of myeloplastic polycythemia, the true
plethora vera of the older authors.

AUSTRIA.

Vienna, Sept. 29th, 1907.

Diagnosis of Cerebro-Spinai. Meningitis.

The differential diagnosis of sporadic “stiff neck”
has been puzzling the profession for some time, and
every experiment and expedient has been resorted to with
the real object of solving the problem. Holker records
15 cases of this disease, and only six of them responded
to the bacterial test during the first week of the illness.
In other two cases of the 15 the test was positive after
one week’s duration of the disease. The remaining
seven never responded to any test, although the spinal
fluid was examined long after as well as during the
illness.

Recently a new theory for the differential diagnosis
has been supposed to be established in the state of
the lymphocytes in the liquor cerebro-spinalis

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Oct. 2 , 1907-

CORRESPONDENCE.

Holker thinks this rather speculative, and ought to be
entertained with caution. . ,

The syphilitic or para-syphilitic and tubercle are the
two closely allied diseases which require to be elimi¬
nated from the cerebro-spinal meningitis. He finds
the same leucocytes in simple meningitis and
undoubted tubercle as in cerebro-spinal meningitis, and
affirms that the latter has a great number of forms
among the white blood corpuscles.

He concludes that the specific coccus is too late in
its appearance for any practical use that can be made
with it, even when it is found.

The Chronicity ok Icterus is Hematic.
Benjamin and Sluka, after long and careful examina-
tion of icterus, have come to the conclusion that the
disease is haematic and transmissible from father to
son. In several cases which they have observed, no
physical or anatomical difference could be found in
the organs of the body, but they have found the
disease ameliorated or attenuated in the third genera¬
tion when the grandfather, father, and son were
examined ; the latter had the disease in a less intense
degree than the grandfather.

In the child the icterus was decidely less, the
urobilin and urobilinogen diminished, the haemato-
porphyrin and cholic stools were entirely absent. The
haematic changes are the most notable ; the red blood
corpuscles are fewer, but the individual erythrocyte
holding a surplus of haemoglobin or poikilocytosis

E roduces a blood anomaly, which leads them to
slieve that the production of the blood or some noxa
is the disturbing factor in the production of icterus.
The first exciting cause seems to be the destruction of
the ervthrocyte, while the increase of the spleen in
father and son acts as a “spodogener” in accomplish¬
ing the destruction of the red blood corpuscles.
Balantidlum Coli Typvs Malmsten.
Glaessner showed microscopic preparations of a
living parasite taken from the stools of a patient
suffering from amoeban enteritis. The protozoon was
very mobile, and could be easily distinguished as the
balantidium coli, measuring 0.01 by 0.07 millimetres
and having an oval appearance. The body is covered
with a fine hair which assists it in its boring and
oscillating motions when moving forward. It is
usually transmitted to man through the dejections of
pigs, and carried to the intestine of the human being
by green tubers and vegetables. The usual therapeutics
are small doses of calomel from 0.05 to 0.1 of a
gramme, with quinine, extractum filicis maris, carbolic
acid in pill and ice water clysters. The latter is the
more effective, but it has to be used boldly with the
other adjuncts.

Obituary.

Another of Austria's medical philanthropists has
passed away in the person of Dr. Anton I.oew. An
alumnus of Vienna University he studied under
Oppolzer, graduated and, according to the custom of
the daw travelled over Kurope. On his return he built
and equipped a hospital in 1881 with the latest
improvements of the time, which gave an impetus to
the progress of medical science in Austria. He was
associated with Billroth in founding the Red Cross,
and was consulted in the erection of all hospitals in
the Empire.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

Resignation of Dr. Rutherford, Crichton Royal
Asylum. —It is announced that Dr. Rutherford has
resigned the post of Superintendent of the Crichton
Royal Institution, Dumfries, which he has now
occupied for nearly a quarter of a century. General
regret will be felt that reasons of health have com¬
pelled him to take this step. Since he received the
appointment he is now about to demit, the Crichton
Asylum has been greatly enlarged, thanks to his un¬
remitting energy. The pauper patients have been
removed from the neighbourhood of the institution,
and placed »a a separate asylum in the grounds, which

The Medicai Press. 367

extend to 800 acres. A handsome memorial church
has also been erected, and the country house of Friar's
Carse, formerly the property of Mr. Crichton, the
founder of the institution, has been purchased. All
these improvements have been carried out at the
instigation of Dr. Rutherford, and their magnitude
may be judged of when it is stated that together they
cost over £1 10,000. Dr. Rutherford was born in 1840,
and after studying his profession in Edinburgh and on
the Continent, he returned to Scotland in 1866 with
the intention of entering upon general practice. He
translated Griesenger’s “Mental Diseases” for the new
Sydenham Society, and this evidence of the direction
in which his tastes lay led to his being offered an
assistantship in the Birmingham Asylum. In 1870
he succeeded the late Sir John Sibbald as Superin¬
tendent of Argyll and Bute Asylum, and thence was
translated to the large asylum of Lenzie. It was in
that capacity that his introduction of recent methods
of treatment—extension of employment and freedom
for the patients—won for him general recognition as an
asylum administrator. His work attracted much
attention all over the world, and he received the
honorary membership of a number of foreign Psycholo¬
gical Societies—French, Belgian, Italian, and
American.

Problem of the Inebriates.— The Corporation of
Glasgow have issued their sixth annual report on the
working of the Girgenti Inebriate Reformatory, which
is licensed for females only, and has accommodation
for 58 inmates. The report covers the year 1906, and
has been delayed in consequence of an abortive attempt
by the Corporation to have the Inebriates Act
amended. In consequence of their failure to do this
and also on account of a reduction of the Treasury
grant from 10s. to 7s. 6d. per inmate per week, they
have resolved to discontinue this reformatory. On
December 31st, 1905, there were 41 inmates, and
during 1906 there were 17 fresh admissions, the total
number since the opening of the home being 130
patients. The average age of the 1906 admissions was
27 years. The inmates are employed at farm work,
sewing, knitting, etc. ; a number of them, accompanied
by attendants, are permitted to visit their friends for
a day. Writing and receiving letters is permitted.
Gratuities of 3d. a week for good behaviour, and 3d.
a week for work done, are allowed. Concerts and
musical evenings are got up, and educational facilities
are afforded in the evenings. Nine patients were
allowed out on license under the charge of suitable
guardians. Of these, three relapsed and were re¬
admitted ; two did well, but were re-admitted for
accidental reasons ; two did well, and their sentences
expired while under license ; two are at present doing
well. A large number of escapes took place, which is
no doubt partly due to the fact that the institution is
not walled in. Twenty-four inmates were involved in
attempts to escape; two are still at large. The
expenditure amounted to 24s. per inmate per week, of
which 10s. 7d. was provided by the Treasury, and
the balance by the Corporation. Dr. Cunningham,
Medical Officer, states in his report that three inmates
are, in his opinion, border-line cases, and may require
to be transferred to an asylum. Four inmates have
required treatment for epilepsy. Dr. Cunningham
adopts the following classification of the patients: —
(a) 1st class, excitable hysterical patients with inability
to control temper and passions ; (6) 2nd class, weak-
minded, imbecile patients, who are indifferent to their
surroundings, and make no attempt to conceal their
position ; (r) 3rd class, accidental or periodical

drunkards, in whom a fit of depression precedes a
bout; they have small resisting power, and are easily
led for good or bad ; (d) 4th class, patients in poor
physical condition and mental health, from unhealthy
surroundings, bad food, neglected education; the
drinking bout is of long duration. Of the 130 patients
admitted since the home was opened, the distribution
among the different classes was as follows:—(a)
Hysterical patients, iS; (b) weak-minded, 17; (c)

accidental drunkards, 22; {d) chronic inebriates. 73.
Dr. Cunningham regards the chronic inebriates as
practically hopeless. The treatment is essentially the
same as that of mental disorders, the object being not
merely to stop drinking, but to suppress the craving.

Digitized

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368 The Medical Press..

OBITUARY.

Oct. 2, 1907.

Two years ago drug treatment was begun, the remedies
used being atropin. sulph. gr. 1-100 daily, and a mix¬
ture containing sodium, quinine, ammonium, and
aloin. It has proved an absolute failure. Turning
to the tables of discharges for 1904, 1905, and 1906,
we find the after histories of 54 patients. Of the 29
who were discharged during 1904, all except seven had
further convictions against them during 1905 and 1906,
and therefore must be regarded as failures. Of the
seven who escaped conviction one married and has
relapsed, one is unknown, one is dead, one is in the
poorhouse, one did well while on license, two con¬
tinue to do well. Of the 22 who had further convic-
tions against them, one is said to be in domestic
service and doing well, another did well but is dead,
and another is a farm servant. That is to say, two
out of 29 remained cured for at least two years, and
two more did fairly well. Of 16 patients discharged
during 1905, seven escaped further conviction, three
are known to have relapsed, one is in Canada, and
three are doing well. Only one of those convicted for
drink is known to be doing well now. Of the nine
patients discharged during 1906 only three are known to
be doing well. Excluding the last year, we thus have
total discharges of 45; of these five are cures at the
end of 18 months to 24 years ; four have had subse¬
quent convictions, but are doing well now. These
figures need no comment; they tell plainly enough
how little prospect there is of reforming the class of
patient who is admitted to an inebriate home. It is
hardly to be wondered at that the Corporation of
Glasgow have resolved to discontinue the Girgenti

Retreat. .

Edinburgh Post-Graduate Course.— This course
was brought to a termination on September 27th, and
has proved even more successful than its predecessor
of last year. On September 13th the President and
Fellows of the Royal College of Surgeons gave an “ At
Home ” to members of the course, and the post¬
graduates, in their turn, showed their appreciation of
the classes by entertaining their teachers to dinner at
the Caledonian Station Hotel on the 26th.

BELFAST.

The Late Dr. Mullan, of Ballymena.—D r
Andrew Mullan, of Ballymena, co. Antrim, who died
last week at Larne, was well known for many years
in his county. He graduated in the old Queen’s
University in 1866, taking the degrees of M.A. and
M.D. He took a widespread interest in various
religious and philanthropic organisations, and will be
much missed in his district, where he was highly
respected. . _ . .

Public Health. —The Public Health Committee of
the Corporation is following up its campaign of bill-
sticking by issuing a card of instructions as to pre¬
cautions to be taken against tuberculosis, and pro¬
poses to send this card to schools and factories.

House Refuse.— The question of ashbins instead of
ashpits was discussed at the last meeting of the Com¬
mittee, and it was stated that the annual cost of the
fortnightly cleansing of 80,000 ashpits was estimated at
£31,000, while the removal of the contents of a similar
number of ashbins would be less than ^20,000. The
bin system has been in use in Liverpool for many
years, apparently giving satisfaction, and it is probable
that it will be introduced into Belfast.

The number of cases of cerebro-spinal meningitis
notified last week was only four, and one death oc¬
curred. The total death rate from zymotic diseases
was 1.8.

LETTERS TO THE EDITOR.

WHERE ARE THE POLICE?

To the Editor of The Medical Press and Circular.

Sir, —Your attention has doubtless been called to a
new patent medicine, said to have been derived from
ancient Egypt. Marvellous virtues are claimed for it,
and it is retailed to the public at one shilling and a
penny per box. Now when one looks at the way this
nostrum has been advertised in the public newspapers,
it is evident that an enormous sum must have been

already spent in advertising. Its broadsheets are
signed by a name that suggests some sort of a con¬
nection with other more or less notorious quack
remedies. To the ordinary medical man this pernicious
trade venture is a cruel and fradulent imposture, to be
paid for in the long run with tears and blood by a
deluded public. How is it that newspapers with any
claim to respectability can descend to take money from
these rogues? How is it that Scotland Yard and the
Home Office permit such frauds to go unchecked?
There is hardly one of these notorious quack remedies,
which have brought millions of money to their owners,
that could not be successfully prosecuted for conspiring
to obtain money under false pretences. Where are
the police?

Yours faithfully,

An Irate Practitioner.

Brighton.

OBITUARY.

PROFESSOR CHARLES STEWART, LL.D., F.R.S.

. By the decease of Professor Charles Stewart, F.R.S.,

I which occurred on Friday last, after a somewhat pro¬
tracted illness, the Royal College of Surgeons of Eng¬
land has lost an official who nas held the office of
conservator of the museum for the past 23 years.

After attending as a medical student at St. Bar¬
tholomew’s Hospital, Professor Stewart obtained the
qualification of membership of the Royal College of
Surgeons in the year 1862. He was admitted a Fellow
of the Linnean Society in 1866, and became President
of the Society during the years 1890 to 1894, and in
the following year served as Vice-President. Professor
Stewart was also a Fellow and Vice-President of the
Royal Microscopical Society, and became one of its
honorary secretaries in the year 1878. He was trea¬
surer of the Anatomical Society of Great Britain and
Ireland from its foundation until 1891. During the
period 1894-1897 he held the office of Fullerian Pro¬
fessor of Physiology at the Royal Institution, and de¬
livered several evening lectures at the same place. He
was admitted a Fellow of the Royal Society in the
year 1896, and obtained the Honorary LL.D. of Aber¬
deen University.

Before being appointed Conservator of the College
of Surgeons’ museum. Professor Stewart was Curator
of the museum of St. Thomas’s Hospital, Lecturer on
Comparative Anatomy, and Joint Lecturer with Pro¬
fessor John Harley, on Physiology at that institution.
He was subsequently appointed Professor of Biology
and Physiology at Bedford College. In the year fol¬
lowing his apoointment at the College of Surgeons he
was elected Hunterian Professor of Human and Com¬
parative Anatomy, and held this lectureship until the
year 1894.

The true value of Professor Stewart’s scientific work
is not to be judged solely by his writings, which, in
spite of the vast extent of his knowledge gained from
personal observations, were comparatively few in num¬
ber, but it is to be seen rather on the shelves of the
college museum in the unrivalled series of preparations
and dissections by which he sought, in continuation of
the work of previous conservators, to illustrate im¬
portant phases in the evolution of the organic world,
and thus to amplify the original scheme of Tohn
Hunter, whose collection forms the nucleus of the
college museum. Professor Stewart was also a master
in the art of lecturing. His easy and lucid style, com¬
bined with a rare power of swift and effective draw¬
ing on the blackboard, would have made his lectures
notable, quite apart from the peculiar personal charm
of his delivery.

FRANK J. LOCHRANE, M.D., Ch.B.Glasg.

We regret to record the death, which occurred on
September 21st at Derby, of Dr. Frank J. Lochrane,
after a few weeks’ illness. Dr. Lochrane, who was
only 29 years of age, showed great promise as a
member of the profession. He was a native of
Glasgow, and studied at the University in that citv,
at Edinburgh, Vienna, London, and Dublin. He
graduated M.B. and Ch.B. in iqoi, and three years
later took his M.D. degree. His first appointment

Digitized by GoOgle

Oct. a, 1907.

REVIEWS OF BOOKS.

The Medical Press. 369

after qualifying was that of house physician and
surgeon at Glasgow Royal Infirmary, and he after¬
wards became house surgeon at Peterborough Hospital.
He went to Derby in 1905, being appointed house
surgeon at the Women’s Hospital on the death of Dr.
Henderson. Pounds, to whose private practice he also
succeeded. A few months ago he was elected a member
of the honorary staff of the Derbyshire Royal
Infirmary, in the capacity of gynaecologist. He was
unmarried.

REVIEWS OF BOOKS.

ULCERATION OF THE CORNEA (a)

In writing a book such as this the author gives us
good evidence, if any were needed, as to how our
bacteriological knowledge of ulcers of the cornea is
maturing. While not failing to give a good clinical
picture of each form of ulceration, Dr. Macnab devotes
most of his efforts to establishing, as far as possible,
a classification of corneal ulcers founded on the
bacteriological findings and the treatment he has found
most suitable for each.

In Chapter I. we find the usual methods of examina¬
tion described. Dr. Macnab gives a preference to
Hartnaek’s loupe, but we think Berger’s after a short
trial becomes very easily managed, and has the
advantage of leaving our two hands free to manipulate
a lens for oblique illumination and fixing the lids.
He tells us the sensibility of the conjunctiva, lid
margins and cilia is greater than that of the cornea,
and on page 25 “it must be noted that the sensibility
of the cornea is not very acute, and certainly is quite
dull when compared to that of the conjunctiva and
lid borders.” These are pronouncements hard to
reconcile with clinical and personal experience. In
Chapter III. hypopyon keratitis, or pneumo-coccal
ulcer, as Dr. Macnab prefers to call it, is fully
described, a translation of Saemisch’s description being
given. The possibility of anterior synechia taking
place without a complete perforation of the cornea,
due to the perforation of Descemet’s membrane, is
pointed out as a fact. Some of the difficulties of the
diagnosis and the study of the life history of the pneu-
moccus are here given. For the active treatment of
the infiltrated margin of the ulcer Dr. Macnab advises
either the electric cautery or pure carbolic acid, but
before doing so he lays stress on the importance of
thoroughly scraping away sloughs and loose epithelium
to facilitate the complete and direct application of
the cautery.

Ulcers due to streptococcus, pyocyaneus, Fried-
lander’s B., B. coli commune, staphyloccus, etc., are
considered in Chapter IV. In subsequent chapters we
find ulcers due to infection from the various forms of
specific conjunctivitis, Mooren’s and Zur Nedden’s
ulcers described. Chapter X. is a useful one. It
takes us over the bacteriology of organisms found in
corneal ulcers.

In the last chapter are described the operations for re¬
moval of the lacrymal sac, Saemisch section, and what
the author has christened the “ Corneal Plastic Opera¬
tion.” In treating of the first-named operation Dr.
Macnab does not give any advice as to the anaesthetic
used. He refers to the troublesome haemorrhage gene¬
rally met with, and advises as a remedy for it the use of
the Muller and Axenfeld retractors. These are un¬
doubtedly indispensable, but we cannot say that they
always act as efficient controllers of the blood flow,
whereas, we have reason to appreciate the good results
of subcutaneous injections of cocain, or eucain, and
adrenalin both as to anaesthesia and bloodlessness.
The cor neo-plastic operation, more recognisable as
Kuhnt’s transplantation of conjunctiva, is well
described, and is deserving of more general use as a
preventative of staDhyloma cornea and in hastening
the process of healing.

There are a few errors that are inexcusable, perhaps,
such as the spelling of Mr. Priestley Smith’s name

(«) " Ulceration of the Cornea.” By Angus Macnab, B.A., B.Sc.,
M B., Ch.B., F.R.CS. Pages xiv., 196. ao illustrations. London:
Ballike, Tindall and Cox. 1907. Price 5s.

and that of Professor UhthofF, but these by no means
forbid a full welcome being given to Dr. Macnab’s
efforts to lead us on to a more scientific knowledge
and classification of corneal ulcers.

RECTAL DISEASES (a).

We have received for review the third edition of Mr.
Harrison Cripps’ well-known work on diseases of the
rectum and anus. The book also includes the fifth
edition of the Jacksonian prize essay on cancer of the
rectum. This portion of the book has been rewritten,
and to it has been added a table of 380 consecutive
cases which occurred in Mr. Cripps’ private practice.
The book as a whole furnishes a most valuable mono¬
graph on rectal disease.

The author’s comments on the value of a speculum
as an aid to diagnosis of rectal disease, especially
when used in the surgeon’s consulting room, is short
and to the point:—“It will generally end in a fluid
motion on your couch, and the rapid vanishing of
the patient who is seldom reclaimed.” We should
like, however, to find some reference to the sigmoido¬
scope. If this instrument is of no value for diagnostic
purposes, then this fact should be stated as a guide to
Mr. Cripps’ readers. If it is of value, then a descrip¬
tion of its working might with advantage be included.
Personally we regard it as calculated to be of as
great value in these cases as is the electrically-lighted
cystoscope in cases of disease of the bladder.

As is proper, the nature and treatment of the various
foims of haemorrhoids receives full attention, as do
such subjects as prolapse, abscess, fissure, stricture.
In discussing the treatment of pruritus ani, the opera¬
tion for this distressing condition devised by Sir
Charles Ball has not received the mention to which
its novelty and value appear to entitle it.

The Jacksonian essay on rectal cancer which has
been added in the present edition, and which can also
be obtained as a separate publication, occupies the
last nine chapters of the book. A long chapter is
devoted to the etiology of rectal cancer, and as the
etiology of this form of cancer differs in no particular
from that of any other form of cancer, the chapter is
practically devoted to the etiology of cancer wher¬
ever it may occur. This involves a great deal of dis¬
cussion, which, however much it may have been suit¬
able in the case of a prize essay, is, we cannot help
thinking, entirely out of place in a work on rectal
diseases. As well might the chapter on rectal abscess
be prefaced by a long discussion on the nature and
source of pyogenic organisms. Mr. Cripps’ book is of
quite sufficient length and importance to enable all
unnecessary matter to be dispensed with, and there¬
fore we should like to suggest that in a subsequent
edition its size be somewhat curtailed by the exclusion
of such matters as the etiology of cancer.

EYE INJURIES (*.)

This volume comprises post-graduate lectures
delivered by Dr. Ramsay which have been rewritten,
and are now published “in the hope that they may
prove helpful to general practitioners.” Their scope
being clinical, all discussion of theories has, as far as

E Dssible, been avoided. One is at once struck by the
andsome way in which the book is produced—the
paper being unusually rich, the print large, and the
illustrations, of which there are about sixty, some
coloured, are unusually beautiful. Dr. Ramsay has
a nice clear style, and makes his remarks interesting
by the relation of cases which have come under his
observation. The advice given to the general practi¬
tioner is reliable, and cannot but be of service to
those readers for whom it is mainly meant. We are
glad to see in Chapter VI. that Dr. Ramsay has had
experience of injecting argyrol into the anterior
chamber of eyes which have become infected from
perforating wounds, those desperate cases that call

(a) " On Diseases of the Rectum and Anus, Including the Fifth Edi¬
tion of the Jacksonian Prize Essay on Cancer." By Harrison Cripps,
F.R.CS., Senior Surgeon to St. Bartholomew's Hospital, ftc., See.
Third edition. London: J. and A. Churchill. 1907.

(6) “ Eye Injuries and Their Treatment.” By Maitland Ramsay,
M.D. Pages 210. Plates 23. Glasgow: James Maclehose and
Sons. 1907. Price 18s.

itized by G00gk

37 ° The Medical Press.

REVIEWS OF BOOKS.

Oct, a, 1907-

for prompt and radical treatment. The reviewer s
experience is limited to one case where panophthalmitis
was fully expected. A few drops of 5 per cent, argyrol
injected into the anterior chamber acted so quickly
that next day the hypopyon had disappeared, the pupil
was well dilated and chemosis and pain were gone.
After removal of the soft lens useful vision resulted.

In diagnosis of sympathetic irritation the author
lays stress on the spindle shaped enlargement of the
blind spot as demonstrated by Bjerrum’s screen. He
takes this sign to mean congestion of the optic disc.
At the same time a low degree of myopia may be
present. Without wishing to account for these signs
Dr. Ramsay tells us that they disappear on removal of
the exciting eye. Reading on we come to sympathetic
inflammation, and we find ourselves in a technical
discussion as to its pathogenesis. Six rules afford
reliable and concise guides as to when to enucleate and
when not to enucleate.

Dr. Ramsay does not approve of the modern
tendency of confining ourselves to local treatment
only, with which we are quite in accord, but we think
he goes somewhat far in the opposite direction in the
following:—“Again, in a case of keratitis, most
gratifying results are often obtained by following the
old-fashioned plan of blistering the eyelids with solid
caustic; and in iritis, when the disease is tending to
relapse time after time, the application of a blister
often brings about such a change that recovery goes
on afterwards without interruption. A more pro¬
nounced result still is obtained if the blistered surface
be kept open by the application of an irritating oint¬
ment or by D’Albespeyre’s paper, and in all deep-
seated chronic inflammation an open blister contributes
largely to the means of a cure. When the inflamma¬
tion is due to syphilis, the presence of an open sore
is, in my experience, most helpful, and therefore, in
such instances, I have not the slightest hesitation in
inserting a seton in the nape, and keeping it there
for several months. So strongly, indeed, am I con¬
vinced of the value of such measures that I feel that
those who do not fully avail themselves of them de¬
prive their patients of an important source of help.' 1

Inasmuch as most general practitioners have their
own ideas as to what an “Alterative Pill” or “Iron
Pill ” ought to be, we think the sixty pages devoted
to the Pharmacopoeia of F.ye Diseases might have been
curtailed considerably. We congratulate Dr. Ramsay
on the masterly work he has produced and his pub¬
lishers on the way in which they have accomplished
their part.

ever to be aware that the ether inhaler, so often called
by Clover's name, was in reality a modified copy 0
the original ether inhaler, adapted by Ormsby, of

D We advise all who either now adminster anaesthencs
or who hope to do so, to purchase this little book, as
it will give them many useful hints on the subject.

LECTURES ON CLINICAL SURGERY (a).

We have read through these practical clinical lec¬
tures and addresses, which the author tells us have
already appeared in the columns of the British Medical
Journal and the Clinical Journal. They are printed
as they were delivered, in rather a colloquial sty .
so as to emphasise the lecturer’s meaning to tm
class. The lectures comprise such practical subjects
as: The Course of Intra-abdominal Inflammation, on
the Recognition and Management of Intestinal Ob¬
struction, Carcinoma of the Breast and its Sprea
into the Lymphatics, Varicose Veins, etc. The lec¬
tures are not only interesting and practical, but are
most readable, and many a young operating surgeon
or general practitioner will derive a great deal 01
sound useful information from their perusal, which
will be of service to him in his practice, where diffi¬
cult and doubtful cases come before him.

PRACTICAL ANESTHETICS (a).

The author states that the object of this little book
is to furnish a short guide to those who have not the
leisure to study other large manuals on the subject.
The work is divided into eight chapters, and runs into
over 170 pages. When a surgical operation has to be
performed we consider the selection of an anaesthetic
and its administrator is all-important—sometimes far
more important than the operation itself, as regards
danger to the patient. It is very pleasant indeed for
a patient about to undergo a serious surgical operation
to be able to sink calmly and safely into the mysterious
sleep of insensibility, trusting only in the goodness of
his Maker and the skilful knowledge of his operator
and anaethetist. Practitioners too often are called on
in a hurry to administer an anaesthetic for an
emergency operation, and frequently without much
special knowledge of the subject. We consider no one
should be allowed to adminster an anaesthetic unless
such a person has had some preliminary training in
the administration of all descriptions of anaesthetics in
a hospital, under the direction and supervision of a
skilled anaesthetist. The author describes the many
difficulties and dangers of anaesthesia, and gives much
practical information to the beginner, as regards what
to do, and what to avoid. He does rot appear, how

(•) “ Practical AiuFvthetlca.” By H. Edmund O. Boyle, M.RC.8.
L.R.C.P. Assistant Anesthetist to 8t. Bartholomew’s Hospital, etc.
Oxford Medical Publications. Illustrated. Pp. 178 . Published by
Henry Frowde, Oxford University Press,' Amen Corner, E.C., end
Messrs. Hodder and Stoughton, Warwick Square, London, E.C. 1907
Price 6s. net.

GOUT (M

The third edition of this well-known work hardly
calls for a detailed notice. It is written in the clear
and lucid style that one has learned to associate with
all that comes from the author’s pen. Yet the boot
does not simply mark time in our scientific attitude
with regard to gout. Dr. Luff herein (p. 64) formally
abandons his theory of the renal origin of the maladv,
with which his name has been so long associated,
and he now adopts the view that a bacterial toxin
is probably the primary cause of gout. This change
of opinion serves to illustrate the obscurity that still
surrounds the etiology of this important disease. For
our own part we are inclined to think that hardly
enough stress is laid by investigators upon the
tertium quid in the shape of some peculiar predis¬
position in the constitution of the patient. In dis¬
cussing treatment we note that the use c»f the galvanic
current is advocated in conjunction with massage m
order to promote absorj>tion of (Edematous infiltration
and deposits. Similarly cataphoresis of gouty joints
with potassium bicarbonate or lithium iodide is
advised. The local electrical treatment of gout is a
branch of therapeutics that deserves more attention
that it receives at present from medical men. Patients
suffering from acute or subacute attacks of gout ait
warned against resorting to the Turkish bath. The
book is well published, it goes without saying, and
it is the plain duty of every physician to master its
contents.

TUBERCULOSIS, THE REAPER, (c.)

The fact that this popular treatise on the tuber¬
culosis problem has now reached a second edition after
having been widely distributed throughout France
by the order of the Minister of Public Instruction
affords ample evidence that the work at least has been
appreciated, and it may be hoped will prove of lasting
service to the people of France. It is clear that it
tuberculosis is to be eliminated from civilised countries,
it can only be by the instruction of the masses and the
acquiescence of citizens, and particularly of parents m
the practical conduct of such anti -tuberculosis

(a) “Clinical Lectures end Addresses on Surgery." By C. B-

Lockwood, Surgeon to St. Bartholomew's Hospital. London. Ono
Medlaal Publications. Illustrated. Pp. 275 . Published
Frowde, Oxford University Press, Amen Corner, E.C., and
Hodder and Stoughton, Warwick Square, London, E.C. 1901 - roc
6 s. net. „ p,

(b) " Gout: Its Pathology, Forms, Diagnosis, and Treatment.
Arthur P. Lufl, M.D., D.Sc., Physician to St. Mary’s Hosp UL Thjw
Edition. Cassell and Co., London and New York. 1907- ,c ?' M i n (i.

(c) “ La Grande Faucheuse: vade-mecum de l'Education a ,
tuberculeuse dans la famille, i l’tcole, k l’atelier.” By Dr. r«n*?“
Barbary. Pp. xL-340, with 46 figures. Second Editioo. 1w
F. R. de Rudeval, 4, Rue Antoine Dubois. 1907. Price. 7

Oct. 2, 1907.

REVIEWS OF BOOKS.

The Medical Press. 37 1

measures as Dr. Barbary so well enunciates and explains
in his manual. The work is constructed on common-
sense lines and can be readily followed by any intelli¬
gent layman. In a simple but forcible manner, he
explains the nature, causation; pathology, and clinical
manifestations of pulmonary tuberculosis and discusses
the principles of prophylaxis and treatment in a manner
more adapted for the physician than the man in the
street. The book is perhaps more suited to the
family practitioner than to the unscientific head of a
household. Particulars are given of a number of
sanatoria, and climatotherapy and the use of mineral
waters are discussed. In the closing chapter the anti¬
tuberculosis campaign as conducted in France is briefly
described. There are a number of illustrations, and
two maps roughly indicating the geographical situa¬
tion of the chief sanatoria in Germany and Belgium.
Although there is a table of contents, there is, in accord¬
ance with the unpardonable custom of French authors,
no index.

MATERIA MEDICA AND PHARMACY, (a)

This remarkably compact and well-digested com¬
pendium of materia medica and therapeutics is such an
old friend that comment is almost unnecessary. This
edition has been carefully revised and brought up to
date, and this is especially the case in respect of organo¬
therapy, even that interesting departure in treatment,
the employment of the now famous opsonic index,
receiving a full meed of attention. We would respect¬
fully urge the author to abandon the use of the term
“ tubercular ” (which is, strictly speaking, an anatomi¬
cal term) in lieu of “ tuberculous,” e.g., derived from
tubercle.

The work will be found an extremely convenient work
of reference by practitioners, more particularly now
that the study of materia medica and therapeutics has
unhappily been placed in the background of medical
education. Prescribing, it has aptly been remarked,
is becoming a lost art, and many medical men affect
scepticism in regard to the use of medicinal agents,
mainly on account of the difficulty they experience in
handling them—an art that is of the highest import¬
ance in the daily routine of practice, as much as, indeed,
a knowledge of anatomy and physiology. The
latter, indeed, are but the means to an end, and that
end is therapeutics. Patients want to be treated, and
diagnosis, after all, is, or should be, only a preliminary
step in that direction.

WRIGHT’S MEDICAL ANNUAL.

This useful publication is so well known to the
profession and so justly valued, that there is little
need for comment on each successive issue. This
year’s number contains some sixty pages more than
that for 1906, and the number of contributors is also
a little increased. Among the new contributors
are Mr. Sampson Handley, who discusses cancer
in a notable article, an excellent summary of present
knowledge on the subject ; Mr. Robert Jones, who
writes on Nerve Anastomosis and Nerve Grafting ;
Dr. Batey Shaw, who writes on Diseases of the Ductless
Glands, and Dr. Whitridge Williams, who writes on
the Toxa-mias of Pregnancy. It will be seen that the
editors spare no pains to obtain writers of special
authority in their various subjects. We have tested
the book on many points, and while noting a few omis¬
sions, we have failed to find any serious flaw. As
is almost inevitable, there is a certain lack of proportion
between the different articles, and a certain want bf
uniformity of treatment. Some writers give mere
abstracts of recent literature, while others contribute
critical articles of original value. Taken altogether,
however, the book is invaluable to the general practi¬
tioner, as he has long ago learnt. We deprecate
the tendency to increase the bulk of the book, though,
as the price remains the same, it would be ungrateful
to grumble.

(a) " Materia Medica, Pharmacy, Pharmacology, and Therapeutics.”
By W. Hale White, M.D., F.R.C.P., Physician to and Lecturer on
Medicine at Guy's Hospital, dec. Tenth Edition. Price 6s. 6d. net.

THE SIGMOIDOSCOPE, (a)

This little book gives a good working description
of an instrument which ought to be in far greater use
than it actually is. The form of sigmoidoscope which
the author recommends is that originally devised by
Professor Strauss, and which he has slightly modified.
He emphasises the importance of obtaining the proper
and best pattern when purchasing an instrument, as
there are several poor imitations of it on the market.

Having described the mode of using the instrument,
the author proceeds to describe the appearances seen
by its aid in various pathological conditions. There
are also several illustrations, which, however, would
be of more value if they were coloured, but we presume
the increased cost would be too great for a book which
must necessarily meet with only a limited demand.
We can cordially recommend the little work to any
one who is desirous of acquiring a knowledge of the
mode of using a useful instrument.

PALMER ON MASSAGE, (b,

The appearance of the third edition of this book
testifies to its excellence as a handbook. The wide
experience of the authoress in the massage depart¬
ment of the London Hospital has taught her what
are the essential points required by a learner of the
act. Accordingly we find a reference to anatomy
and physiology that is sufficiently full without being
burdened with unnecessary details. There we may
see good illustrations and tables, and chapters are
added on the Nauheim treatment and massage of
children. On the whole this is one of the best special
works of the kind with which we are acquainted,
and a nurse requiring a handbook of massage, would
do well to choose a Palmer’s book.

Plague at Oran.

Plague has broken out at Oran. According to the
Paris papers, there have already been two deaths, one
of a porter, and the other of the wife of a railway
official. The number of cases in one journal is re¬
ported as four, and in another as n. The centre of
infection is in the store sheds of the Chamber of Com¬
merce, where the victims were at work, and where rats
are said to have been found. Admiral Philibert has
announced that all war and transport ships belonging
to the State have left Oran and proceeded to Mers-el-
Kebir. The base of operations has been transferred
from Oran to Algiers.

Notification of Births.

The Local Government Board have just issued a
circular to local authorities explaining the new Notifi¬
cation of Births Act. The object of the measure,
which will only be in operation where it has been
adopted by the local authority with the consent of the
Board, or has been declared to be in force by the
Board, is to provide a speedy means whereby informa¬
tion of the birth of a child may be given to the medical
officer of health of the local authority, so that, if neces¬
sary, advice may be given to the mother in regard to
the rearing and nurture of the child. The Board ob¬
serves that there is no occasion for imposing upon
parents and others the obligation of notifying births in
the special manner provided by the Act unless steps
are taken to carry out the ultimate object of the
measure, viz., the giving of advice and instruction to
those who have charge of the infants, and in ordinary
circumstances the Board would not be prepared to
consent to the adoption of the Act unless it appeared
that arrangements had been made for this purpose.
These arrangements would usually be best carried out
by local agencies under the medical officer of health.
The Board trusts that the local authorities will con¬
sider the question of adopting the Act and of co-opera¬
ting with any agency that may exist, so as to secure
its successful operation.

(«) “ The Sigmoidoscope: A Clinical Handbook on the Examination
of the Rectum and Pelvic Colon.” By P. Lockhart Mummery, B.C.
Cantab. F.R.C.S.Eng. London: BaiUiere, Tindall and Cox. 1906.
Pp. 86. Price 5s. net.

(a) " Lessons on Massage.” . By Margaret D. Palmer. Third Edition.
London : BaiUiere, TindaU and Cox, Henrietta Street, W.C. 7s. 6d.
net.

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372 Thb Medical Press.

WEEKLY SUMMARY.

Oct, 2, 1907,

Weekly Summary of Medical Literature,
English and Foreign.

Sp ecidUy compiled for Thb Medical Press and Circular.

RECENT PATHOLOGICAL LITERATURE.

Howell’s Granules. —In 1890 Howell pointed out that
in the blood of cats following a hasmorrhage large
numbers of the red corpuscles may contain a single
good-sized piece of nuclear matter, too large to be
called a granule, and having the shape and appear¬
ance of a large nucleolus. Since that time other
observers have studied them, and doubt has been ex¬
pressed as to whether they were nuclear in origin, or
merely basophile granules, such as are met with in
many forms of anaemia. Morris ( Johns Hopkins' Hos¬
pital Bulletin , July, 1907, page 199) now describes
them for the first time as occurring in human blood,
in various cases, such as typhoid fever and pernicious
anaemia. He has also found them in the blood of two
foetuses, and believes that they appear always in
association with increased blood formation. As found
in the blood of rabbits poisoned with pyrodin, he
describes the structures as round or oval in shape, and
almost invariably eccentrically situated in the con¬
taining corpuscle. The outline is well defined, and
occasionally there is noted a paler zone in the
protoplasm of the cell surrounding the nuclear par¬
ticle. Unlike basophilic granules, they take up a
purple colour like that of the nucleus with
Romanowski’s skin. M.

Cephalic Tetanus. —Friedlander and Meyer have
observed a case of cephalic tetanus {Deutsche Med.
Woch , 1907, No. 28) in which the spasms and paralysis
remained limited to a very small muscular region, but
in which the intensity of the disease was nevertheless
great. The duration of the period of incubation and
the entire course of the disease were very long, but the
case ultimately ended fatally. The facial paralysis
was very distinct, and involved the abducent, the
oculo-motor, and the trochlear nerves, as well as the
facial nerve itself. The authors consider the various
possible causes of this paralysis, and conclude that the
most likely underlying pathological change is an
ascending neuritis. M.

Orthostatic Albuminuria. —According to the investi¬
gations of Porges and Pibram (Deutsch Archiv. fur
Klin. Med. Bd. xc., p. 367) it is probable that orthos¬
tatic albuminuria is caused by changes in the kidney
circulation. General influences, such as changes in
the general systemic circulation, appear to be with¬
out any real influence. Amongst the local conditions
which lead to venous stasis in the kidneys they in¬
clude an increase in abdominal pressure caused by
changes in the position of the body, and changes in
the position of the kidneys themselves. They believe
also that spasm of the small arteries of the kidneys
may in many cases also cause albuminuria. The
knowledge that such spasm is present in the living is
of course only obtained indirectly, and is, as a rule,
merely the result of exclusion of other causes. M.

Vaquez Disease. —Hnktek ( Casopis likaru ceskvet,
1907, p. 687) has investigated a case of idiopathic
polycytheemia occurring in a labourer aged 56, who
had suffered during three years from dyspnoea, giddi¬
ness, and a dark red colour in the face. As a child
he had suffered much from epistaxis and haemorrhage
from other mucous membranes. Objectively one
found marked facial cyanosis; the mucous membrane
of the mouth of a deep red colour; marked carotid
pulsation; dilated superficial veins; blood pressure
150 m.m. Hg.; and a splenic tumour extending down
as far as the crest of the ilium. The number of red
cells was fourteen million per c.m.m. ; the haemo¬
globin reached 188 per cent.; and the white cells
36,000 per c.m.m. The urine was highly albuminous,
After a period of three months no change was found

in the condition. The author discusses the etiology,
and suggests that it may be due to defective destruc¬
tion of red cells, owing to an absence of the suprarenal
secretion. Experimentally, injections of adrenalin
have been found to cause extensive blood destruction.
Various remedies were made use of in the case, but
without avail. M.

Blood Formation in the Liver and Spleen.— During
foetal life the liver and spleen have haemopoietic
functions, and pathologically during adult life it seems
likely that they resume these functions, as, for
example, in pernicious and other severe anaemias. In
order to ascertain whether such a reversion in
function can be induced experimentally, Morris has
produced anaemia in rabbits. (Johns Hopkins' Hosf.
Bulletin , July, 1907, page 200, etc.) by the subcu¬
taneous injection of pyrodin. The conclusions at
which he arrives are as follows:—(1) The anaemia
caused by pyrodin is one with a high colour index, and
results from injury to certain of the red cells, which
are then removed from the circulating blood by
phagocytes in spleen, bone-marrow, and liver. (21
The increased blood destruction leads to compensating
increased formation. (3) Heightened activity of the
haemopoietic functions of the bone-marrow is met
with, and myeloid elements occur in the spleen and
occasionally in the liver. (4) The changes in liver and
spleen are similar histologically to those seen in
normal rabbits’ embryo. From this it seems likely that
the spleen and liver had resumed their haemopoietic
function. (5) Haemosiderosis of organs occurs as in
pernicious anaemia. M.

Phagocytic Action of the Alveolar Cells. —Briscoe
{Journal of Pathology and Bacteriology , October, 1907I
reports a very elaborate investigation of the nature and
functions of the alveolar cells of the lungs. The fol¬
lowing are the more important of his conclusions:—
(1) The mononuclear cells of the alveoli are powerful
phagocytes. (2) The phagocytic action of these cells
depends on an opsonin. (3) With a mild infection,
by the help of an opsonin, and without the aid of
leucocytes, the alveolar cells can free the lungs of
organisms. (4) If the infection is more virulent, the
leucocytes give active assistance. (5) Phagocytosis is
more rapid when the animal infected has been pre¬
viously immunised than when a normal animal is em¬
ployed. (6) For some time after infection phagocytosis
is limited to the alveolar cells. (7) The bronchioles,
not being lined with phagocytic cells, are at a dis¬
advantage as compared with the alveoli in regard to an
infection spreading downward. R.

An Anti-Gonococcic Serum. —Rogers and Torrey
{Journal of the American Medical Association , Septem¬
ber 14, 1907) report the mode of preparation of, and
the results of treatment by, an anti-serum for gonor¬
rhoea. Rabbits were at first used for preparing the
serum, but as it was found that rabbit serum, though
sufficiently potent, might also be- very toxic, sheep
were afterwards substituted. Full-grown rams were
found most suitable, and ten injections were given
intra-peritoneally. The first inoculation consisted of
the twenty-four surface growth from eighteen
square inches of solid culture medium, emulsified in
about 30 c.c. of physiological salt solution, and heated
for half an hour at 65 deg. C. After an interval of
about a week the second injection was given, consist¬
ing of the growth from about thirty square inches,
emulsified and heated as before. The third inocula¬
tion consisted of about eighteen square inches of
unheated growth, and thereafter increasing doses were
given up to a maximum of about forty-five square
inches of unheated growth. After nine or ten inocula-

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1

Diqitizi

Oct. 2 , 1907.

MEDICAL NEWS IN BRIEF.

Thu Medical Pkess. 373

tions, a little blood was drawn and tested for agglu¬
tinins. If agglutinins were present in quantity the
animal was regarded as highly immunised, and it was
bled to death, the serum being collected. The gono¬
coccus used for making the inoculations was of mixed
strains, with the view of producing a polyvalent serum.
The serum was administered in doses of about 2 c.c.
each. The authors do not regard the serum as having
any potency toward acute gonorrhoeal lesions, such as
acute urethritis, and they do not advise its use in such
cases. They furnish sufficient clinical reports as to
its use in more chronic gonorrhoeal infections, such as
arthritis, gleet, cystitis, leucorrhoea, to justify a fur¬
ther trial. The criticism is to be made that the
authors do not establish the specificity of the serum
as an anti-serum to gonorrhoea. They by no means
exclude the possibility, which they do not perceive,
that the curative effects of the sheep's serum may be
due, not to the action of an anti-serum, but to a vacci¬
nation. We do not find any experiments to show that
the serum as actually used was sterile of gonococci.
Moreover, the therapeutic effects are very similar to
those of vaccination by dead gonococci. R.

Causation of Atheroma. —Rickett reports [Journal of
Pathology and Bacteriology, October, 1907) a series of
experiments on the causation of atheroma. It had
previously been pointed out that the prolonged adminis¬
tration of adrenalin was almost invariably followed by
atheroma of the arteries, and it had been held that this
result was due to a toxic action of the adrenalin on the
vessel walls. In opposition to this, Rickett held that the
cause of atheroma was purely mechanical, viz., the
continued high blood-pressure. To put the matter to
the test, he tried the effect on the vessels of rabbits of
the continued injection of other drugs which have
similar effect to adrenalin as regards blood-pressure,
though differing from it and from each other in most
other respects. With squills, with barium chloride,
with tobacco, and with nicotine, Rickett succeeded in
producing an atheromatous condition of the vessels.
That this change was not due to a merely irritant
action seems to be established by the failure to produce
it by the continued intravenous injection of potassium
cantharidate. This drug was chosen because, though
highly irritant, it causes no rise of blood-pressure.

R.

Origin of Rodent Ulcer. —Noon [Journal of Pathology
and Bacteriology, October, 1007) discusses briefly
some of the views which have been held regarding the
point of origin of rodent ulcers. His seven observa¬
tions support the doctrine that this form of tumour
starts in the malpighian layer of the epidermis, near
the necks of the hair follicles, and from the reflection
of this layer, which forms the outer root sheath of the
hair. He furnishes plates which would be difficult to
reconcile with any other opinion. At the same time,
the possibility is admitted of another form of tumour,
which clinically would be regarded as rodent ulcer,
originating in the epithelium of the sweat-glands. No
notice, however, is taken of the modern suggestion
that rodent ulcer is an endothelioma of the superficial
lymphatics. R.

Medical News in Brief

Royal Academy of Medicine In Ireland.

The annual general meeting of the Royal Academy
of Medicine in Ireland will be held in the Royal
College of Surgeons, on Friday, October nth, 1907,
at 4.30 p.m., when the annual report will be sub¬
mitted, and the officers and members of Sectional
Councils will be elected. The offices for which
candidates may be nominated are:—General Secretary
and Treasurer ; Secretary for Foreign Correspondence ;
Presidents of the Sections of Obstetrics, Pathology
and State Medicine ; Member of Council in the Sections
of Medicine, Surgery, Obstetrics, Pathology, Anatomy
and Physiology, and State Medicine. A Fellow is
ineligible for election on more than two Sectional
Councils. No Fellow can be a candidate for election
on both Medical and Surgical Councils.

Deportation of an Engllali Lady from America.

A sad case of suicide and homicidal mania has just
transpired by the return to England on the White Star
liner “Adriatic,” which arrived at Southampton from
New York, of a young English lady evidently well
connected and with ample means. She is said to be
the daughter of a millionaire London banker, and
arrived in New York on the “Oceanic” on May 31st
last. The poor lady’s conduct during the outward
voyage was so strange that she was taken to the private
sanatorium of Dr. Curtiss at Flushing, Long Island,
near New York, where, however, she did not improve
iu health. On the contrary, she became worse, and
ultimately the most luxurious suite on the “Adriatic”
was engaged for her, and with an army of attendants
and nurses she was taken on board and given in
charge of the Commander, Captain E. G. Smith.
Painful scenes of violence and an attempt at suicide
were made by the afflicted lady prior to the sailing of
the ship. The Immigration Commissioner of New
York refuses to discuss the case, and would not say
whether or not she was being deported by the Immi¬
gration Authorities.

A -Supreme National Health Authority.

The proposal has been thrown out that a prelimi¬
nary conference of the representatives of the Sanitary
Committees of the County Councils, County Boroughs,
and Municipal Boroughs (Metropolitan and Provincial)
and Port Sanitary Authorities of England and Wales,
shall be held in London on November 13th, 14th, and
15th, for the purpose of considering the question of
the establishment of a permanent Union of the Sani¬
tary Authorities of the Kingdom into a Supreme
National Health Authority. As we said last week, the
absence of uniformity of action on the part of sanitary
authorities generally in furtherance of questions con¬
cerning the public health of the country has been
recognised for a long time past, and, on account of
the diversity of the interests involved, has hitherto
been regarded as an almost insurmountable difficulty
as well as a cause of much waste of energy and time
in attempts to carry out broad measures of sanitary
reform. This difficulty may, it is thought, be mini¬
mised, if not entirely overcome, by a combination of
the respective bodies into one great whole for the con¬
sideration and treatment of the hygiene of the nation
at large. Many sanitary authorities have already
undertaken to send representatives to the conference,
and favourable replies have been received from a large
number of others. The Chairman of the Executive
Committee is Alderman Dr. H. W. Newton, of New¬
castle-upon-Tyne, and Mr. Henry E. Armstrong,
Medical Officer of Health for Newcastle-upon-Tynfc, is
hon. secretary.

Bristol Royal Infirmary.

The Bristol Medico-Chirurgical Journal contains
some strong comments on the new rules adopted at the
Bristol Royal Infirmary. “By what right,” says the
editor, “do the committee or the 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 In¬
firmary? The living governors and their lay com¬
mittee have neither built nor endowed the institution,
and are mainly the inheritors of the generosity of by¬
gone 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 in¬
herit it from their medical forefathers, but they, too,
add their quota to the good repute. The governors
inherit the buildings and endowment, and it is theirs
to maintain ; but so, too, the medical profession in¬
herit the medical prestige, and that is theirs to main¬
tain. But. alas ! and here is the pity, the lay governor,
realising that there is a prestige attaching to his hos¬
pital, considers it is his to manipulate even to the
detriment of the medical staff. If you serve our in¬
stitution, 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 prac-

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374 The Medical Pkess.

MEDICAL NEWS IN BRIEF.

Oct. 2 , 1907.

Using as pure physicians, surgeons, and specialists—
that you have suggested yourselves because it appeared
a real advantage to the institution—but, notwithstand¬
ing 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 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
profession, serve another hospital, to gain experience
outside our walls, that you may become better phy¬
sicians or surgeons. . . . We do not suppose for a

moment that the generous and honourable laymen of
cur 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 un¬
divided, 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 duty 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.”

5t. Bartholomew’s Hospital New Buildings.

The site of this ancient institution has recently been
extended by the purchase of one and a half acres of
adjoining land from Christ’s Hospital. The founda¬
tion-stone of the first new block of buildings was laid
by His Majesty the King in 1904, and formally opened
by H.R.H. the Prince of Wales, President of the Hos¬
pital, in July last, it being ready and in full working
order at the opening of the winter session yesterday.
The new buildings contain the following accommoda¬
tion :—The club rooms of the students’ union, resi¬
dential quarters for the house physicians, house sur¬
geons, and other members of the residential staff, and
for the maternity clerks during their periods of duty.
A separate dining room, with a smoking and a recrea¬
tion room, are provided for the resident medical
officers, and each has his own sitting-room and bed¬
room. All are conveniently arranged and furnished
so as to afford accommodation for the resident staff
second to none in the kingdom. Beside these there is
a new casualty department, 140 feet long and 45 feet
Wide, which gives seating accommodation for 850
people : a new medical out-patient department, and a
surgical out-patient department, an operation theatre,
a dressing and sterilising rooms, etc., have also been
added. There are also departments for diseases of
women, ophthalmic, and aural cases, and for diseases
of the throat and nose. Special accommodation has
been also provided for orthopaedic, skin, X-ray, and
electrical cases, whilst additional rooms have been set
apart for the dental department, and a new clinical
lecture theatre, and a new chemical laboratory com¬
plete these extensive and ideal premises.

St. Mary's Hospital Medical School. Paddington.

As the result of the examinations for the Entrance
Scholarships, 1907, held on September 23rd, 24th, and
25th, the following awards have been made:—Open
Scholarships in Natural Science: £145, J. T. S. Gib¬
son, Aske’s Haberdashers’ School; ^78 15s., C. R.
Harrison, BaJham School; /5a 10s., W. B. James,
Derby Municipal Technical School; £52 10s., C. E. S.
Jackson, Haileybury College. University Scholarships •
60 guineas, H. B. Richmond, B.A., King’s College,
Cambridge. Exhibition of 30 guineas, P. N. Cave
B.A., University College, Oxford..

Medical Man's Straggle en a Liner.

«X? R -' French, the surgeon on the White Star liner
• la l es “C. had an alarming experience during the
l ovage to New \ork last week, narrowly escaping from
death at the hands of an insane stoker. On the third
day out, one of the stokers came to him in his surgery.
Dr. French had no reason to feel alarmed at the man’s

fnIt e wt C J’.? Ut J WaS L SU J'P rised when the latter turned
and locked the door behind him. Then, without any

warning, the stoker threw himself upon the doctor,
hurled him to the floor, and fiercely attacked him.
Dr. French was unable to resist the maniac’s strength,
and could only cry out for help. The stoker held him
by the throat, and the unfortunate doctor was being
rapidly strangled when one of the ship’s officers, find¬
ing it impossible to effect a rescue by means of the
door, fired a revolver through a grating and shot the
lunatic. The man fell back badly wounded, and Dr.
French hastily flinging open the door pinned the man
to the ground until assistance arrived.

Sanitary Committee.—Notification of Births, Doctors'
Objection.

The General Purposes Committee reported that they
considered the advisability of the adoption of the Noti¬
fication of Births Act, 1907, and that the Town Clerk
reported that the Act, which required adoption by the
Council with the consent of the Local Government
Board, required the father of a child, if residing in
the house where it was born or any person in attend¬
ance upon the mother at the birth, or within six hours
after, to notify the birth to the Medical Officer of
Health for the district within 36 hours of the event,
the notification being in addition to the ordinary regis¬
tration of birth. The Act provided that a person
should not be liable to the penalty prescribed for non-
compliance if he had reasonable grounds to believe
that some other person had given the notice, and that
the notice might be given by post-cards, which were
to be supplied, stamped and addressed by the local
authority, free of charge to any medical man and mid¬
wife who applied for them.—It was resolved that the
Council be recommended to take the necessary steps
for adopting the Act.—Mr. Peacock moved the
adoption -of the report, and Mr. Tonkin seconded.—
Dr. Preston King moved that the matter be referred
back to the committee for further consideration in
order that the opinion of the medical men of the city
might be obtained. The adoption of the Act was only
optional, and he thought the committee ought to refer
it to the Bath branch of the British Medical Associa¬
tion. The Act placed upon the medical men, in the
absence of the father, the necessity of notifying the
birth, and thus rendered him liable for doing some¬
thing for which he got not one penny or thanks of any
sort. If the Government had simply reduced the time
during which notification was required to be made,
and retained the machinery of the old Act, which
made the father responsible, it would have been all
right.—Mr. Tonkin said the Act seemed to him to be
a very sensible one. All that was required to be done
was that postcards should be sent notifying the birth.
—Alderman Vincent seconded Dr. Preston King's
amendment.—Mr. Spear said the idea on the part of
the committee was that the Act would be adopted.
Dr. Symons reported the recommendation then, but
now thought it would be better to withdraw it and refer
it back on the ground that the medical men of the
city objected to writing a postcard and sending it
unless they were paid for it. He (Mr. Spear) was not
in sympathy with the attitude of the medical profes¬
sion.—Dr. Ryan said he would be very sorry to think
that the medical profession in Bath as represented by
Dr. Preston King would stand in the way of such an
excellent measure, and he personally would be very
sorry to accept anything for the trouble of writing a
postcard of that sort. He hoped the matter would not
be referred back.—Dr. Preston King said that those
words, as coming from another medical man, were
hardly justified. He was not speaking personally, but
from what he could gather from one or two medical
men who were also absolutely impersonal in the
matter, because they were not affected by it. Before
an Act which was optional was adopted, the persons
who were going to be affected by it ought to have the
chance of being consulted, and those in question
would not have that chance if the Act was adopted
that morning. It was not the question of a fee that
was the mam thing, but the fact that the Act would
render medical men liable to a penalty if they did not
do certain things. They had a right to be consulted.—
Mr. Spear pointed out the duty of sending the card
was not thrown upon the doctor primarily, but upon
the father, and the doctor was not liable to a penalty

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Oct. a, 1907.

MEDICAL NEWS IN BRIEF.

1 The Medical Press. 375

if he had reasonable ground for believing that the
notice was sent by someone tlse in the house. The
Act had been passed as part of a great question—the
question of infantile life in the country. He was glad
to know that Dr. Ryan was thoroughly in favour of
the proposals.—The Medical Officer said he did not
think they should throw upon the medical men the
necessity of sending the postcards. His own idea at
the time the recommendation was passed by the com¬
mittee was that it would not call upon the medical
men at all. When the Act was before Parliament the
idea was that the medical men should not be made
liable, but owing to bad faith the clause was included.
—Mr. Spear said that any prosecution would have to
be first ordered by that committee. They would not
be likely to see an injustice done a medical man of
the city.—Dr. Preston King s amendment was lost by
five votes to four, and the recommendation in favour
of the adoption of the Act was then carried unani¬
mously.

Prizes tor Mothers.

The town of Leipzig has resolved to give prizes to
mothers who nurse their own babies for a certain
length of time. The mothers applying for prizes are
under the supervision of doctors, midwives, and certain
female clerks of the town orphanage. Midwives who
persuade mothers with success to nurse their own
children are entitled to a money present.

The Sea Water Cure.

A tragical ending to an experiment with Dr.
Quinton's sea water injection cure has just thrown an
aristocratic family into mourning.

Count Victor Benedetti, grandson of the last Ambas¬
sador of the Empire at Berlin, and godson of Prince
Napoleon and Princess Mathilde, was taking a rest
from overwork at Fontainebleau with his father and
mother. In spite of their remonstrances, being
attracted by the wonderful accounts given of the
success of Dr. Quinton’s methods, he insisted on try¬
ing them. The most minute precautions were taken
to obtain the freshest serum, and the operation of sub¬
cutaneous injection was performed.

The next day M. Benedetti complained of violent
headache, and on the following morning high fever
set in. The celebrated surgeon, Dr. C'uneo, was hastily
summoned from Paris, and he hoped at first that it
might be possible to localise the poisoning, but the
strength of the patient was not equal to the vigorous
treatment required, and he sank quickly.

It is not yet certain whether the materials used were
defective, or whether the constitution of the patient
was naturally refractory to a treatment which has
certainly produced marvellous results on others, but
the case proves that the new remedy is one that, for
the present, at least, must be viewed with mistrust.

The Royal University of Ireland.

The following candidates have passed the under¬
mentioned examinations :—

The First Examination in Medicine.—Pass.—Samuel
Acheson, Abraham N. Berman, Mary K. Carroll,
Vincent A. Cox, Frederick Crooks, Cuppage Burke,
Daniel J. Enright, Samuel K. Foster, George H. Hayes,
Thomas Hill, Richard McCulloch, Harold McDonald,
Thomas J. R. Maguire, Henry F. Moore, George R.
Naylor, Louis J. Power, Joseph Prendivilte, Adiel
E. H. Reid.

The following candidates may present themselves for
the further examination for Honours in the subjects
set after their respective names; those qualified in two
or more subjects may present themselves for all:—
Vincent A. Cox, Frederick Crooks, Daniel J. Enright,
Samuel R. Foster, Thomas J. R. Maguire, Henry F.
Moore.

The Second Examination in Medicine.—Upper Pass.
—Richard H. Barter, Harold Black, Michael J.
Fogarty, Thomas J. Kilbride. Patrick D. McCullen,
Stephen A. McSwiney, Michael Moloney, Denis
Murphy, Thomas Reynolds, Charles J. Simpson, James
Stewart. All the above candidates may present them¬
selves for the further examination for Honours.

Pass.—James T. Brady, Percy M. J. Brett, Francis J.
Burke, Louis Cohen, George Cooper, Robert C.
Cummins, Thomas A. Daly, Ernest S. Dixon, Herbert
Emerson, Thomas Fitzgerald, Philip J. Gaffikin,
George S. Glass, B.A., James J. Hanratty, Charles A.
P. Harrison, Timothy F. Hegarty, Daniel Higgins,
Robert A. Kerr, Alfred J. Moran, Joseph K.
O’Sullivan, Gerard Sheridan, William J. Smyth, John
Stephenson, Bernard Teeger, Francis J. Wisely.

Exempt from further examination in Practical
Chemistry.—Jane L. Law, Mary A. Murphy.

Apothecarlea' Hall of Ireland.

At a meeting of the Court of Directors the following
were elected Examiners for the ensuing year: —
Chemistry and Physics.—Prof. Hugh Ryan, D.Sc.,
F.R.U.I. ; J. J. O’Sullivan, L.R.C.P.S., D.P.H.
Biology.—Prof. D. J. Coffey, M.D., F.R.U.I. ; John
Knott, M.D. Anatomy.—Prof. Frazer, M.D.,

F.R.C.S. ; P. J. Fagan, F.R.C.S. Physiology.—Prof.
D. J. Coffey, M.D., F.R.U.I. ; John Knott, M.D.
Medical Jurisprudence.—W. Fottrell, L.R.C.P. and
S.I. ; J. C. McWalter, M.A., M.D., D.P.H. Phar¬
macy.—J. A. Walsh, L.R.C.P. and S.Edin. ; J. C.
iMcWalter, M.A., M.D., D.P.H. ; E. F. Hanrahan,
M.B., B.Ch. Materia Medica.—John Evans,

L. R.C.S.I. ; John D. Crinion, L.R.C.P. and S.
Pathology.—J. L. Keegan, F.R.C.S. ; R. J. Rowlette,

M. D. Hygiene.—Sir C. Cameron, C.B., M.D. ; C. J.
Powell, F.R.C.S., D.P.H. Ophthalmic Surgery.—H.
Mooney, F.R.C.S. ; F. Odevaine, F.R.C.S. Medicine.—
John Marshall Day, M.D., D.P.H. ; John 0 "Donnell,
M.B., B.Ch. Surgery (appointed by the General
Medical Council).—Sir Lambert Ormsby, M.D.,
F.R.C.S. ; Prof. Conway Dwyer, M.D., F.R.C.S.
Midwifery and Gynaecology.—Gibbon Fitzgibbon,
M.D. ; R. J. Fleming, M.D.

Uni varsity of Durham-

The following candidates have passed the first
examination for the degree of Bachelor in Medicine,
September, 1907: —

1. —Elementary Anatomy and Biology, Chemistry
and Physics.—Honours.—First Class.—John Hamilton
Barclay, Michael Brennan. Honours—Second Class.
—William Hudson. Pass List.—Joseph Jopling
Brown, Eleanor Walkinshaw.

2. —Chemistry and Physics.—John Bain Alderson,
Ronald Grieg Badenoch, Richard Murray Barrow,
Roger Errington, David Farquharson, Sarah Louisa
Green, Thomas Albert Hindmarsh, Laurence Heber
Warneford Iredale, Frank Hutchinson Kennedy, John
Lumb, Benjamin Bell Noble, Charles O’Hagan,
Arthur Hyde Wear.

3. —Elementary Anatomy and Biology.—Louis
Ernest Seide Gelle, Harold Llewellyn James, Russell
Vyoyan Steele.

The following candidates have pased the second
examination for the degree of Bachelor in Medicine : —

Anatomy, Physiology, and Materia Medica (Pass
List).—Oscar Frederick Don Airth, Isaac Bainbridge,
Helen Grace Clark, Robert Vickers Clayton, Bloom¬
field George Henry Connolly, John Hare, Samuel
Littlewood, George Cuthbert Mura M'Gonigle, John
Howard Owen, Madeline Rosa Shearburn, Matilda
Ann Sinclair, Eric Hemingway Shaw, Carl Johan
Valfrid Swahnberg, Olivia Nyna Walker, Stanley
Worthington, James Carruthers Young.

The following candidates have passed the third
examination for the degree of Bachelor in Medicine : —
Pathology, Medical Jurisprudence, Public Health,
and Elementary Bacteriology. — Honours — Second
Class.—Robert Raffle. Pass List.—Hubert Cyril Wil¬
loughby Allott, Harriett Amelia Apps, Alexander Hay
Bower, John George Campbell, B.A., Leslie Wilson
Evans, Patrick Albert Galpin, Francis Frederick
Hare, Edward Pierce Hughes, John Pritt Jackson,
Annie Viccars Mack, Charles James Neilan, Ruth
Nicholson, Charles Elias Reindorf, Theodore W. Stally-
brass, Harold Widdrington Sykes, Dorothea Mary
Tudor.

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376 The Mbdical Puss. NOTICES TO CORRESPONDENTS.

NOTICES TO
CORRESPONDENTS, S*c.

CoRREsroNDENTs requiring a reply in this column ere par¬
ticularly requeeted to make uae of a Diitinctive Signature or
Initial, and to avoid the practioe of signing themselves
“ Header," ’’ Subscriber," ' Old Subscriber," eto. Much con¬
fusion will be spared by attention to this rule.

SUBSCRIPTIONS.

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each year begin on January 1st and July 1st respectively. Terms
per annum, 21 s.; poet free at home or abroad. Foreign sub¬
scriptions must be paid in advanoc For India, Messrs. Thacker,
Spink and Co., of Calcutta, are our offloially-appointed agents.
Indian subscriptions are Rs. 15.12.

ADVERTISEMENTS.

Fob Oms Insertion :—Whole Page, £5; Half Page, £2 10s.;

Quarter Page, £1 5e.; One-eighth, 12s. 6d.

The following reductions are made for a series:—Whole Page, 13
insertions, at £3 10s.; 26 at £3 3s.; 52 insertions at £3, and
pro rata for smaller spaces.

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6 d. per line beyond.

Reprints. —Reprints of articles appearing in this journal oan
be had at a reduced rate, providing authors give notioe to the
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should be done when returning proofs.

Original Articles ob Letters intended for publication
should be written on one side of the paper only and must be
authenticated with the name and address of the writer, not
neoessary for publication but as evidenoe of identity.

THE INVENTION OF SPECTACLES.

To the Sditor of The Medical Press and Circular.

Sib,—Y our correspondent on this subject in the last issue
(September 25th) is in error in supposing that the quotation
■' Now we see through a glass," etc., might be translated
" through glasses." The Greek word means a “ mirror.”

Yours faithfully,

Hetwood Smith.

25 Welbeok Street, Cavendish 8quare, W.,

September 26th, 1907.

M. O. H.—As with most questions, there are two sides to the
health visitor matter. In his last report, the medical officer of
health for Hammersmith says: " It is interesting to note that,
notwithstanding the fact that the oouncil appointed a lady
health visitor, with the object of lessening the infantile mortality,
it has Mtusdly gone up eleven per 1,000 as compared with
London. These facts rather tend to prove that the onuses of
Infantile mortality are, to a very considerable extent, due to
social conditions, and are beyond the power of sanitary authori¬
ties to prevent. I am not of opinion that any practical good is
achieved by the appointment of lady health visitors." We are
inclined to think that suoh an opinion is not that generally
held.

School Htqixnist —The French have a much more thorough
procedure for the prevention of infectious diseases through
school influence than anything we know of here. In a recent
ediot from the Minister of Publto Instruction to publio elementary
school authorities, the most stringent precautions are specifically
enjoined. For instance, in the case of soarlet fever, not only
is the ohlld to be excluded from school, but his boolu are all to
be destroyed, and genera] disinfection of the eohool oarried out.
Similar precautions are enjoined in the case of measles, and
all pupils under six may be excluded from school as well. With
regard to small-pox, re-vaccination of all teachers and children
is required, in addition to all other measures.

JHtctirgB of the goatlits, XtOxcct *, Sec .

Wrdnesdat, October 2nd.

Medical Graduates’ College and Poltclihic (22 Chenies
Street, W.O.).—4 p.m.; Mr. J. Berry: Clinique. (Surgical.)

Thursday, October 3rd.

Medical Graduates’ College and Policlinic (22 Chenies
8 treet, W.C.).—4 p.m.: Mr. Hutchinson: Clinique. (Surgical.)

North-East London Post-Graduate College (Pnnce of
Wale’s General Hospital, Tottenham, N.).—4 p.m.: Opening
Lecture:—Dr. W. H. White: The Various Conditions causing
Enlargement of the Liver. (In conjunction with the North-East
London Clinical Society.)

8t. John’s Hospital tor Diseases or the Shin (Leicester
Square, W.C .).—6 p.m.: Chesterfield Lecture:—Dr. M. Dook-
rell: The Present Position of Dermatology.

Fridat, October 4th.

Medical Graduates’ College and Policlinic (22 Chenies
8 treet, W.C.).—4 p.m.: Mr. A. Lawson: Clinique. (Eye.)

North-East London Post-Graduate College (Prince of
Wales’s General Hospital, Tottenham, N.).—10 a.m.: Clinique: —
Surgical Out-patient (Mr. H. Evans). 2.30 p.m.: 8 urgical Opera¬
tions (Mr. W. Edmunds). Clinique:—Ophthalmologies] (Mr.
Brooks). 3 p.m.: Clinique: Mediod In-patient (Dr. M. Leslie).

^ppoiirtmems.

Dai. W. F. L.. M B., B.C.Csntab., M.R.C. 8 ., L.R.C.P.Lond.,
Medical Officer and Publio Vaccinator for the Parndon, Nate-
ing, and Roydon Districts of the Epping Union.

O ct. 2, 1907.

Evans, R. E., M.D., M.S.Edin., Certifying Surgeon under the
Factory and Workshop Aot for the Newoastleton District of
the oounty of Roxburgh.

Hilton, Albert, L.8.A., Medical Offloer of Health to the Hurst
District Oounoil, Ashton-under-Lyne.

Kino, D. Bartt, M.D., M.R.C.P.Edin., Examiner in Medicine
and Clinical Medioine at the University of St. Andrews.

March, Geoffrey Collet, L.R.C.P.Lond., M.R.C. 8 ., District
Medioal Offloer by the Dorchester (Dorset) Board of Guar¬
dians.

Riogall, Robert Marmaduee, L.R.O.P., Third Assistant Medical
Offloer to the Devon Oounty Asylum, Exminster.

Turnor, P.W., L.R.C.P., M.R.O.S.Eng., Certifying Surgeon under
the Factory and Workshop Act for the Penkridge District of
the oounty of Stafford.

Van Buben, Asa Claude Ali, M.D., B.S.Lond., L.R.C.P.,
M.K.C.S., Honorary Anaesthetist to the Torbay Hospital,
Torquay.

UacanneB.

Riccartsbar Asylum, Paisley.—Resident Medical Officer. Salary,
£120 per annum, with board and apartments. Applications to
J. M. Campbell, Clerk, Parish Counoil Buildings, Paisley.

Manchester, University of.—Senior Demonstrator in Physiology.
Salary, £150 per annum. Applioationa to the Registrar.

Manchester Royal Infirmary.—Resident Surgical Officer. Salary,
£150 per annum, with board and residence. Applications to
Walter G. Carnt, General Superintendent and Secretary,
Manchester Royal Infirmary.

Jersey Dispensary.—Resident Medioal Offloer. Salary, £120 per
annum, with furnished quarters and attendance. Applications
to Secretary.

Bradford Poor-Law Union.—Resident Assistant Medioal Offloer.
Salary, £100 per annum, with rations, apartments, and
washing. Applications to Qeorge M. Crowther, Clerk to the
Guardians, Union Offioes, 22, Manor Row, Bradford.

Brompton Hospital Sanatorium.—Assistant Medioal Offloer.
Salaiy, £150 per annum, with board, lodging, and washing.
Applications to the Secretary, Brompton Hospital, London.

Worcester County and City Asylum.—Third Assistant Medioal
Offloer. Salary, £140 per annum, and all found. Application
to Superintendent, Powiok, Worcester.

Three Counties (Gloucester, Somerset, and Wilts) Sanatorium for
Consumptives, Winsley, near Bath.—Resident Medioal Offloer.
Salary, £200 per annum. Applications to the Secretary.

Provincial Hospital, Port Elisabeth.—Assistant House Surgeon.
8 alaiy, £225 per annum, with board and residence. Applioa¬
tiona to H. Chaplin and Co., 9 Fenohuroh Street, London,
E.O.

Hull City and County Lunatio Asylum.—Second Assistant Medical
Offloer. Salary, £150 per annum, with board, apartments,
washing, and attendance. Applications to the Chairman of
the Asylum Committee, care of the Town Clerk, Town Hall,
Hull.

Lewes Dispensary and Infirmary and Viotoria Hospital.—Resident
Medioal Offloer. 8 alary, £120 per annum, furnished apart¬
ments, board, ooal, gas, washing, and attendance. Applica¬
tions to Secretary.

jBirihe.

Dunn. —On Sept. 23rd, at Murree, Punjaub, India, the wife of
Major H. N. Dunn, R.A.M.O., of a son.

Hill. —On 8 ept. 25th, at Rainoliffe, Dorset Road, Bexhill-on-Sea,
the wife of Walter de Marohot Hill, M.R.O.S., of a daughter.

JWarriagcB.

Coated—Ewer.— On Sept. 24th, at the Cathedral, Capetown,
South Africa, John Coates, F.R.C. 8 ., seoond son of Edward
Coatee, of Fulham, London, and Heaoham, Norfolk, to Wini¬
fred Julia, only daughter of William Thomas Ewer, of
Prince’s Avenue, Muswell Hill, London.

Cunningham—Winter. —On 8 ept. 27th, at St. John's Church,
Westminster, Robert Allan Cunningham, Captain R.A M.C..
seoond son of R. A. Cunningham, Esq., of Ballybofey, Co.
Donegal, to Hope Caroline, youngest daughter of the late J.
E. Winser, Esq., of Hamburg.

Dennis—Ruce. —On Sept. 25th, at St. Ambrose Church, Bourne¬
mouth, Albert Lewis, youngest son of the late Rev. G. M.
Dennis, of West Meath, Ireland, to Constanoe Anne, youngest
daughter of the late David Ruok, Esq., M.R.C.S., of Ciren-
oester, Gloe.

Sears—Dew. —On Sept. 28th, at Sydenham Baptist Church,
Forest Hill, Charles Newton Sears, M.D., B.S.Lond., M.R.C. 8 .,
L.R.C.P., of “ Point View," Burnt Ash Hill, Lee, second son
of J. Tresidder Sears, Esq., J.P., of Lee, to Annie Florenoe,
the youngest daughter of Charles Dew, Esq., of Forest Hill,
London.

Braths.

Jenkins.—O n Sept. 26th, at Colomendy, Ruthin, Josiah Roberts
Jenkins, M.D., J.P., in his 8 lst year.

Meakin.—O n Sept. 21st, at Nordrach-upon-Mendip, Captain
Harold Budgett Meakin, M.D. (Indian Medioal Servioe), aged

8tewabt. —On Sept. 27th, Professor Charles Stewart, LL.D..
F.R.S., of 38 Lincoln’s Inn Fields, Conservator of the
Museum of the Royal College of Surgeons of England, aged
67.

White.—O n Sept. 2rd, at Hampstead, Major R. W. Persae White,
Welsh Regiment, ton of the late Robert Persae White,
F.R.C. 8 .I., Dublin.

Digitized by LjOoql e

The Medical Press and Circular.

"SALUS POPULI SUPREMA LEX."

Vol. CXXXV. WEDNESDAY, OCT. 9, 1907. No. 15

Notes and Comments.

Thu quack dealers have not hitherto
displayed their wonted enterprise in
Radium for the exploitation of radium as a cure.
Everything. Considering how electricity and
other kindred discoveries have in
the past enriched unscrupulous scoundrels
who advertised them as cure-alls, and con¬
sidering also how much more activity there
is in the quack world now-a-days, one can¬
not help wondering whether the enormous price of
radium or whether its feeble therapeutic power
has been the drawback. As to the price, that need
not, on the electric-belt theory, be a consideration
at all, for it would not matter whether radium was
present or not so long as the advertisements and
the testimonial writers said that it was; and as to
therapeutic powers the mere fact that doctors had
found it of little service would have been the best
card a quack-merchant could play to show the
unique character of his “ discovery.” Nevertheless,
we have waited in vain. Last week, however,
“The Radite Company” ventured into the field
and issued a leaflet describing the virtues of their
“radite powder,” composed mainly of pitchblende
and radite, and containing radium. This wonder-
ful powder brings radium into the therapeutic field
of the million, and it should be purchased, sav the
company, by all persons suffering from pain of any
kind, all persons suffering from eczema, psoriasis,
acne, and other skin diseases, and persons whose
hair is growing thin, and so on.

The powder is to be applied in
■“ Freckles and various ways, either on a pad, or as
Other Morbid “ radite water,” or as a “ radium disc,”
Growths.” which latter will remove warts,
corns, moles, birthmarks, freckles,
and other morbid growths (sic). Malign surface
tumours, rodent ulcers, cancer of the skin, and
sores in general, may be greatly ameliorated, and
in many cases cured by the application of a radium
disc. Such a disc is supplied in leather cases for
7s. 6d., whilst “radite powder” costs 5s. per
ounce. Now, as radium bromide itself costs
^ 453 , 59 2 P er ounce, according to the statement
of the company, it would make a pretty calculation #
to ascertain how much radium is contained in radite
powder, but perhaps this poverty in the element
should really be regarded as the safeguard of this
preparation, in that there is not much likelihood of
radium-burns. In order that “radite” may become
better known a competition on the lines of the
present Limerick craze is being organised, and
whether the competition or the remedy is to prove ;
the more popular remains to be seen. Still, now ,
the ice is broken we shall probably- soon have as
many quack advertisements of radium preparations
as there lately were of electric belts and batteries,
and all of about equal therapeutic efficacy.

With regard to quack medicines,
Australia last Christmas the Government of

and Quack Australia appointed a Royal Corn-

Medicines. missioner, not a medical man, to
inquire into the question of quack
medicines in the Commonwealth, and to recom¬
mend what steps should be taken with regard to
them. This gentlemen, Mr. Beale, has recently
issued his report, which is a very voluminous one,
and the conclusions he comes to are most far-
reaching and important. He recommends that
letters-patent should be issued for approved and
novel formulae for the prevention and cure of human
ailments, and though this suggestion would sweep
;rway all present patent medicines, not one of which
is novel or original in any degree, we fear it would
tend to act as a commercial incentive to real dis¬
coverers who now give their work freely to the
world. Still, such a rule would do no harm if it
were more honoured in the breach than in the ob¬
servance, except in so far as concerns the denying
of patents to remedies that are not novel, and such
refusal in itself would constitute a valuable reform.

But Mr. Beale’s further recommen-
And Their dations are those which lie at the

Cure root of a11 P ro P er P atent

regulation. He suggests that every
patent medicine when retailed shall
bear its formula of preparation on a label; that
no advertisement shall be allowed on the article
itself or its covering; that no advertisement
of anv proprietary or secret cure shall be allowed
to be published; and that transmission of advertis¬
ing matter concerning such medicines through the
post shall be forbidden. If we make the slight re¬
servation that genuine new preparations prepared
by respectable firms should of course be made
known to medical men through the post and by ad¬
vertisement, we can most cordially endorse Mr.
Beale’s conclusions, which would finally dispose
of the most glaring public fraud of the day. It is
a humiliating but none the less a well-deserved
reproach that this Colonial Commissioner should
point to the Mother Country as demanding “an
eighth share in the full retail price of every, even
the most pernicious, proprietary specific under
quasi-medical pretence.” We recently drew atten¬
tion to the interesting fact that the Cape Legisla¬
ture recognised the undesirable character of cer¬
tain cancer “ remedies,” and forbade their sale;
New Zealand is making a big struggle against the
newspaper interest to rid herself of the plague;
and Australia has its way now mapped out for it,
if it will move. The “ Old Country ” has not even
turned in its bed.

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378 The Medical Pbkss

LEADING ARTICLE.

Oct. 9, 1907.

Temperance

Research.

We have been asked to notice the
proposals of the Education Com¬
mittee of the National Temperance
League with regard to some opera¬
tions they hope to take in hand.
This committee is asking for funds to promote
scientific research into the nature and effects of
alcohol, to translate scientific treaties on the same
subject from Continental language into English, to
distribute literature dealing with the effect of
alcohol on the human organism to leaders of
thought, to hold education conferences, to promote
the teaching of hygiene and temperance in schools,
and to publish fresh evidence as obtained regarding
the deleterious action of alcohol on the tissues.
These are highly commendable objects, and the
committee is strongly manned with names which
command respect, but we cannot help thinking that
the League, being a militant one, would do well
to leave research alone. Scientific inquiries are
best conducted in an absolutely impartial
atmosphere; indeed, we might say, can only be so
conducted. The temptation of making facts square
with predilections is so great to our frail human
minds that any research work conducted by the
League would necessarily fall under the suspicion
of being biassed, and surely there must be plenty
of educative work to be done on facts already
known.

LEADING ARTICLE.

THE SHEFFIELD UNION INFIRMARY
DEADLOCK.

The touch of sensationalism given by the lay
Press in their headlines, “ Doctors on Strike,” in
connection with the recent occurrences at the
Sheffield Union Infirmary', was in no way
justified. There has been no “strike.” The rules
and regulations under which the staff worked
did not conduce to comfort and pleasure on the part
of the resident staff ; dissatisfied with their position,
they resigned, as they had a perfect right to do,
and there had been several resignations during the
preceding year. The Guardians wished to have a
visiting staff, consisting of a physician and a
surgeon, whose position was to be more or less
honorary, but who were to receive an honorarium
or salary for their services, fixed respectively at
£141 15s. and ^115 10s. a year. They were
fortunate in securing the services of two of the
leading men in the town to take the positions,
chiefly because of the increased clinical experience
attached thereto. No one could say that the re¬
muneration erred on the side of full market value,
when it is remembered that they were responsible
for the treatment of all the patients in a hospital of
500 beds, and that they were bound to visit three
times a w’eek, the rate of pay being less than £1
a visit. To assist them, three resident medical
officers were appointed, their positions being on a
par with that of house surgeons in an ordinary
hospital. The main source of difficulty arose in
trying to meet the requirements of the Local
Government Board, as to having a responsible
officer to discharge the duties of “ Medical
Superintendent.” Neither of the visiting staff
accepted that position. It was sought to place
the burden upon the senior resident medical
officer. Whilst asking him to take on these duties,
the Guardians refused to define the limitations of
his duties and responsibilities. The resignations

which have taken place from time to time arose
from the friction to which this unsatisfactory con¬
dition of affairs not unnaturally gave rise. The
residents say that the Guardians treated them with
a want of prop?r consideration when they brought
matters to their notice; the Guardians seem to have
thought that all that these young men had to do
was to receive any orders that were given to them,
and carry them out without any reference to what
their feelings in the matter might be. It is hardly
surprising that this scheme of the Guardians was
found in practice not to work, however estimable it
might have been in theory. The absence of a well-
paid, responsible officer at the head of affairs,
whose duty would be to see that the requirements
of the Local Government Board were properly
carried out, who, on the one hand, would have the
affairs of the hospital, as to staff and management,
well under control, and on the other, would
be responsible to the Board for the administration
of the institution, is the real cause of the recent
breakdown of the Guardians’ scheme, and of the
resignations which have taken place. The cost
of the recent scheme was ^557 5s.; when one
remembers that there are 500 beds in the hospital,
no one can say that the Guardians rate the services
of their medical men too highly. The old order
having passed away, the new scheme of the
Guardians is as follows : There are three resident
men to be appointed; a superintendent medical
officer, who is to be between thirty and forty years
of age, and who is to have a salary of ^300 a year,
with board and residence, and two assistant medical
officers, with salaries of ^100 and £80 respec¬
tively, the total cost to be ^480. The change
effects a saving of some £75 5s. Three men are
to do the w’ork of the five that held the appoint¬
ment before. The writer of “Current Topics” in.
the Sheffield Daily Telegraph says, “\Ye should
like to know how it comes about that if three
doctors are sufficient now, five were employed
heretofore. In other words, can three men do five
men’s work? The saving, of course, is fatuousp
the figure is too small to worry about. It is only
efficiency that matters in such a case.” Of course,
if men are to be fouud who are satisfied with such
remuneration for so responsible a post as that of
medical superintendent, having reached the age of
between 30 and 40, there is no more to be said; the
Guardians would be foolish to pay more. Possibly
the class of cases admitted to such infirmaries may
not be such as to require a high order of medical
knowledge or skill, and there are men whose
ambition in life would be quite satisfied, at such
an age, with the benefits and emoluments of such
a post. They are not likely to go much farther in
the race of life. We can but wait and see how
matters work out.

The Guardians tried to throw the responsibilities
of the resignations upon the Sheffield District of
the B.M.A. They said it was the result of action
taken by the District. This, of course, the local
secretary was able at once to repudiate. The
District had taken no action in the matter until
after the resignation of the three residents.
They then considered matters, and came to
the conclusion that it was not their concern;
but, contrary to the wishes of several men in the
District, they passed a resolution, that “ they con¬
sidered, under the circumstances, that the posts at

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Oct. 9, 1907.

CURRENT TOPICS.

The Medical Press. 379

the Infirmary were untenable.” Those who ob¬
jected to their taking any notice of the affair at
all did so on the grounds that, as they were not
going to meet a delegation from the Board of
Guardians to discuss matters, or mix themselves
up in the affair, it would be wiser to say nothing,
as any action of theirs would only be taken on a
cne-sided statement of what had taken place.

THIRD REPORT OF THE ROYAL COM¬
MISSION ON VIVISECTION.

The Royal Commission on Vivisection has just
issued the third volume of the minutes of evidence
taken before it, and without prejudice it may be
said to be even more damning to the “ cause ” than
its predecessors, little encouraging as they were.
An interesting witness was Lord Justice Moulton,
who, as an eminent lawyer and a scientific man
having had no personal contact with experiments
on animals, may be regarded as what he was
actually called by Lord Selby “a highly qualified
outsider.” Lord Justice Moulton, both from the
point of view of the increase of knowledge and from
that of ethics, was in favour of the practice of ex¬
periments on animals under due regulation, holding
that one is justified in the present state of affairs in
inflicting a lesser evil when there is a reasonable
prospect of avoiding a very much greater one. But
from the logical moderation of Lord Justice Moul¬
ton we turn to the utterances of the Hon. Stephen
Coleridge, who was under examination for three
days, and who managed in that time to execute a
series of verbal gymnastics which may well puzzle
both his satellites and the objects of his venom.
Since the days of the Bayliss libel trial, when Mr.
Coleridge was convicted by twelve of his fellow
countrymen of the sin of “ talking through his hat,”
there have at times been signs almost of grace in
that eminent protagonist, but we confess that we
raised our eyebrows when we read that Mr. Cole¬
ridge, in his evidence, said that he directed himself
against the infliction of suffering, but did not ob¬
ject to the utilisation of animals for scientific pur¬
poses, provided it was painlessly conducted. We
must not too hastily assume that Mr. Coleridge is
now a moderate vivisectionist, as these words would
seem to imply, for it seems he considers anaesthesia,
when testified to by expert physiologists, as not
sufficient for his purposes. Apparently he con¬
siders scientific men as ready to state any untruth
to cover their misdeeds. Experimenters, he said,
would deny a breach of the Experiments on Animals
Act, 1876, just as he himself would deny a breach of
the Motor Car Act. *T drive a motor car, and when
I go 'beyond the speed limit and a policeman asks
me, I say, ' No, I am not going beyond the speed
limit.’ Nothing would keep me from going be¬
yond the speed limit except the presence of a
policeman in the car.” On being asked whether
he would expect his word to be disbelieved, Mr.
Coleridge replied, “ No, I do not say so.” If any¬
one can make rhyme, reason, sense, or consistency
out of Mr. Coleridge’s efforts before the Commis¬
sioners, they will have accomplished a task beyond
the powers of plain men who are accustomed to use
the word “ Yea ” and “ Nay ” in their exact and
literal signification. Miss Lind-af-Hageby, of
“ Shambles of Science ” fame, gave evidence to
the effect that she did not believe that
vivisection experiments were generally carried on

under deep surgical anaesthesia—and against a
woman’s belief it would be absurd to argue—and
also that she objected to vivisection on the whole
principle of exploiting the lower animals for our
supposed service and use. The latter is a com¬
prehensible position, but if adhered to by a
society which eats beef and eggs, drinks cows’
milk, drives in ’buses (not motor), and wears boots,
it would entail considerable change in custom. Be¬
yond these witnesses there were some minor anti¬
vivisection lights, and a number of scientific and
medical men, but their evidence pales into in¬
significance before that tendered by Mr. Coleridge
and Miss Hageby.

CURRENT TOPICS.

The No Man’s Ground of the Milkman.

The community has much to endure at the hands
of the milkman. Not least of all is the crashing of
his pails and the rattling of his springless carts.
When the small things of social reform come to be
handled by county councils we may hope to have
springs fixed to his—and for that matter to all
tradesmen’s—barrows, and buffers attached to milk
cans, so as to lessen their brazen and altogether un¬
necessary clatter. So much for milkman’s form,
now for his material. On the whole there can be
little reasonable doubt that an immense amount of
diluted milk is daily palmed off upon a long-
suffering public. In spite of laws and by-laws
galore the merry milkman, with a mild twinkle in
his meditative eye, goes his way from morn to
eve placidly retailing water at the price of pure
cow’s milk. Truth to say, legislation, whether of
Parliament or of local council chamber, has left
him on a sort of Tom Tiddler’s ground, whence
he may survey with indifference the heathen raging
of the sanitary authorities. If he is haled into
court all he has to do is to produce a warranty of
purity from the farmer who has sold him the milk,
and to swear he has retailed it in the same con¬
dition. He promptly leaves the court without a
stain upon his character. The farmer never at¬
tends, and the difficulties in the way of fixing the
offence upon the farmer are hopeless. The way
out of the wood—as recently pointed out by the
correspondent of a London daily—is to summons
both milk dealer and farmer together, and let them
fight it out in court. Then there would be some
chance of the honest ratepayer coming by his own.

The Veterinary College and Unqualified
Practice.

The College of Veterinary Surgeons, fortunately
for its diplomates, seems prepared to protect their
rights in a way that might well be taken to heart
by our own Medical Colleges. At Feltham Petty
Sessions the Veterinary College prosecuted an
Ashford resident, named Wilson, for stating
that he was specially qualified to practice a
branch of veterinary surgery by publishing
the description “canine and feline medical
expert.” The owner of a St. Bernard puppy stated
that he took the dog to defendant, who produced
a stethoscope, and having examined the dog all
over, said it suffered from kidney disease. £1 was
paid, and the dog left with defendant, who wrote
saying the animal was suffering from rickets, and

E

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CURRENT TOPICS.

Oct. 9, 1907.

later, again, from worms. The dog was with him
from April 15th to June 13th, and 12s. 6d. was
paid weekly. The defendant stated he had prac¬
tised for seven jears in Ashford as a canine and
feline medical expert. He had never claimed to
belong to the Royal College of Veterinary
Surgeons. Had he omitted the word medical from
his description dogs and cats would have been
brought to him for an opinion as to their value
only. The Bench convicted defendant, and im¬
posed a fine of 20s., including costs. It would be of
interest to know in how many instances, say, during
the past twenty years, prosecutions for illegal
practice have been undertaken by the Royal Colleges
of Surgeons of the United Kingdom. Their atti¬
tude in this respect, indeed, to some extent, war¬
rants the inference that having taken the quali¬
fication fees of their diplomate their interest in his
welfare ceases. In any case it is abundantly clear
that our own Royal Colleges have neglected the
duty that should be encumbent upon them of pro¬
tecting their fellows, members and licentiates against
the inroads of unqualified practice. It is no excuse
for these ancient and wealthy corporations to plead
that their statutory powers are insufficient. A little
well-directed importunity would doubtless long ago
have secured the necessary legislation. What the
much-abused general practitioner wants is a one
portal qualification with stringent laws against un¬
qualified practice.

Deficient Mortuary Accommodation.

The inadequate mortuary accommodation in
many parts of the United Kingdom, both rural and
urban, has been the cause of public protest time out
of mind. In certain districts, indeed, it has drifted
into the position of a recurrent scandal. One of
the worst features of the lack of proper accommo¬
dation is that dead bodies are often taken to public
houses, where they lie in an outhouse until the
inquest is held in the convenient taproom adjoin¬
ing. As a rule, after a few strong protests, the
matter is allowed to drop, and the same dismal
tragedy is enacted again and again. Were all
coroners as strong and determined as Dr. Drage,
the Coroner at New Barnet, it is likely that before
long the general public mortuary accommodation
of the country would be considerably increased.
At a recent inquest, 'being informed that a body
had been placed in a stable infested with rats, he
declared it was the duty of the overseer to provide
a place for the reception of bodies. He then
directed his officer, pending the provision of proper
accommodation, to take bodies to the drawing-room
of the nearest overseer. This order naturally
brought the overseer up in arms. First, he pro¬
vided temporary accommodation, and then can¬
celled his order, whereupon the Coroner’s officer
declared he would take the next body to the
overseer’s house, where, if refused admission, he
would leave it on the doorstep. We understand
that Scotland Yard has been summoned to the
spot. Meanwhile, further developments may be
awaited with interest.

Poisons in Sweetmeats.

It is, of course, a law of the land that certain
poisonous drugs may not be sold to the public,
except by registered chemists. The reasons for
such limitation are obvious, and it is of importance

to the safety of the public that the law in this
matter should be strictly obeyed. By many methods,
however, it is systematically evaded, and to one of
these Sir James Crichton-Browne has drawn atten¬
tion in a recent address. He has had analyses
made of lozenges of various kinds commonly sold
by grocers, and it has been found that such poison¬
ous drugs as chloroform and chlorodyne are con¬
stituents of many of them. These noxious bodies
are commonly combined with such innocent drugs
as liquorice and linseed, and the compound is 9old
ostensibly to relieve cough. Sir James has evidence,
however, that the lozenges are widely consumed
as mere dainties, and there is little doubt that they
are used for their analgesic properties. Analysis
of certain lozenges sold in Liverpool showed from
2 to 3 per cent, of chloroform present. These
lozenges were on sale in small confectionery shops,
and could be bought without difficulty in any quan¬
tity. In other cases, lozenges containing chlorodyne
were obtained with equal ease. There would seem
to be no practical difficulty in the way of checking
this noxious trade, now that public attention has
been drawn to it. It is comforting to reflect, how¬
ever, that so-called “ chlorodyne ” lozenges often
contain no vestige whatever of the drug in ques¬
tion. A cheap substitute is used by proprietary-
nostrum vendors, in accordance with the universal
rule among that fraternity, which hates expensive
ingredients as the Devil is reputed to hate Holy
Water.

The Police and the Medical Profession.

Nowadays a great deal is heard about the high¬
handedness of police methods, and there seems to
be in many cases a certain amount of justification
for the charge. While making full allowance for
the difficulties of a position which, on the whole, is
filled with credit and honesty, it is nevertheless
necessary to remind the force at times that they
are the servants and not the masters of the public.
The recent absolutely indefensible action, of the
police in their prosecution of Dr. Bagley, of Man¬
chester, for obstructing and assaulting the police
in the execution of their duty, affords an extra¬
ordinary picture of what an arrogant police official
can do in defence of his own illegal act. Dr.
Bagley was called in to an old man who had at¬
tempted suicide, and whose throat he stitched up.
He remonstrated when the police wished to remove
the old man to Ancoats Hospital, and joined the
sons in an ineffectual resistance to that removal.
The magistrates held that the police had no right
to enter the house and remove the man without a
warrant, and they dismissed the case against Dr.
Bagley. The latter, however, incurred costs to
the extent of £30, which the Watch Committee
refused to pay. The local medical profession have
sent a strongly worded remonstrance to the Man¬
chester authorities. It certainly seems hard that it
should cost a private citizen £30 to teach the police
an elementary lesson in their rights as regards ap¬
prehending an Englishman in his own house. After
this occurrence possibly the Watch Committee will
consider the advisability of classes of instruction
and test examinations for its police constables.

The Mid wives’ Act.

The Midwives’ Act has now been before the
public and the medical profession long enough to
justify comment upon its results. On the whole

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Oct. 9, 1907.

PERSONAL.

The Medical Press. 3^1

it may be said that while, on the one hand, there
is no tangible evidence that the maternity of the
kingdom is now being conducted under more
favourable conditions, there is, on the other hand,
considerable reason to believe that the forebodings
of the medical profession are being more or less
fulfilled. The general practitioner has to some
extent ceased to devote himself to the serious prac¬
tice of midwifery, a branch of work which was
formerly one of the mainstays of the professional
income. Moreover, it should be remembered that
all knowledge in midwifery, on which the midwife
depends for guidance, has been founded on the
accumulated experience of many centuries of
medical practice. The exercise of this most
arduous craft has been handed over to a partially-
educated class of women, the most crucial part of
whose technical education consists in acquiring an
inkling of the complications that need the highest
of all possible professional endowments by way of
skill, knowledge, and power to act. Has the
average mother gained by the institution of that
hybrid, the licensed midwife? We think not, for
while a cold water douche has been thrown upon
her old and faithful friend, the family doctor, she
has been provided with a substitute who is ad¬
mittedly unequal to face the unexpected, which in
midwifery is often the difference between life and
death. Now the midwife shares with the medical
man the honorary privilege of notifying births, a
logical extension of her rights that must fill with
pleasure her drawing-room friends.

The Strait Jaoket in the Workhouse.

A recent inquest held by Mr. Walter Schroeder
on a patient who died at the Hampstead Work-
house Infirmary reveals a state of affairs that ap¬
pears to demand full official inquiry. It seems that
a man was sent to the institution named at 2 p.m.
on Wednesday last, and died at 7.35 next morn¬
ing, without having been seen by a medical man.
About 11 o’clock on the night of his admission he
became noisy, and the lunatic attendant, on his
own authority, placed him m a strait jacket; he
collapsed at 6.40 a.m. The medical attendant was
telephoned for at 7 a.m, but the patient died before
his arrival. This appears to be one of the recur¬
rent workhouse scandals of a familiar type in which
a delirious patient, a non-resident medical officer,
a strait jacket and an overworked single-handed
attendant play the chief part. It is to be hoped the
Local Government Board will, in this instance,
intervene so effectually that the possibility of a
repetition of anything of the kind may be rendered
impossible. At certain London institutions we be¬
lieve something of the same kind has been going
on for year after year. Where are the Medical
Inspectors of the Local Government Board?
Surely they were familiar with the shortcomings
of the Hampstead Workhouse Infirmary organisa¬
tion.

The Workmen’s Compensation Act Referees
as Witnesses.

Now that the medical referees have begun work
in the Courts under the Workmen’s Compensation
Act it is desirable to consider the circumstances
under which their office is discharged. Not long
ago in the Liverpool County Court a point of vital
importance was raised by counsel. It appeared

that the medical referee had agreed to give evi¬
dence on behalf of defendant. His position was
commented upon by the appellants in the severest
terms. Quite reasonably, as it will appear to most
plain men, they held that the referee, having
accepted a judicial position, was by implication
cut off from acting as a partisan expert. Counsel
submitted that to adopt the latter function was
indecent, and contrary to public policy, and that it
was a difficulty provided against in the Act. The
other side maintained that the referee was not
bound to the county court in any official capacity,
and his official appointment began only when he
was appointed to any particular case. The judge
held the same view, and ruled it was competent for
the referee to appear as witness; but in such a
case he would be invalidated from acting subse¬
quently as referee to the Court. As a matter of
good taste it would seem desirable that medical
referees, except under most exceptional circum¬
stances, should refrain from appearing as expert
witnesses in compensation claims.

PERSONAL.

Dr. John Freeman, of University College, Oxford,
has been elected to the Radcliffe Travelling Fellow¬
ship for this year.

We regret to record the death of Dr. Seneca D.
Powell, Professor of Surgery in the New York Post-
Graduate School and Hospital.

Sir Felix Semon will give a lecture to the Man¬
chester Medical Society on October x6th on “English
and German Medical Education—A Parallel.”

Dr. George Reid will read a paper to the Incor-

S orated Society of Medical Officers of Health on
ctober nth, at 5 p.m., on “The Planning of Schools.”

Dr. Montague Murray will open the course of
post-graduate demonstrations at Charing Cross
Hospital with a lecture on “Medicine,” to-morrow
(Thursday).

Dr. J. Kingston Fowler, President of the Medical
Society, will give his introductory lecture on October
14th at the inauguration of the 135th Session of the
Society.

The Watch Committee of the Bradford Corporation
have chosen for the chief police surgeonship William
Wrangham, M.D. The appointment is for twelve
months.

Canon Arnott, who was once Lecturer in
Pathology at St. Thomas’s Hospital, is to preach
before the Society of Apothecaries at St. Andrews-by-
the-Ward robe.

Sir Lauder Brunton, M.D., LL.D., will deliver the
inaugural address of the winter session at the London
School of Tropical Medicine, Connaught Road, Albert
Dock, on Monday, October 21st.

Sir Thomas Barlow, President of the Section, will
give the opening address of the Clinical Section of
the Royal Society of Medicine at 20, Hanover Square,
on Friday, October nth, at 8.30 p.m

Dr. James Collier opened the winter session of the
National Hospital for Paralysed and Epileptic,
Queen Square, London, yesterday (Tuesday) with a
lecture on “Local Lesions of the Spinal Cord.”

Professor Osler, F.R.S., will give the opening
address at the University College Medical Society on
October 16th on “The Influence of Medical Society on
the Education of the Medical Student." Sir Thomas
Barlow will be in the chair.

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Oct. 9, 1907.

382 The Medical Press._ CLINICAL LECTURE. ___

A Clinical Lecture

ON

THE SPHYGMOMANOMETER IN MEDICINE.

By ROBERT SAUNDBY, MJXEdin* Hon. LLD* Hon. MSc., FJLCPXond.,

Professor of Medicine In the University, and Senior Physician to the General Hospital, Birmingham.

The old authors described the pulse as large or
small, hard or soft, quick or slow, and so late as the
reign of Charles II. Sir John Floyer, of Lichfield,
was the first who began to count it by its
number of beats per minute, for which purpose
he invented a special watch. From the time of Sir
John Floyer the old terms “quick” and “slow” have
been replaced by numbers and recorded in figures, so
that in this respect at least every medical practitioner,
thanks to him, thinks accurately and precisely. But
for nearly two hundred years the other features of the
pulse remained undetermined. In the sixth decade of
the last century the sphygmograph of Marey placed
in the hands of the clinician an instrument which
enabled him to record upon paper the oscillations of
the pulse, and to compare the curve of the hard pulse
of Bright’s disease with that of the soft pulse of
pneumonia, and to study the changes produced by
alterations of the valves of the heart the stethoscopic
signs of which had recently been brought to perfec¬
tion. The sphygmograph of Marey, excellent instru¬
ment though it was m the hands of patient and skilful
observers, has been superseded by the simpler and
more easily applied form introduced by Dudgeon,
which has remained practically unmodified for twenty
years—a striking test to the sound principles of its
construction. A careful study of pulse tracings and a
comparison of their curves shows that the amount of
information to be derived from them has limits,
and that contrary to what had been thought by the
earlier observers it is impossible to rely upon them
for estimating the blood pressure. The blunt-headed
tracing often met with in high pressure pulses is due,
not directly to the pressure, but to the prolongation of
the systolic wave, which may proceed from other
causes, and the pressure-gauge attached to the
sphygmograph is conditioned by too many factors,
such as the thickness of the tissues surrounding the
radial artery, the rigidity of the instrument, and the
tolerance of the patient, for the results to be relied
upon. Various sphygmometers have been invented to
supply this defect, such as the capsule of Prof, von
Basch, which was constructed on the principle of an
aneroid barometer, or Oliver’s pulsometer, in which
the force of the circulation is measured by the com¬
pression of a spiral spring. My experience of these
instruments is that their readings are too variable
in the hands of different observers to be of value.
It was, therefore, a distinct advance when Barnard
and Hill introduced an instrument consisting of a
mercurial manometer, which measures in millimetres
the pressure required to obliterate the pulse at the
wrist. At the present time the sphygmomanometer of
Riva-Rocci, as modified by Dr. C. J. Martin, is pro¬
bably the best instrument available for clinical work ;
by it, in the course of two or three minutes, the
pressure in the radial artery can be read off in milli¬
metres of mercury. The pulse should be counted and
recorded at the same time and observations which
are intended to be compared should be made in the
same position, either sitting or lying down, and the
manometer should stand at the same level as the
patient’s heart. I have been using Dr. Martin’s
instrument daily for the last year, and have accumu¬
lated sufficient data to enable me to say something of
the practical help it may give us.

In the course of this lecture it is not my intention
to discuss the pulse pressure in all diseases, even if
I had sufficient material from which to draw con¬
clusions, but I propose to direct attention to some
general facts and to the results of observations in
certain forms of disease.

The Normal Pressure.

From my own observations with this instrument the
normal arterial pressure in healthy young adults has
usually been between 125 and 140 mm. Hg.

Age.

It is generally asserted that advancing age is in
itself a cause of raised blood pressure, and so far as
my observation goes this seems to be true, that is to
say, people over 70, even when in perfectly good health
and with no signs of arterio-sclerosis in the shape of
thickened radial artery, have a blood pressure of
about 170. Healthy middle-aged or elderly persons
do not show any rise. Children on the other hand do
not necessarily have a low pressure, and often are
above the normal without any obvious cause. In fact,
if my limited observations are to justify any conclusion
it is that in infants and quite young children the
blood pressure is more often from 140 and 150 than
below, although where there is serious illness it may
fall lower than it does in adults, as for instance in
a child aged two years and four months, with
broncho-pneumonia and fluid in the left side of the
chest, the blood pressure was only 70 and pulse 160.
Among adults low blood pressure (below 100) is very
uncommon even where the patient is very ill. Thus
I have recorded a blood pressure of 98 in a boy aged
14 with malignant endocarditis, and 95 in a boy of 13
with pericarditis; a girl of 14, suffering from phthisis,
had a pulse of 120 and a blood pressure of 95 to 100.
A man aged 34, with malignant endocarditis, had a
blood pressure of 125, and a man aged 48, with fatal
pericarditis, had a blood pressure of 185! I have
seen the blood pressure as low as 95 in a married
lady aged 43 with atonic dyspepsia, but it is in my
experience quite an exceptionad case.

Alcohol.

The influence of alcohol on the blood pressure was
not quite what I had anticipated. The effect of half
an ounce of whisky on a young man aged 28, in good
health, is shown in the following table :—

Time. Blood Pressure. Pulse.

12.13 ••• *5° ••• 68

Half an ounce of whisky with soda water.

12.25

*35

64

12.37

170

60

12.52

. > 3 °

56

In the case of a man with general dropsy from sub¬
acute nephritis supervening upon chronic Bright’s dis¬
ease, who had been ill two months, but had previously
been very temperate in regard to alcohol and
tobacco:—

Time. Blood Pressure. Pulse.

5-35 205 ... 72

Half an ounce of whisky with soda water.

5 55 - 2 3 ° ••• —

8.25 ... 225 ... —

A man, aged 58, had been admitted for epistaxis;
he had some albuminuria and a hypertrophied heart;
pulse, 78; blood pressure, 230. On low diet the pres¬
sure dropped to 135, and then rose to 143; after half
an ounce of whisky it rose in six minutes to 150, and
fell gradually to 135, at which it remained for the
rest of the evening, and was at that figure at 10.15 the
following morning.

Another man, aged 39, who had been a heavy-
drinker and smoker, was admitted with mitral disease
and dropsy. There was a faint haze of albumen;
pulse, 100; blood pressure, 160. On June 5th he had"
half an ounce of alcohol; 15 minutes later the blood
pressure had fallen to 150, and 1} hours later to 145.

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A man, aged 43, with aortic and mitral disease, and
of alcoholic habits, whose urine contained a trace of
albumen, had a pulse of 116; blood pressure, 140;
some time after admission his pulse was 60; blood
pressure, 145.

Time. Blood Pressure. Pulse.

12.7 ... 145 ... 60

Half an ounce of whisky with soda water.

12.23 ... 170 ... 44

12.33 140 ... 46

1.13 ••• T 3 S ••• 45

1.57 ... 150 ... 60

The pressure remained at the last figure late in the
evening, and was still the same the following morning.

Lastly, a man, aged 35, suffering from aortic dis¬
ease, of alcoholic habits, with albuminuria ; pulse 80,
and blood pressure 140. Some weeks after admission
his pulse was 60, blood pressure 165. Half an ounce
of whisky with soda water:—

Blood

Pressure. Pulse.

After 10 mins. ... 168 ... 54

,, 20 mins. ... 145 ... 58

„ 35 mins. ... 145 ... 56

The following morning his pulse was 76, blood pres¬
sure 150.

On looking ov->r these figures, it will be seen that,
although, as a rule, a slight rise of pressure occurred
a few minutes after laking the whisky, the rise was
slight, and not more than might have been caused
by the absorption of a certain amount of fluid. In
the case of the healthy man there was a slight initial
fall, followed by a slight rise, and then another fall.
In most the initial rise was followed by a fall, and in
only one was the pressure permanently raised—viz.,
in the case of advanced Bright’s disease with dropsy.

In all the cases where a record has been kept, the
pulse rate and the blood pressure have risen and fallen
together.

On the other hand I do not find that chronic alco¬
holism, where it has not been complicated by Bright’s
disease, causes permanent high blood pressure; indeed,
where the patient’s general health is falling off, it may
be quite low, as in the case of a patient, aged 50,
suffering from chronic alcoholism, with gastritis and
enlarged liver. His pulse was 114, and blood pres¬
sure 125; another patient, aged 36, with the same
condition, pulse 84, blood pressure 125; a third,
aged 64, with cirrhosis and ascites, after the ascites
had disappeared, pulse 96, blood pressure 145.

Tobacco.

The statement has been frequently made that
smoking tobacco raises the blood pressure and con¬
sequently embarrasses the action of a wealc heart. I
do not doubt that there is sufficient clinical experi¬
ence to warrant us in continuing to give advice to
patients who suffer from weak hearts, whether due to
valvular disease or not, to smoke little or not at all,
but the sphygmomanometer does not show any marked
alteration in either pulse or blood pressure, after
smoking.

Hesse has undertaken a series of experiments in
order to determine whether tobacco exercises any
direct influence upon the circulation. The subjects of
these experiments were partly medical students and
partly patients in hospital. The state of the blood
pressure and the frequency of the pulse were noted
before, during, and after smoking one, two, or three
cigars in succession. In 17 out of 25 cases there was
a slight increase of the frequency of the pulse, asso¬
ciated with a rise of arterial pressure, which was
sometimes marked ; in five the rise of pressure was
unaccompanied by increase in the frequency of the
pulse, and in three the blood pressure fell slightly,
while the pulse frequency rose a little. It was notice¬
able that the chief increase in blood pressure occurred
in subjects whose ages were from 45 to 57 years, while
in young people the alteration was much less marked,
so that it would appear that when the organism is
young it adapts itself more readily to the injurious
effects of tobacco. The result was influenced by the
presence of certain organic diseases, especially
pulmonary emphysema. It is important to observe
whether the subject is, or is not, used to smoking

tobacco; it would naturally be supposed that the
effect would be more marked in the latter case, but
it did not appear to be so, although the number of
cases in which the point was tested was too small to
enable any definite conclusion to be reached. The
effect of tobacco on both the blood pressure and the
pulse frequently reached its maximum at the end of
from twenty to forty minutes when they returned to
the normal limits. In three instances, after the
experiment, a slight accentuation of the aortic second
sound was observed.

The observations that I have been able to make
have been few in number, but so far as they go they tend
to show that at any rate in the case of habitual
smokers the effect of the use of the weed on the blood
pressure is slight. The first case was that of a man
who is a tolerably heavy smoker and whose blood
pressure at 9.34 a.m. was 140; pulse 84 ; in the course
of the day he smoked half an ounce of hand-cut
tobacco and two pipes of twist. His pulse and blood
pressure were taken at intervals with the following
results: —

Time.

Blood Pressure.

Pulse.

IO -35

144

82

12.15

140

84

6 p.m.

160

84

Next morning.

84

9.40 a.m.

... 140

No doubt this table shows a rise of 20 mm. at
6 p.m., but in this man’s case the blood pressure has
been frequently even higher; there is no reason to
ascribe it to smoking, as he was an habitual smoker
and began to smoke in the morning directly after the
blood pressure was taken at 9.35, so that any effect
due to tobacco should have been observed earlier in
the day.

The other man smoked daily a quarter of an ounce
of tobacco. His blood pressure was as follows: —

Time.

Blood Pressure.

Pulse.

9.30 a.m.

... 120

60

10.40

120

72

12.15

100

80

6 p.m.

120

Next morning.

74

10 a.m.

... 120

68

In this case there seems to have been a slight
acceleration of pulse with lowering of the blood
pressure as the result of smoking. These subjects were
elderly men; the first was a case of polycythamia and
the second one of chronic diabetes; both men had
been for long under observation. The diabetic patient
is weak, and is probably suffering from the degenera¬
tion of the heart which occurs in advanced cases.

Diabetes.

According to Potain diabetes is a disease accom¬
panied by high arterial tension, his average being 220
in hospital patients, and 260 in private practice, with
a minimum of 100 and a maximum of 310!

On the other hand, Vaquez in his report to the
Seventh French Congress of Medicine (see La Semaine
Mtdicale , 1904, p. 339) insisted on the fact that the
tension is normal in many cases.

J. Teissier thought cases with increased tension
generally belonged to the class of fat diabetics, while
those with low tension were the cachectic type, or those
complicated by phthisis.

Ambard (Semaine Mtdicale , 1906, p. 362) said that
the cases with high tension were those with
albuminuria, although all cases with albuminuria did
not show high tension.

Severie (Paris Thesis) has studied 29 cases of
diabetes and two of diabetes insipidus ; the maximum
was 240 and the minimum 90. Those with high tension
were either cases of marked Bright’s disease or gouty
or arterio-sclerotic patients, with or without albumi¬
nuria. The tension varied from ipo to 240. Another
case was at the same time arterio-sclerotic, albumi¬
nuric, and tubercular; the tension was at first 180,
and fell rapidly to 120, and death occurred suddenly.
Another patient, diabetic for four years, showed some
signs of early phthisis at the left apex and had had
haemoptysis, yet his tension was 220. These examples
show that pulmonary tuberculosis does not necessarily

Digitized b

y Google

384 The Medical Press.

ORIGINAL PAPERS.

Oct. 9, 1907-

lower the blood pressure. The majority of diabetics
who were neither emaciated, nor albuminuric, nor
arterio-sclerotic showed a blood pressure about
normal (?) 160, 170, or 180; in one case the tension
was as high as 190 in a man of 50 (he was passing
153 grms. of sugar daily), and as high as 240 in another
patient, aged 54, with neither cardiac nor pulmonary
trouble nor albuminuria.

Those with low tension were chiefly tubercular. Ten
tubercular diabetics had tensions ranging from 100 to
150, the average being 129. But cases showing marked
failure of nutrition, with rapid cachexia, even when
free from tubercle, occasionally showed low tension.
For example, a man of 55, whose diabetes was only
of 14 months’ duration, had lost 50 lbs. in weight,
and, in spite of diet, passed 204 grms. of sugar in 24
hours; his tension was only 120 to 130; another man
of 33, passing 8 to 10 litres daily, with 600 to 900 grms.
of sugar, in spite of diet, had a tension at first of
200 to 270, falling rapidly while the cachexia made
progress, and was only 90 when he died. Cases of
tubercular diabetes show a rapid fall of tension a few
days before death, and it may be said that a marked
low tension is always a bad prognostic in diabetics,
whether the patient is or is not tuberculin On the
other hand, high tension is not a specially grave indi¬
cation, unless it rises to about 250, when it should
give cause to fear various complications, especially
cerebral haemorrhage ; but the fat type of diabetic may
often present a tension of 190 to 210 without involving
any immediate aggravation of the diabetes. Such are
the conclusions arrived at by Dr. Severie.

I have studied the blood pressure in 25 cases of
diabetes, of which 7 were albuminuric. The maximum
blood pressure was 180, and the minimum no; the
maximum of 180 was reached, but not exceeded, in
both albuminuric and non-albuminuiic series. The
lowest pressure amongst the albuminuric cases was
120, but this patient was tubercular, and it occurred
soon before his death. Of the non-albuminuric cases
the lowest was no; this was also a few weeks before
the death of the patient, who was not tubercular, but
old (67), weakened and worn out by the disease. The
average pressure amongst the albuminuric cases was
143, and the non-albuminuric cases 139, but the albu¬
minuric cases were on the average considerably older
(50) than the non-albuminuric cases (38). The only
tubercular case was among the albuminuric patients,
and his low blood pressure had some effect in reducing
the average. One death occurred in each series, and
each fatal case gave the lowest recorded pressure.
The conclusion to be drawn from these cases is that a
low pressure (below 130) is of bad prognosis, and is
only met with in cases which have not long to live,
but a single observation must not be relied upon, as a
neglected patient may be run down and weak, and his
blood pressure be very low, but after treatment he
may recover, as in the case of a man I have at present
in hospital; yet such a drop indicates that the case
is grave and the condition serious, as it undoubtedly
was here, for it was accompanied by loss of weight
and di-aceturia.

Heart Disease.

Nothing is more paradoxical than the figures given
by the sphygmomanometer in cases of heart disease,
for even when uncompensated and requiring the patient
to be confined to bed, the pulse tension sometimes is
above normal, often normal, less often slightly re¬
duced, and rarely or never lower than no to 115,
except in children. In aortic regurgitation pressure
may be quite high (210 to 220), and it was never less
than 125. In some cases of mitral disease it was as
low as no and 115, but was usually about 140, and
occasionally as high as 180. Apparently the heart
keeps the circulation to the normal level so long as it
continues to beat, in spite of valvular disease or even
grave lesions of the myocardium. A case of angina
pectoris in a man aged 50 showed a blood pressure of
210 and a pulse of 60; there was no albumen in his
urine, but he had used alcohol and tobacco. In leuco-
cythaemia, simple anaemia, and in Hodgkin’s disease,
the blood pressure was low, but never much below
normal limits, the minimum being no in a case of
slight anaemia, with marked debility.

Bright’s Disease.

As might be expected, it is in Bright’s disease that
the sphygmomanometer gives most marked departures
from the normal, but it is only in chronic nephritis
that high readings are constant. In acute and sub¬
acute cases the blood pressure is often normal, and I
think it might be said that in cases that look like
acute or sub-acute nephritis, where the blood pressure
is over 160 or 170, the probability is that the case is
one of chronic nephritis, upon which an acute or sub¬
acute attack has supervened. On the ether hand, cases
of nephritis where the blood pressure is not high are
those not complicated by cardio-vascular disturbances.
A high blood pressure may fall before death, as it did
in a case of cardiac hypertrophy complicated by peri¬
carditis, where it fell from 190 to 175, and subse¬
quently to 125. In chronic Bright’s disease the blood
pressure is over 160 or 170, and may reach or exceed!
300, which is the limit of the scale on the instrument.

Uric Acid.

There is an impression generally entertained that
atients whose urine deposits uric acid suffer from
igh blood pressure, but so far as I have been able to-
observe such cases, I do not think there is any neces¬
sary connection. A boy, aged 9, in the hospital under
my care, passed uric acid very persistently, but his-
blood pressure was never more than no, pulse 72.
Two brothers, aged 16 and 17, pass uric acid con¬
stantly in large quantities ; the younger has a blood"
pressure of 120, pulse 72, and the elder, blood pres¬
sure 145, pulse 54. A man, aged 56, is gouty, and his-
urine constantly liable to deposit uric acid ; his blood
pressure is only 145, and pulse 72. A soft large puls&
is, moreover, commonly met with in gouty people.
Seven cases of headache were associated with uric
acid ; of these three were males and four females ;
three were over 40 years of age, and four under. One
only showed a pressure over 150 mm., but that case-
was a woman with albuminuria; one only was below
120 mm., a boy aged 14; the rest ranged from 120 to
140, and were therefore within normal limits.

Bibliography.

E. Hesse. —“Der Einfluss des Rauchens auf den-
Kreislauf.” Deutsch. Arch. f. kirn. Med., 1907,.
LXXXIX., 5—6.

Severie. —“Valeur prognostique de l’hypertension et
de l’hypotension chez les diab&iques.” La Semaine
Midicale, 1907, p. 362.

Note .—A Clinical Lecture by a well-known teacher
appears in each number of thie journal. The lecture for
next week will be by W. Sale White, M.D.Lond., F.R.CP.
Load., Senior Physician to and Lecturer on Medicine at
Quy'e Hospital, on “Enlargements qf the Liver'*

ORIGINAL PAPERS.

ON SUNDRY FORMS OF PSEUDO'
RHEUMATISM OF TOXIC ORIGIN-

By M. S. LASSANGE, M.D.,

Of the Faculty of Medicine of Peril.

[Specially Reported for The Medical Press and
Circular.]

The articular troubles which affect a similarity to
rheumatism—acute and sub-acute polyarthritis—fall
into one of two categories— e.g., pseudo-rheumatism of
infective origin, and true articular rheumatism. Apart
from true acute articular rheumatism, which is, in all
probability, a morbid entity caused by a specific
organism, we sometimes meet, in the course of intoxi¬
cations, with articular manifestations of an acute
character which strikingly resemble true rheumatism.
These may be grouped under the term pseudo¬
rheumatism of toxic origin. There are consequently
three varieties of rheumatism—true articular rheuma¬
tism, infective pseudo-rheumatism, and toxic pseudo¬
rheumatism.

Digitized by GoOgle

Oct. 9, 1907.

ORIGINAL PAPERS.

Pathogenesis.

Bacteriological research has not as yet determined
the specific organisms of rheumatism, so that we are
tempted to look for what our forefathers called “the

f eccant humours,” which, in the light of our present
nowledge, may be taken to mean toxins, poisons
which are elaborated in, or introduced into, the
organism, and set up changes in the blood, lymph, and
intercellular plasma. As a matter of fact, the nature
of these poisons has not as yet been clearly defined ;
yet the predominating factor in the pathogenesis of
toxic pseudo-rheumatism is individual predisposition.
This predisposition, which amounts to a genuine idio¬
syncrasy, has for effect that the individual will suffer
from more or less marked rheumatic manifestations
in the course of an intoxication which in another
would be wanting, and its place taken by a toxic
eruption. We recognise this predisposition without
being able to define it. It may, of course, be inherited,
but what is transmitted is not rheumatism itself but
rather a predisposition to contract that disease. Are
there not, however, toxins which, when present in the
blood, exert a selective action on the joints? It is
highly probable that such is the case, for in these cases
the poisons attack the articular and peri-articular
structures, setting up inflammatory lesions charac¬
terised by pain, swelling, and loss of function, and
determine complications in the big serous membranes
—endocardium, pericardium, pleura and meninges. It
is therefore impossible to gainsay the selective action
of certain poisons on articular and peri-articular
tissues, but this influence does not always manifest
itself, and, moreover, it does not explain all cases. It
is probable, too, that in many instances the articular
troubles in toxic pseudo-rheumatism are consecutive
to changes in the nervous system brought about by
the intoxication. This is not a new view, for Reveill4-
Parize wrote:—“There is one view which was at first
lost sight of, for it goes very far back, but is now
rapidly gaining in favour. Many practitioners hold
that rheumatic and muscular pains, whatever their
distribution, are originally dependent on an affection
of the spinal cord, this being manifested by the sen¬
sitiveness of certain points in the spinal region.” This
view is admitted by Friedlander, and recently by
Trollard, of Algiers. It may consequently be conceded
that the poisons are capable of acting on the articular
centres of the spinal cord, in support of which view
may be mentioned the frequency of polyneuritis,
paralysis, and psychical disturbances in the course of
various intoxications.

Clinical Data.

We will begin with the exogenous poisons that may
determine arthropathies simulating rheumatism. Ali¬
mentary toxins often give rise to pseudo-rheumatism
of variable severity, which Bouchard believes to be
due to the ingestion of the ptomaines and toxins pre¬
sent in decomposed meat. Friquet, in his thesis, col¬
lected numerous instances of alimentary intoxication
followed by articular pain and synovial exudation
which proved refractory to the salicylates. Moreover,
instances are on record in which alimentary intoxica¬
tion has given rise to epistaxis, dry pericarditis, double
pleural effusion and mitral endocarditis.

Certain medicinal poisons—chloral, quinine, anti-
pyrine, copaiba, and iodoform—have been known to
cause similar symptoms. According to Fraser, eserine,
and, according to Gubler, colchicine, may also deter¬
mine joint pain with profuse sweating. In cases of
accidental poisoning articular disturbances have often
been noted, as, for instance, in chronic poisoning by
arsenic or copper. Lead poisoning deserves special
mention in this connection, for not only do we get
plumbic gout, but also acute attacks of joint pain,
which Sauvages describes collectively under the term
metallic rheumatism. The joints and muscles become
very painful, and the symptoms are most severe at
night. The etiology of all these cases is certain—
vix., an intoxication which is or is not grafted on a
pre-existing diathesis.

Articular affections due to endogenous poisons may
be dependent on many causes. Of the poisons thus
formed within the organism, some are due to vitiated
metabolism. Under ordinary circumstances these

The Medical Peess. 385

poisons are eliminated by the eraunctories without any
trouble, but in presence of fatigue, over-work, and
certain external causes the secretion of these toxins is
increased by organic changes, and if the normal paths
of elimination are obstructed, we are apt to get morbid
disturbances, more particularly articular fluxions.
This, indeed, was the reason that led our predecessors
to ascribe an attack of rheumatism to the sudden sup¬
pression of normal or accidental evacuations, such,
for instance, as profuse or local perspiration. When
the bye-products of metabolism accumulate in the
blood we get the uraemic state, and one variety of this
uraemia is arthralgic, as to which Jaccoud says:—
“This form must be rare, to judge by the silence of
authors in respect thereof, but I wish to call attention
to it, not as something new, but especially because it
may tend to tender the diagnosis obscure. I remem¬
ber the case of a woman suffering from chronic kidney
disease who was seized with very severe pains in all
the joints. Next day she developed uraemic convul¬
sions, which soon merged into coma ; yet the joint pain
persisted, for, even when coma was complete, pressure
on the articulations was the only thing that changed
the expression of her otherwise impassive face. At
the same time she made reflex attempts to get away
from the painful pressure. In another case, one in
which the patient was found comatose in the street,
pressure on the knees and other joints provoked inar¬
ticulate cries and contraction of the facial muscles.
On examining the urine, we found it laden with
albumen, and containing numerous casts. Post¬
mortem examination confirmed the diagnosis of renal
disease.” These joint pains occur not only in uraemia,
but also in Bright’s disease, showing that renal
elimination is inadequate.

But even when the kidney is working properly, accu¬
mulation of the poisons may still take place if they
are produced in too large quantities. In this con¬
nection we must examine the two principal sources of
organic poisons—viz., a disordered digestive tract and
microbial foci.

Digestive auto-intoxication has been thoroughly
investigated by Bouchard, and among the disturbances
consequent thereupon we get articular affections, not
to speak of osseous deformities in the extremities
(Heberden’s nodes), or of slowly progressive joint
troubles, reserving our attention for the more acute
manifestations. These troubles, which may be asso¬
ciated with digestive disturbance, or may alternate
therewith, present the greatest analogy with ordinary
rheumatism. The articular pain is accompanied by
loss of appetite, furred tongue, palpitations,
dyspnoea, constipation or foetid diarrhoea, often asso¬
ciated with disagreeable dryness of the throat.

The practical conclusion to be drawn from these
facts is that, in the etiological examination of rheu¬
matic manifestations, we must always bear in mind
the possibility of digestive disturbances, and, when
found to be present, instead of giving irritating medi¬
cines which would aggravate the condition, we must
institute an anti-dyspeptic regimen and clear the in¬
testines by repeated saline laxatives. This method of
treatment will often succeed when the specific medica¬
tion fails.

The so-called bilious rheumatism which occurs in
the form of acute or sub-acute polyarthritis in the
. course of biliary cirrhosis or common cholemia,
belongs to the same group. Rheumatism occurring
during pregnancy is also probably a manifestation of
gravid intoxication.

Now as to the microbial toxins. Can they determine
similar arthropathies? We are hardly justified in
asserting that such is the case ; yet instances are on
record in which pseudo-rheumatism associated with
certain infections has been shown to be of toxic origin.
When for therapeutical purposes we employ attenuated
microbial toxins or the serum of an immunised animal,
we not infrequently get eruptions and joint pains
which are due to the seropathy. Articular pain
strikingly resembling that of rheumatism is particularly
frequent after injections of tuberculin and anti-
diphtheric serum. Poncet, who has made numerous
subcutaneous injections of tuberculin, looks upon
these accidents as the result of intoxication induced by
Koch's lymph, and he compares them with the out-

ORIGINAL PAPERS.

38b The Medical Press.

bursts of articular rheumatism which he has met with
in non-rheumatic phthisical subjects supervening when
the cough and expectoration have been arrested. He
says:—“ If, under the influence of a too efficacious
medication, the natural emunctory represented by the
expectoration is suppressed, the retention of pus and
tuberculous products in the cavities gives rise to auto¬
intoxication. In such cases retention is an exchange¬
able term for absorption— i.e., permeation of the
organism by toxins produced in the pathological focus
from which they can no longer make their way out.
Articular complications may, under these circumstances,
supervene in die form of acute articular rheumatism.”

The toxic origin of certain rheumatoid arthropathies
following the injection of anti-diphtheric serum was
first called attention to by Dr. Moizard. In 1895
Gaillard brought before the Hospitals’ Medical Society
a case in which acute polyarticular rheumatism set in
a fortnight after an injection of anti-diphtheric serum
in a patient who had streptococcic angina, and was
attributed by the author to the direct action of the
injection. A child of 5 who had been given a similar
injection by Dr. Sevestre developed a rosy eruption on
the back of the hands, and the joints became swollen,
with pain in the neck and vertebral column. Many
such cases have since been placed on record, and the
toxic origin of the articular troubles is now generally
admitted. It follows that microbial toxins, even when
the organisms themselves do not find their way into
the joint, may give rise to arthralgia like that of
rheumatism, and we can understand the distinction
made bv Poncet in respect of tuberculous rheuma¬
tism:—“Apart from specific or plastic tuberculosis
with typically tuberculous products, there is an in¬
flammatory tuberculosis which often assumes a rheu¬
matic aspect. The bacillus is in this case wanting,
and the case is one of toxic but not bacillary
arthritis. ”

The same procession of events is seen in blenorrhagia
and scarlet fever. Sometimes the articular manifesta¬
tions are due to the intrusion of the microbe into the
joint, and when this follows scarlet fever there is
serous suppurative arthritis or suppurative arthritis
ab initio , while in blenorrhagia we have pseudo-
phlegmonous arthritis. In the other cases we get more
or less disseminated polyarthritis, never followed by
suppuration, in which bacteriological examination
gives negative results.

Conclusions.

In all the cases referred to, the etiology of the arti¬
cular manifestations is characterised by an intoxication
bearing on subjects possessed of a special morbid pre¬
disposition which it is difficult to define but the exist¬
ence whereof is incontrovertible. In some instances
the intoxication is obvious, and constitutes the sole
cause that can possibly be invoked, as when the
poisons are of extraneous origin— e.g., taken with the
food, or in medicinal form, or by accident. In other
cases the arthropathy appears to be due to toxins
elaborated within the organism. In the last-named the
intoxication is unquestionable, and its influence in the
production of articular manifestations approximately
certain, as has been shown, but it is then much more
difficult to define the exact origin of the poison by
reason of the complex and multiple reactions of the
tissues.

But in virtue of what mechanism do these exogenous
or endogenous toxins determine rheumatoid pheno¬
mena? In the present state of our knowledge, no
answer can be vouchsafed, so we are fain to content
ourselves with suggesting various plausible hypotheses
based on the study of the pathological conditions.
Moreover, it is highly probable that the mechanism
varies according to the nature and the quantity of the
poison.

However this may be, all the recorded cases present
certain points of resemblance. Cases of toxic pseudo-
rheumatism all have a certain family resemblance.
Their analogy enables us to classify them and to
differentiate them from a whole series of arthrites due
to the presence in the joints of an infective agent.

Toxic pseudo-rheumatism may take the form of
simple arthralgia or actual rheumatism strictly com¬
parable with true rheumatism. The onset is sudden,

Oct. 9, 1907.

is characterised by pain in a certain number of joints,
remaining polyarticular for several hours, but soon
becomes more pronounced in one or two big joints
which remain affected longer than the others. The
pain alone may persist, and it presents certain pecu¬
liarities. It resembles that of true rheumatism, as
described by Lass&gue. It is not really an intra-
articular pain, but a sensation of burning tension or
arthralgia around the joint, corresponding to the inser¬
tion of tendons or of the muscles covering it. Move¬
ment is more painful than pressure of the joint. The
inflammatory phenomena that accompany the pain
are, as a rule, not very pronounced ; there is but slight
swelling and redness, and intra-articular effusion,
though possible, is exceptional. In short, it may be
said of toxic rheumatism, in respect of the local
symptoms, what Lass&gue said of true articular
rheumatism—viz., “that they are especially extra-
capsular, whereas infective arthritis is essentially intra-
capsular.”

The characteristic physiognomy of toxic rheumatism
is not exclusively due to the local symptomatology.
Although in some instances they may seem isolated,
and although the more or less severe articular pain
sometimes constitutes the whole symptomatology of
intoxication, in the majority of instances the arthro¬
pathy is only one feature of a whole category of dis¬
turbances usually regarded as of toxic origin. The
most striking are the cutaneous manifestations so fre¬
quently met with in association with various intoxica¬
tions—profuse sweating and diverse eruptions, prurigo
urticaria and polymorphous erythemata.

The course of toxic pseudo-rheumatism is sufficiently
characteristic. The acute attacks are remarkable for
their comparative mildness, their ephemeral duration,
and the variability of the phenomena. But in the long
run, should the attacks be repeated, as may happen in
the course of chronic intoxication, it ends by the
formation of plastic products manifested by crackling,
with dull, persistent pain.

These-characters and this course enable us to dis¬
tinguish the arthropathies under consideration from
the microbial arthrites which only attack one joint,
or only a few joints, remain localised therein, and are
often followed by suppuration.

To conclude, it may be stated that a poison that has
permeated the organism in predisposed subjects may
give rise to articular disturbances very similar to those
of true rheumatism, and these rheumatoid phenomena
resemble each other closely enough for it to be justi¬
fiable to classify them in a special group—the group
of toxic pseudo-rheumatism. Lastly, although it was
not our object to revive the theory of the toxic origin
of ordinary articular rheumatism, such theory being
notoriously inadequate, it is probable that the causes
of toxic pseudo-rheumatism, together with the cases of
infective pseudo-rheumatism, will be found to cover
the great majority of cases still regarded as true arti¬
cular rheumatism. For, should a specific agent be
discovered in this affection, it will always be possible
to relegate it to one or other of the two groups of
pseudo-rheumatism already established. In some in¬
stances, indeed, this agent may be localised in a joint
and set up a rheumatic arthritis, this being an infective
accident; in other cases, when the blood merely
conveys poisons elaborated by this agent in the tonsils,
or perhaps in the intestine, these poisons may, either
directly or vid the nervous system, act upon the joint
structures and give rise to purely toxic arthropathies.

THE RAVAGES OF TUBERCULOSIS
IN IRELAND, (a)

By R. F. TOBIN, F.R.C.S.I.,

Burgeon to the Hospital.

The statistics of the death-rate from this disease,
the only official information we have of it since it is
not notifiable, are pretty generally known. Still, as
you may not have meditated on them as you
should with your morning prayers, I shall briefly
lay them before you. I quote the Registrar-

(a) Being a Lecture Introductor; to the Pees Ion 1907-8 ot the
Medical School at St. Vincent's Hospital, Dublin.

Digitized by L^ooQie

ORIGINAL PAPERS.

Oct. 9, 1907.

General. In his report for 1906, under the
head of tuberculosis, he says:—“ I find that
there were 11,756 victims, inhabitants of Ireland; in
other words, out of a total of 74,427 deaths registered
in Ireland during the year 1906 no fewer than 11,756,
or 5.8 per cent., were sacrificed to a disease which is
in a great degree preventable. Year after year these
facts are published, and although the members of the
medical profession are strenuous in trying to awaken
the public to a state of affairs that can only be con¬
sidered as destructive to the community, yet, compara¬
tively speaking, our countrymen are not alive to the
dangers which threaten them.” In another part of the
same report he points out that “by far the greater
number of the descendents were in the effective age
periods of life, the highest number for both sexes fal¬
ling in the age period between 25 and 35 years.” In
another column the average annual death-rate from
tuberculous disease during the last five years is shown
to be over 12,000.

Now, it has been calculated that the ascer¬
tained mortality from tuberculous diseases may
be safely multiplied by ten in order to represent
approximately the number of persons living and
seriously affected in the area in which the deaths oc¬
curred. Doing this with the figures before us we
arrive at the appalling fact that there are at this
moment 120,000 people scattered over this country
suffering in a more or less advanced degree from this
infectious disease. In my opinion this calculation is
under the mark, for patients suffering from tuberculous
disease in outlying parts of the body are much more
numerous than patients suffering from phthisis pul-
monalis, and they generally live a long time. It is also
interesting to compare the statistics of population, and
of disease, in Ireland and Scotland. On doing so
during the last sixty or seventy years we find—I am
roughly speaking—that while in Scotland tuberculous
disease has fallen one-half, and the population has
doubled, the reverse is the case in Ireland. Tubercu¬
losis has markedly increased, and the population has
fallen one-half. Surely these are facts we should let
sink deeply into our consciousness. Now, carry your
attention to this further view of the situation. You
are all aware that in actual warfare the degree to
which the effectiveness of an army is diminished by
deaths, wounds, and disease is not computed by
merely substracting the loss so occasioned from the
total strength. There are other factors to be con¬
sidered. The effects on the morale of the troops of a
large sick rate and death rate, the numbers required
to wait on the sick, the degree to which their transit
blocks the lines of communications, the extent to which
they in various ways hamper the efficiency of the men
in health. All these have to be taken into account
before you can judge of the degree to which sickness
impairs effectiveness. Will anyone say it is different
in civil life? That the sick child or the sick wife
doesn’t hamper the whole household, that the morale
and earning power of its strongest hand is not impaired
by the weak one ; that he is not a depressing influence
far beyond his own home. You, no doubt, feel in¬
clined to interrupt me by saying:—“We have all felt
it, we all know it.” My answer is, measure it, mul¬
tiply it by one hundred and twenty thousand, and
there you have the extent of an omnipresent force
called into existence by these bacilli over and above
the killed and wounded that they claim. It is, as I
have said, an appalling bill. It raises the question,
is not this the question of questions and ought not all
other questions stand aside until it is solved ?

It is now some years since Pasteur gave to this world
an announcement which stands only second to another
“message of great joy,” and one, the truth of which, as
time goes on. is more and more recognised by the
scientific world. “A day will come when in Berlin, in
London, in Paris man will not die of diphtheria, of
typhoid, of scarlet fever, of cholera, or tuberculosis
any more than he dies in these cities to-day from the
venom of snakes or the teeth of wolves. ” It is inter¬
esting to contemplate the different use made of the
scientific fact contained in this announcement by two
distinct nationalities. We, who are imbued with the
conceit and pusillanimity of Western civilisation,
heard it and went our way on motor cars, tram cars,

The Medical Press. 387

bicycles, shoe-leather and bare feet as if nothing at
all had been said. So much so that when Sir
Frederick Treves repeated this same sentence quite
recently, we received it as something quite new, and
he had to write to the papers to say that it was to be
found at page 129 of Frankland’s “Life of Pasteur.”

i apan also heard it, as it lay in terror of extinction
y the Muscovite flood then spreading in the East.
Dare they draw the sword on Russia? If they were
to do so they would lose 50,000, perhaps, roo,ooo in
fair fight. They were satisfied to bear that loss. But
what of deaths from disease? They knew the follow¬
ing figures collected from the history of warfare, “of
every hundred men lost in war twenty die from fair
fighting, eighty from disease.” I can answer for these
figures, for I was assistant to Longmore when he was
compiling the tables that bear his name, and on which
they are founded. With these statistics before them
the drawing of the sword seemed hopeless. Fifty
thousand deaths from wounds meant an additional
two hundred thousand deaths from disease, and put¬
ting the mortality as high as 1 in 10, this number of
deaths from disease meant two million cases of sick¬
ness. If you call to mind what I have already said of
how a large sick list in warfare interferes with effec¬
tiveness, especially when operations have to be carried
on at a distance from the base, you will see that their
case was hopeless. It was a pitiable state of things,
for the love of race was strong in them. Then they
heard the message of Pasteur. They realised what could
be done by a successful application of his discoveries.
We know the rest. We know where Japan stood then
and where she stands now, but listen to the figures of
the fight. I give them from a book I would advise
everyone to read, “ The Real Triumph of Japan,” by
L. L. Seaman, who was in the position of a military
attach^ to the Japanese Army during the war :—52,946
killed in fair fight, 11,992 killed by disease. They are
results that ciy “pause ” to European civilisation. Let
me indicate the main features of the measures by which
these results were obtained. The medical profession
was placed, as regards position and power, not above
or below, but on a level with the other great depart¬
ments of the State. So placed it was found worthy
of the trust reposed in it. Its members studied not
Squire’s Pharmacopoeia and the Dictionary of Treat¬
ment, but the works of Pasteur and Koch and Parkes
and their many followers. Sanitation was made the
first duty of medical officers. If a regiment with one
medical officer was engaged in an action on its way
to a certain camp, and there were, say, twenty
wounded, the surgeon on arrival allowed the wounded,
to whom, when they were picked up, first dressings
had been applied, to lie on their litters till he had
looked into everything likely to affect the health of the
men. The water was tested, and the wells marked fit
or unfit for drinking. If there was no good water,
what there was was filtered or preferably boiled, and,
rice being added, it was both a safe and nutritious
drink. So on with other things. Finally every soldier
was given an elementarv idea of the rules of health,
and these soldiers (herein lies the strength of Japan)
had the self-restraint and the patriotism to do what
they knew was right. How do we act here? What of
our knowledge and self-restraint and patriotism? We
see a secret foe spreading over the country practically
unopposed, killing and maiming and scattering its in¬
habitants.

As a race we are nearer to extinction than were the
Japanese. What are we doing? Is the fate that
threatens us the fitting outcome of our ineptitude?
Here a word about the position of the medical profes¬
sion in this crisis is required. Where are we, and what
are we doing? We are in the position assigned us by
the public, by whom, it is said, we are valued, but
apparently not sufficiently so to induce them to make
us responsible for the conduct even of affairs of
health. We have no power and we have very little
influence in the State. We are not men like judges,
generals, magistrates, policemen, who draw their in¬
comes from the public purse, and who are, therefore,
from a pecuniary point of view independent of the
good opinion of their neighbours. On the contrary,
we, as a profession, are dependent for the means of
living on fees received from individuals from day to

388 The Medical Press.

ORIGINAL PAPERS.

Oct. 9, 1907.

day. The good opinion, therefore, of that representa¬
tive person, the man in the street, not in a general, but
in a particular way, is necessary to us. This notwith¬
standing, we are for ever preaching hygiene, temper¬
ance, and other unpleasant truths to people who don’t
want to hear. Can you expect more from us? Can
you ask us to refuse you, after you have been duly
warned, the thing you demand? Medicine is a great
and noble profession; still its members have in them
some human nature, and some appetites, for the satis¬
faction of which fees and not ideals are required.
Now what do the public want in this matter of tuber¬
cular disease? They want treatment and liberty.
Treatment according to some of the recognised forms,
since there is no cure—liberty to scatter their bacilli
over the land. Now as to preventive medicine. There
are, I am told, only two men in the whole of Ireland
who are paid to give their whole time as sanitary
officers. There is also, it is true, a medical officer of
health in every town and dispensary district; but you
can only judge how far he meets the requirements of
the situation when you know what is his salary—what
his equipment. Has he a diploma in public health?
and, above all, are his hands free?

Now let me sum up the case before you. There
are in the country one hundred and twenty thou¬
sand cases of tuberculous diseases. An infectious
disease, a preventible disease, a disease that
means sickness extending over years, bringing
death and disablement to those it attacks—sorrow
and ineffectiveness to those who escape. This fact,
made clear to us by statistics, is confirmed by the
state of affairs in general. You can apply the term
decline to the condition of the country as truly as you
can to an advanced case of phthisis in the wards.
Things will not mend of their own accord. On the
contrary, if nothing is done, they will grow worse.
For the disease is scattered everywhere, spreading its
germs as a daisy does its seeds. That is the first point.
The next is that means are at our disposal to tackle
this great plague, but the great majority of the public
do not care. They do not really care. They will not
focus their attention on the question. There is no
public purse-opening force in their sympathy. Their
attitude is characterised by indifference and parsi¬
mony.

What is the first step in this state of things to
be set right? Here are my views briefly. Nothing new,
as I have already told you. Education, and again
education, on the questions of public health for the
cultured as well as for the working classes. Who is to
be educated? Each individual Irishman. Not in any
special way county councillors or members of Par¬
liament, or even the English Government, but each
man and woman and child who is given room on the
land called Ireland. He is to be taught that health is
the first duty, and the best economy, whether he con¬
siders himself or his country. Further, that the attain¬
ment of health consists in the carrying out of certain
rules the enforcement of which lies partly at his door,
partly with the corporations whom he elects to repre¬
sent him. There will then remain only one question,
“What About Compulsory Notification? ” On this I
hold very definite views. There are medium courses.
Much could be done by admonition and supervision,
especially if the number of nurses throughout the
country were increased. One thing, anyhow, is certain
—if notification were made compulsory, we would in
a few years have very valuable information about this
disease. There is no knowing what points it might
bring out. That information being obtained, the whole
question should be considered by all the councils col¬
lectively. They should combine and call to their assist¬
ance the best advice the world can provide, and there¬
upon with full information before them, thev should
decide on what measures to take, just as if it were a
question of drainage or of water supply.

There is much else to be said, but you will joyfully
agree there are limitations to an address. We must,
however, not let pass without recognition what many
enthusiastic men throughout the country, what the
Registrar-General, the National Society for the Pre¬
vention of Consumption, and the Women’s National
Health Association of Ireland have been doing.

THE SPONTANEOUS FRACTURE OF
URINARY CALCULL («)

By T. R. BRADSHAW, B.A., M.D., F.R.C.P.,

Physician to the Liverpool Eoyal Infirmary.

The occurrence of spontaneous fracture of a
urinary calculus followed by expulsion of the frag¬
ments through the urethra, though it has been
recorded from time to time, is a comparatively rare
event, and I think that an account of an instance
I have met with in my own practice will not prove
without interest.

The subject of the condition is a gentleman, now
in his eighty-first year, who led an active profes¬
sional life until ten or twelve years ago. About
twenty years ago he began to pass small uric acid
calculi per uretnram, and this has continued at in¬
tervals up to the present. They were generally
the so-called “ mustard seed ” calculi, but some¬
times much larger. One, which is shown in fi^. 1,
passed in 1891, measures fin. by i in., and weighs
325 mg., about 5 grains. The urine was almost
always acid, and in every respect normal, except
that it seemed deficient in colouring matter, and
on standing deposited crystals of uric acid more
quickly than usual. For many years there has been,
a good deal of irritability of the bladder, with
frequent micturition at night; but there is little,
if any, prostatic enlargement, and the urine is at
the present time quite free from excess of mucus.

On October 22nd, 1901, haematuria was noticed
for the first time, and it has recurred at intervals
until the present. The quantity of blood was
generally small; it was thoroughly mixed with the
urine, and was most noticeable after exercise. It
was seldom present in the morning, but was very
frequently noticed after a walk of a mile or two,
sometimes after a carriage drive. I came to the
conclusion that my patient had a renal calculus,
but, in consideration of his advanced age, and of
the fact that his general health was not com¬
promised, I did not entertain the idea of operative
interference.

On January 5th, 1905, Mr. T. T. Holland took
radiographs, and determined the presence of two
calculi in the right kidney. After this the patient
began to suffer from occasional painful attacks in
the right side of the abdomen, attended with
tenderness in the right iliac fossa, and slight py¬
rexia. Whether these were due to renal colic or to-
appendicitis there was a good deal of doubt, but
on May 30th, 1905, he was suddenly seized with
an agonising pain in the right side of the abdomen,
which was undoubtedly of renal origin. Similar
slighter attacks followed. In January, 1906, he
began.to pass fragments of calculus, and continued
to do so during several months. At the same time
his general health improved. He found he could
take exercise without inducing haematuria as
readily as before. In his own words, he felt as if
he had got rid of something. On June 1st, 1906,
he had a rather sharp attack of renal colic, and on
June 16th he began to pass fragments, and con¬
tinued to do so for a few days. These, when
collected, weighed about 14 grains. One can
hardly doubt that the colic of June 1st was con¬
nected with the descent of a calculus which dis¬
integrated, and was evacuated piecemeal. Again,
last November, more fragments appeared.

As to whether this process is likely to end in the
complete removal of tne calculi, I am not prepared
to offer a positive opinion. I can only say that
my patient can now (May, 1907) take his usual -
exercise with a degree of immunity from bleeding
which he has not enjoyed for some years past.

The treatment adopted was extremely simple,

(«! Paper read before the Liverpool Medical Institution, Noveaibcr
22 nd, 1906 .

zed by G00gle

Oct. 9, 1907.

ORIGINAL PAPERS.

The Medical Press. 389

the object aimed at being to reduce the nitrogenous
intake to the smallest amount compatible with the
maintenance of nutrition, to keep up a flow of
urine, and to maintain the general health by
moderate exercise, regularity of life, and the avoid¬
ance of fatigue. When the uric acid calculi first
appeared, my patient, always an abstemious man,
reduced his diet still further. He became to a
considerable extent a vegetarian, lunched chiefly
on milk puddings, seldom touched butcher’s meat,
dined chiefly on white fish, and gave up drinking
wine altogether. From time to time, especially
when calculi were passed, he used to take small
doses of citrate of potassium, 5 grains once or
twice a day; never enough to make the urine
alkaline.

The possibility of urinary calculi being got rid
of by a process of spontaneous lithotrity, such as
has been going on in my patient’s case, does not
seem to be generally recognised in text-books of
medicine or surgery. I can find no mention of it
in Mr. H. Morris’s “Surgical Diseases of the Kid¬
ney and Ureter,” nor in Prof. Osier’s “Practice of

Fig 1.

Scale of Inches.

Medicine.” The late Sir Wiliam Roberts, in his
great work on “ Diseases of the Kidneys,” dis¬
cusses the possibility of dissolving calculi, but does
not allude to the possibility of their breaking up.
Nevertheless, several cases are on record. Dr.
Prout(i), in 1848, speaks of several instances as
having fallen under his notice, and describes at
length one case, that of a gentleman, aet. 90, who,
after suffering from symptoms of stone in the
bladder, began to pass fragments of uric acid which
had evidently formed portions of a calculus, and
continued to do so occasionally for more than a
year. In the museum of the Royal College of
Surgeons there is an example of spontaneous frac¬
ture which was met with in the practice of Mr.
Southam, and in 1876 a case was related to the
Pathological Society by Dr. W. M. Ord (2). This
patient, a gentleman, aet. 83, passed an enormous
number of fragments, which appeared to be seg¬
ments of multiple calculi, consisting of uric acid
and urates. Subsequently Dr. Ord reported several
other cases in his own practice and that of others,
and ten cases were classified and collated by Wil-
berforce Smith and E. Hurry Fenwick in 1890 (3).

Another notable case was that of Kraus, of
Carlsbad, where a man, aet. 78, some months after

undergoing the “kur,” passed fragments repre¬
senting the ddbris of nearly thirty calculi (4).

At the Egyptian Congress of Medicine, 1902,
Mr. Reginald Harrison reported a case where a
gentleman undergoing treatment with borocitrate
of magnesia passed a large number of fragments,
and I believed it is claimed for various spas that
the same result may follow the use of the waters.

Two questions present themselves. By what
means is the fragmentation brought about, and is
it possible to promote its occurrence by therapeutic
measures ?

1. Dr. Ord (5), noticing that the nucleus was
absent from every fragment which he examined,
suggested that an expansion took place in the
nucleus and led to disruption of the calculus, as
of a shell by a bursting charge. Opposed to this
view is the fact that one of my specimens shows
a perfect nucleus lying in situ with a large frag¬
ment attached to and partly enveloping it (see a
in fig. 2).

2. Dr. Ord thinks that in one case he found the
mycelium (6) of a fungus growing on the fractured

Fig 2.

Scale of Inches.

At A is seen a fragment with nucleus attached.

surfaces. If this was the cause of the breaking
up of the stone we must admit the possibility of
various agencies bringing this result about.

3. A varying degree of acidity of the urine has
been supposed to cause solution of certain of the
layers of a porous stone by undermining the
superficial parts. Of this theory we may say that
as varying degrees of acidity are the rule and not
the exception, if it were true, spontaneous frag¬
mentation should be much more common than
it is;

4. Bigelow suggested that the human bladder
can crush stones as the human hand can crush
walnuts.

5. Finally, we have the old suggestion of Dr.
Prout(7), elaborated in a somewhat different form
by Mr. Plowright (8), that certain calculi have a
distinct radial structure, with a tendency to lines
of cleavage, running from the centre towards the
circumference. Of the truth of this view anyone
may satisfy himself by inspecting the uric acid
calculi shown in section in a pathological museum.
There are some excellent instances in the museum!
at the Liverpool University.

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39 ° The Medical Press.

OPERATING THEATRES.

Oct, g, 1907.

In reviewing the explanations offered, one is
inclined to wonder, if they are true, why spon¬
taneous disintegration of calculi is not a common
occurrence, instead of being, as is universally ad¬
mitted, an event of considerable rarity. The true
cause must be a circumstance, or a combination of
circumstances, rarely present in the subjects of
calculi. Further, whatever the conditions may
be, once established they tend to persist, for ex¬
perience shows that when the fragments of calculi
have once appeared we may expect a repetition of
the occurrence during months or years to follow.
Finally, there is strong reason to believe that uric
acid calculi alone are capable of undergoing spon¬
taneous disintegration.

Mr. Buckstone Browne (9), who reported two
cases in 1890, puts the following leading ques¬
tion : “ Does the alkali in the water of many a
watering-place really deserve the credit of break¬
ing up and .bringing away stones; but, rather, is
not the disintegration of the calculi due to their
being bathed by healthy urine, the result of drink¬
ing freely of water, and of the fresh air exercise
and somewhat restricted diet usually imposed on
the frequenters of these health resorts?"

I am strongly of opinion that alkalies, as such,
play but a very subsidiary part in the disintegra¬
tion of calculi, and that the attempt to dissolve
calculi by bathing them in alkaline urine is likely
to defeat the object in view by leading to the for¬
mation of a layer of phosphates on the stone, a
material which has no tendency to disintegrate
spontaneously.

Dr. Prout, whose views as to the radiating
structure of many uric acid calculi I have already
referred to, points out that healthy urine is so
constituted as never to be in a state of complete
saturation even when cold, that at the temperature
of the human body its point of saturation may
be supposed to be still further raised, and that
healthy urine is probably one of the most powerful
solvents that we can hope to possess for all the
Ingredients likely to exist in urinary calculi. In
this connection it is worthy of note that nearly
every case of spontaneous disintegration recorded
has been in a man who has reached an age at
which metabolism is less active, and the amount
of waste products in the urine is proportionately
diminished.. The circumstances which I believe
have combined to bring about disintegration of
the calculi in my case, and in others like it, are
very simple, but, I suspect, not so frequently found
together as one might suppose. They are the
maintenance of the urine in a healthy condition,
the presence in that secretion of abundance of
water, and the reduction to a minimum of the pro¬
ducts of nitrogenous waste.

Note .—Chemical analysis of the fragments
shows that they consist almost entirely of pure
uric acid. There are traces of sodium and am¬
monia. The fragments vary in colour from almost
pure white to rich pink, but the majority are pale
yellow ochre.

Addendum, October, 1907.—The patient remains
in good health. During the last two months he has
passed numerous fragments of uric acid calculi.

References.

(1) Prout, “On the Nature and Treatment of
Stomach and Renal Diseases,” 5th ed., p. 433.

(2) “ Path. Soc. Trans.,” xxviii., p. 170.

(3) Ibid., xli., p. 183.

(4) Ibid., xxx., p. 314.

(5) Lnc. cit.

(6) “Path. Soc. Trans.,” xxxii., p. 304.

(7) Lnc. cit., p. 435, footnote.

(8) “Path. Soc. Trans., xlvii., p. 132.

'(9) Ibid., xli., p. 188.

•(io) Prout, loc. cit.

CLINICAL RECORDS.

ACUTE NEPHRITIS AND SCARLATINA.

By THOMAS P. CODD, L. & L.M., K.Q.C.P.I.,
L.R.C.S., 1 ., L.M.,

Rotunda, Dnblln.

The following case which came under my obser¬
vation may be interesting to some of your readers.

It was a case of acute nephritis, which
developed afterwards into scarlatina. A girl
set. 11, pale, thin, and of a delicate nature, was
brought to me by her father on August 8th, 1907,
suffering from stomatitis, for which I prescribed a
weak solution of Condy’s fluid as a mouth wash.
Three days after, her father left at my house a
4 02. bottle of urine, smoky in colour. On exami¬
nation, it was found to contain blood, and to be
highly albuminous. He called in the afternoon to
tell me that the child seemed apparently well,
except the condition of the urine; that she was
running about, and, in fact, he was going to bring
her up to my house, not thinking there was much
wrong. Being rather an anaemic child, I gave her
a mixture of licj. ferri. perchlor., and recommended
her to be kept in bed, and get barley water and a
little chicken jelly.

I called to see her the next day. Pulse normal,
temperature 99 deg. F., no sign of any rash what¬
soever, but inclined to be sick.

The mother could not understand when I told
her the danger the child was in, and that she
should be kept in bed.

The mother said she would like the child to be
in hospital, so the same day she was admitted to
the children’s hospital. On examination, they
could not detect anything unusual (except for the
urine); no rash or high temperature. Four days
afterwards the father came to tell me that a rash
had developed, which was pronounced to be
scarlatina rash; consequently the child had to be
sent to the Fever Hospital, Cork Street. The
peculiarity of this case, acute nephritis setting in
first, and with such trivial symptoms, and the
scarlatina rash appearing about six days after, was
most unusual. I have been twenty-one years in
practice, and never came across such a case before :
perhaps some of your readers have. I understand
the child’s kidneys are acting very badly at pre¬
sent, and are only secreting 2 oz. of urine in the
twenty-four hours. The blood has disappeared,
and the albumen still continues.

OPERATING THEATRES.

ROYAL FREE HOSPITAL.

Case of Intestinal Obstruction.—Mr. Joseph
Cunning operated on a girl, «t. 12, who had been
admitted at midnight the previous night. She had
gone to bed at 11 after eating a number of green pears
during the evening. She woke about midnight with
acute pain in the abdomen, vomiting and diarrhoea.
She was then brought to the hospital. She was on
admission suffering from colicky pains, with a short
interval between, pulse 80, temperature normal. On
abdominal examination, the right half of the abdomen
and the hypogastrium were occupied by a swelling
shaped like a stomach, and during the colicky pains
this swelling became more prominent and hard. It
was resonant on percussion ; there was no tenderness
over it or rigidity of the abdominal wall. Rectal
examination revealed nothing, and there was no passage
or either blood or mucus. She herself said she had
had a previous attack like this twelve months ago,
and that since then she had had occasional attacks

Digitized by GOOglC

Oct. 9, 1907.

CORRESPONDENCE.

he Medical Press. 39 1

of sickness in school, but no pain. An enema was
given, but with no result. During the night she was
sick two or three times, but only stomach contents
were brought up. A diagnosis was made of mechanical
obstruction, which might be due to a band, as a result
of the illness twelve months previously, or the case
might be one of volvulus. The question of
intussusception had been considered, but the tumour,
which could be felt, was much bigger than the swell¬
ing usually present in intussusception, and it remained
localised to the right half of the abdomen instead of
progressing in the direction of the colon, and there had
been no passage of either blood or mucus. Mr.
Cunning before operating demonstrated the swelling
and its increase in prominence during a period of
visible peristalsis, and pointed out that this must be
due to hypertrophy of the intestine. He then opened
the abdomen through the right rectus, and found the
intestine adherent to the abdominal wall by fine
filmy adhesions. On separating these extensively it
was found that the abdomen was divided into two
halves, the left being occupied by normal intestine,
the right by intestine covered with sheets of adhesions
like fine tissue paper, with the exception of the middle
of the tumour, which was constricted by a thicker
band of adhesions, thus accounting for the stomach¬
like shape of the swelling. During the process of
separating these adhesions the collapsed ascending
colon and c»cum were discovered to the outer side,
and the appendix was exposed; this structure was
found to be the seat of a previous attack of appen¬
dicitis, which had resulted in the sloughing of the
greater portion of its extent so that only about an
inch of it remained ; this stump was adherent to the
tumour, which consisted of ileum, and all the
adhesions apparently were the result of this attack of
appendicitis. The stump of the appendix was
separated and removed. The tumour was then investi¬
gated, and found to be many feet of the ileum rolled
up in a concertina or accordion-pleated shape, the
coils being held together by fine “chiffon’’-like
adhesions. When the dilated portion of intestine was
exposed there could be felt in it numbers of firm
masses, which were evidently the hurriedly chewed
green pears. All the adherent coils of intestine were
separated, and the abdomen was closed in three layers
after it had been filled with normal saline solution in
the hope of preventing the re-formation of adhesions.
Mr. Cunning said that it had been clear that the
patient had suffered from some chronic obstruction for
a long time; it might be that the attack twelve months
ago was one of intestinal obstruction, or it might have
been one of appendicitis, for the only information to
be obtained was from the girl herself, and she was too
young to be able to give a proper account of her
malady; the attack of appendicitis might have
happened years before. The present attack of com¬
plete obstruction was due to the impaction of a hard
mass of green pears in the ileum which was already
kinked by adhesions. A patient might have a very
small lumen in the small intestine, and yet get along
comfortably owing to the liquid nature of the contents,
but if large indigestible masses were swallowed, im¬
paction was likely to occur and cause obstruction. He
remarked that he had operated at once, although it
was possible, but hardly probable, that the patient
might have overcome the obstruction, but the danger
of waiting was that if she did not overcome the
obstruction the intestine would have become distended,
and not only would there have been more difficulty in
performing the operation, but there would have been
the added danger of invasion of the wall of the intes¬
tine by the bacillus coli, and therefore the risk of peri¬
tonitis. Again, when distended intestine has to be
handled, it is very difficult not to produce abrasions of

the peritoneum, which constitutes one of the great risks
of operating on such cases. With regard to the adhesions
present it was interesting to note that in some cases
of large localised appendicular abscesses, which had
been drained, when the abdomen was opened several
months afterwards, the adhesions had almost entirely
disappeared, yet in such cases as the present one there
was apparently no attempt at the absorption of the
adhesions. For this peculiarity he would not venture
to offer an explanation.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Paris. Oct. 6 th, 1907.

Treatment of Gonorrhoea.

In presence of a patient suffering from a urethral
discharge, the practitioner should first assure himself
of the nature and length of time the discharge has been
observed. If he has good reasons to believe that the
affection i« recent, dating from two to three days at
most, I am one of those, says Dr. Carle, who consider
that in such cases the abortive treatment should be
tried.

A treatment of this kind should produce, in 48 hours,
a complete relief of the acute symptoms—congestion,
abundant and greenish pus, pain, painful miction and
erections. In five days the discharge should be reduced
to a drop in the morning, and at the end of a fortnight
all symptoms of the disease should have disappeared.

At the first visit Dr. Carle commences the treatment
by injections of a solution of permanganate of potash
(4 grains to the quart). With a syringe containing
half an ounce of liquid, he makes a series of injections
(four or five injections are sufficient), each retained a
few seconds. Three hours after a second series is-
made by the patient himself, and repeated every three
hours (day time) up to the sixth day. From the sixth
to the tenth day three series of injections only per day,
then two during the two or three following days, and
finally only one, in the morning. After the fifteenth
day, if no discharge is perceived in the morning, which
is generally the case, the treatment ceases.

Under this treatment the acute symptoms subside
after 48 hours, miction is easy, congestion has
diminished, and pain has almost disappeared Towards
the fifth day the running is reduced to a drop in the
morning, but otherwise, if three hours after micturi¬
tion, a drop of pus is observed to ooze out, the abortive
treatment has failed, and the malady will likely run
its course of six weeks.

The chief feature of this treatment lies in the multi¬
plicity of the injections with a weak antiseptic solution.
No internal treatment is necessary.

Out of 27 patients treated by Dr. Carle, 22 were
definitely cured.

Peruvian Balsam.

The value, as an excellent and easy dressing for
wounds of all kinds, of Peruvian balsam seems to be-
recognised by many surgeons on the Continent. In
one hospital, all recent accidental wounds have been
treated systematically for the last two years with this
substance. After carefully removing from the wounds
all extraneous matter, the dressing is applied and not
repeated for a few days.

Of 25 complicated fractures, thus treated, there was
but one death from traumatic pneumonia; the
remainder recovered without difficulty. Trauma¬
tisms of the hand and the foot with open fractures,
gunshot wounds, wounds of every kind, in fact, were
treated successfully by the balsam. Tetanos was only
observed three times out of 552 cases.

Hyperemia of the Pharynx.

Hypersemia of the pharynx is a symptom of either
nephritis or diabetes when no other has as yet existed.
Sometimes it appears a little before either sugar or

Digitized by Google

3 Q 2 The Medical Press.

CORRESPONDENCE.

Oct. 9, 1907.

albumin can be detected. But there is no means as
yet of knowing to which of these maladies the symptom
will belong. Local treatment avails nothing; the
general condition of the patient should be treated.
The patient should be kept under observation, and put
on a diet special to either of these maladies; absten¬
tion from sugar and a milk diet ordered. If it turns
out to be a case of Bright’s disease the milk regime
will be made absolute; if it is one of diabetes the
patient will be allowed milk and Vichy water, and
the usual remedies prescribed.

GERMANY.

Berlin. Oct. 6tb, 1907.

The seventy-ninth meeting of the Naturalists’
Society was held in Dresden from September 15th to
the 21 st, Professor Naunyn in the chair.

After the transaction of the customary formal busi¬
ness, the report of the commission of inquiry into the
state of education was received. Professors Gutzmer,
of Halle, and Klein, of Gottingen, were entrusted with
the drawing up of the report. The Commission
issued a series of questions respecting scientific educa¬
tion to the higher teaching institutions in Prussia. It
appears from the answers received that 77 per cent, of
the higher schools were in favour of practical physical
school exercises. Practical chemistry was taught in
most of the Realschulen, and ought to be generally.
The equipment for teaching the natural sciences was,
however, at present inconsiderable. A central dep6t
for the furnishing of physical apparatus was not in¬
dicated, but a museum of natural science-teaching
material was very desirable. Students should be in¬
sured against accidents in experimenting and excur¬
sions. The Commission should now be dissolved and
replaced by a general committee of education. The
Government were in general inclined to reforms. The
necessity of biological instruction in the higher classes
of the advanced schools was recognised. Teachers
should not be called upon to teach in subjects in which
they had no practical knowledge. Education in the
University ought to be purely scientific, and by no
means limited to one object (should be Kein blosses
Zweckstudium).

The first scientific general address was by Prof. W.
Hempel, and had for its subject “The Treatment of
Milk.” He pleaded for increased prices in order that
the agriculturist might be able to supply an immacu¬
late milk. Mothers’ milk was unreplaceable, and at
present success had not be obtained in the destruction
of the bacteria of decomposition and of the bacilli of
tubercle, and for this reason he was in favour of get¬
ting the milk of the healthiest possible cows in the
cleanest possible manner and using it unboiled, or
raw. Cows are best kept on the land, and we ought
to try to get the milk forwarded in cooled vans. Only
animals that did not react to tuberculosis and showed
no signs of other disease should be made use of for
the supply of milk.

Prof. Kelling, Dresden, gave a report on his bio¬
chemical blood-serum examinations, and recommended
that in giving the injections of blood, as Bier had
suggested, for carcinoma, the blood should be spe¬
cialised, that was, those kinds of blood should be
used that were furnished by animals against which the
bodies of the tumour patients were known to react,
and the injections should be used in the first instance
for the purpose of producing immunity against re¬
currences.

Prof. Eber, Leipsic, spoke on the importance of
Behring’s

Tuberculosis Immunisation Process

for combating bovine tuberculosis. He was of opinion
that the resisting power of young animals against arti¬
ficial infection with virulent tuberculous material could
be not inconsiderably heightened by preliminary treat¬
ment with tubercle bacilli of the most varied sources,
but that this heightened power was not of long dura¬
tion. There was as yet no proof that Behring’s bovo-
vaccination protected against natural tuberculous in¬
fection. Nothing had been published so far to show
that any other method of combating bovine tubercu¬

losis was superior to Behring’s original protective
inoculation.

Prof. A. Kuttner reported on 230 cases of
Laryngeal Tuberculosis in Pregnancy.

In 12, artificial abortion was necessary, and in 9 it was
successful, but in failed in 3. The result was favour¬
able, however, in 7 only. In 15 cases tracheotomy or a
similar operation was performed, but in only 4 with
success; 200 of the women died either before delivery
or shortly afterwards. Of 116 children 79 died. In
the discussion that followed the paper, the opinion
seemed to prevail that women with laryngeal phthisis
who became pregnant should be warned of the great
danger they ran on account of the pregnancy. Abortion
should be induced if the tuberculosis showed a ten¬
dency to spread. In the latter months of pregnancy
artificial interruption of it always had an unfavour¬
able termination.

AUSTRIA.

Vienna. Oct. 6th. 1907.

Lymphatic Leucocythemia.

Kienbock exhibited to the “ Gesellschaft fur Innere
Medicin” a male, set. 47, from Constantinople, who
was a business man in that city, and who suffered
from a severe form of lymphatic leucocythemia. He
consulted the doctor on December 19th, 1904. He had
then large lymphatics the size of plums, besides packets
the size of nuts. The spleen was 5 centimetres or
two inches below the margin of the ribs, erythrocytes
5,100,000, hemoglobin 14.9, leucocytes 185,000, of
which 90 per cent, were lymphocytes, while the poly¬
nuclear neutrophile leucocytes were 3.5 per cent.

The patient was irradiated at intervals of two and
three months, the application lasting 8 to 14 days at
a time. The whole body was exposed at first, but
finally only the spleen and glands. The doses were
small throughout, not exceeding 2 to 4 quantimetric
units. The effects of the X-rays on the spleen and
glands were notable and rapid; they became decidedly
less within two or three days. The leucocytes fell to
average between 20,000 and 50,000. At the beginning
of the treatment it might be stated a temporary rise
took place, but soon fell again—the lymphocytes taking
the greatest part in this increase, while the polynuclear
leucocytes constantly decreased. The erythrocytes and
htemoglobins gradually fell, the former from 5 million
to 4 million, and the latter in the same proportion—no
granular red corpuscles could be observed in the
examination.

For two and a half years the patient has had inter¬
mitting applications, but from the very beginning be
felt stronger and better fitted for his business than he
had for a long time prior to the commencement of the
treatment. It is now four months since he was
irradiated, but he felt well, although the glands were
still slightly swollen as well as the spleen, and could be
felt below the ribs by causing a deep inspiration.

The erythrocytes are now 4,000,000, and the
leucocytes 18,000.

Obliteration of Aorta.

Schrotter presented an interesting case of obliteration
of the aorta at the arch or the ductus Botalli or Botalii
region, as Hyrtl prefers to call it, having first been
described by Dr. Botal, of Venice. The boy was ten
years old, with the jugulars pulsating; this could be
seen at a distance and corresponded to the carotid
and subclavian. The arteries of the legs were better
felt than seen, but no pulsation could be detected in
the crural region.

The ductus Botalli is a relict of the embryonic form
which in this case seems to have persisted and retained
the collateral circulation through the arteria thoracic*
longa and intercostals which were greatly enlarged as
well as the epigastric artery, which was almost free
from convolutions in its function of descending aorta.
One of the peculiarities of the case was the absence of
palpitation I

Mongoloid Idiocy.

Friedjung presented a girl, et. 16$, with that form of
idiocy known as Mongoloid. Her external appearance

zcdbyCnOcwle
1 O

Oct. 9, 1907.

CORRESPONDENCE.

The Medical Press. 393

had the characteristic symptoms: Small stature and
stunted development. The face was short, suffused with
a constant simper, forehead low, temporal bones
depressed, and eyes with the Mongolian characteristics
—distinct epicanthus and blepharitis. The mouth and
nose were small, while the tongue was large, somewhat
bifurcated. The cheeks were high and red, the ears
small, and the jaws normal, the thyroid was normal
to the feel, the speech explosive, confined to short
phrases. Both hands were large, cold, and distinctly
cyanotic.

Radical Cure of Hernia.

Bernhard has performed the most radical cure for
hernia we have yet heard of. He practised the opera¬
tion on dogs with perfect success, and has now per¬
formed with equally good results on man. The
difficulty hitherto is the presence of the spermatic cord
in the inguinal canal. Bernhard obviates this difficulty
by separating the testis from the scrotum, and throwing
it back into the abdomen, thereafter, entirely closing
the ring.

Castration has always been considered too severe.
This abdominal position preserves the physiological
function, and provides an effectual means of closing
the ring. The question arises : What will be the result
if the testis become diseased and tuberculous or
syphilitic inflammation arise? To avoid this, as a
prophylactic, Bernhard splits the tunical vaginalis
propria, which prevents hydrocele.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

THE PROBLEM OF THE INSANE.

In the eightieth annual report to hand of Murray’s
Royal Asylum, Perth, the Physician Superintendent,
Dr. Urquhart, takes occasion to review the experience
of a quarter of a century and to mention certain
conclusions arrived at. The position of affairs regard¬
ing mental disease is that we have to deal with a con¬
stitutional malady, profoundly affecting bodily nutri¬
tion and secretion, mainly originating in hereditary
defect, and issuing in a liability to repeated attacks of
insanity. This generalized disorder (whether toxic by
impairment of the bodily processes, or by bacterial
invasion) brings the manifestations of mental disorder
into line with other diseased bodily conditions, and
leaves the mystery of madness on a par with the mys¬
tery of rheumatism, which is also of a cyclic character,
quite different from those maladies which, like small¬
pox, appear to confer a future immunity upon the
individual. All insanity is a defect—at least, a de¬
gradation of function, if not a degradation of struc¬
ture. It is a mental reduction, characterised by a loss
of the finer feelings, an inability to adapt, a loss of
restraint on motor manifestations. The evidence for
these opinions is rapidly accumulating. Never before
have scientific observations been so numerous and so
important relative to the study of insanity. These
have become so wide and so intimately connected with
all the ramifications of physiology and pathology, that
it is difficult to keep pace with them ; but if all the
apparatus of our hospitals for the insane is not bent
to the elucidation and treatment of bodily disease,
they are fro tanto failures, obvious and indefensible.
The general summary of results from 1880 to 1904
inclusive, shows that 982 patients were admitted—809
for the first time, and 173 as re-admissions. Of 809
persons admitted, 31 per cent, recovered, 39 per cent,
were removed unrecovered, 17 per cent, died, and 12
per cent, remained resident. The results for cases
(admissions or re-admissions) are nearly the same. The
incidence of neuropathic ljeredity in these 809 persons
is represented by 45 per cent, of hereditary insane, and
72 per cent, of hereditary neuropathy— i.e., with family
tendencies towards the graver neuroses, want of mental
balance, alcoholism, and paralysis. An examination
of the families of insane parents, however, showed that
47 per cent, of the children of insane fathers were
alive and sane, while 29 per cent, were insane; 42 per

cent, of the children of insane mothers were alive and
sane, while 39 per cent, were insane ; 33 per cent, of
the children of insane fathers and mothers (both
parents) were alive and sane, while 44 per cent, were
insane. This morbid heredity falls heaviest on the
eldest child, and rapidly diminishes with the number
of children. There is, even in the most disastrous
class, an effort towards regeneration, and a curability
which does not greatly differ from that of insanity
which is not hereditary in the first instance, although
hereditary defect is apparent in depressing the final
recovery rate, and raising the death-rate. Brief refer¬
ence is also made to the effect of alcoholism, as there
are so many misunderstandings and misrepresentations
on that subject. A hundred and ten cases of chronic
alcoholism were recorded among certified and volun¬
tary patients. The total neuropathic hereditary
amounted to 70 per cent. ; nearly 43 per cent .were
hereditarily predisposed to insanity, and nearly 22 per
cent, to alcoholism. There is no doubt that the alco¬
holic patients received into asylums are generally and
heavily burdened with a morbid heredity, and that
their failure is analogous to that of the ordinary insane
—a failure inherent in the organism, often made more
manifest by environment. Mental stress is often alleged
as the cause of intemperance, as the cause of insanity;
the inevitable complement of the mental stress, how¬
ever, is innate or congenital defect.

Turning to the statistics for the year, we note the
high average of admission (45.8, as against 44.5
in 1906). There is also a large proportion of senile
cases. The average age at the first attack of insanity,
however, was 39.3 years. The general recovery rate
of the asylum for the years 1865-1906 is 35.17; this
year it is 27.02 (compared with 42.85 last year) on the
number of admissions. The percentage of deaths was
6.72, the average rate of the institution being 6.17.
The average daily numbers on the register were:
males 71, females 63. The general health of the
patients and staff has been good, except for an
epidemic of diarrhoea in summer, and of influenza in
spring.

The Reports of the Commissioners speak in high
terms of the efficiency of the institution.

BELFAST.

The Corporation and the Treatment of
Consumption. —At the last meeting of the Public
Health Committee the draft agreement between the
Forster Green Hospital for Consumption and the
Corporation was read. The hospital is to provide
and reserve twenty-five beds similar to the existing
beds in the hospital for the sole and exclusive use of
patients to be nominated by the Public Health Com¬
mittee, and approved. The agreement is to continue
for ten years, during which the Corporation shall pay
to the hospital the sum of ,£2,275 annually. The Lord
Mayor for the time being, the Chairman for the time
being of the Public Health Committee, and two other
persons as the said committee shall appoint, shall be
members of the Hospital Board. The working of this
arrangement will be looked on with great interest, as
certain difficulties are obvious.

Tuberculosis Exhibition. —A meeting was held in
•the City Hall on the 1st instant, the Lord Mayor (the
Earl of Shaftesbury) presiding, to make arrangements
for a Tuberculosis Exhibition in Belfast. Sir John
Byers, Professor Lindsay, Dr. Dempsey, and other
medical men took part, and Drs. Thomas Houston
and J. Mcllwaine were appointed honorary secretaries.

Banbridge Nursing Society. —The annual meeting
of this society was held in Banbridge, co. Down, last
week, and the report read showed the usual busy
year’s work which one has learned to associate with
district nursing societies. But it contained one item
of interest to medical men which such reports do not
generally give; it gave the number of cases sent to the
nurse in different ways. Of a total of 119 patients,
81 were recommended by friends, 21 by doctors, 5 by
clergymen, and 12 by members of committee. This
looks as though the services of the nurse were not so
often utilised by the local medical men as might be the
case.

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394 The Medical Press._ OBITUARY.

LETTERS TO THE EDITOR.

PROTECTION FOR BEAST, NOT FOR MAN.
To the Editor of The Medical Press and Circular.

Sir, —Years ago, and on numerous occasions since,
you have allowed me to point to and discuss, when
called for, the fact that the Veterinary Act affords
greater protection to the profession and the public
than the Medical Acts. This is exemplified once more
by a case reported this week. At Feltham Petty
Sessions, on September 30th, a man was summoned for
using the description, “canine and feline medical
expert,” implying that he was specially qualified to
practise a branch of veterinary surgery. Although the
man was ably defended, and it was not proved that
he had actually suggested to his clients that he was a
veterinary surgeon, he was convicted and fined 20s.
Under the Medical Acts such a conviction is at present
impossible, and there exists no functionary or public
body like the Veterinary College, charged with enforce¬
ment of the law, even if it were applicable. Whether
guilty of no greater real harm than the man in the
present case, or carrying on the grossest system of
cruel quackery and extortion, the unqualified medical
practitioner cannot be prevented from palming him¬
self off as a duly qualified man. He can employ lan¬
guage in his advertisements capable of deceiving not
only the ignorant but the educated public, and there
are hundreds of such men carrying on their nefarious
trade throughout the country. It is impossible to
believe that the Legislature would allow this state of
things to continue if once the facts were forced to the
knowledge of responsible men and statesmen. It needs
no elaborate proof to show that it is at least as im¬
portant to protect suffering humanity as suffering
brutes against the injury which ignorance, incompetence,
and dishonesty can inflict upon them. It is, I hold,
the duty of the profession to take up and force to the
front the question of medical law reform. As a pre¬
liminary step the case for legislation must be made out
clearly and beyond dispute ; and as nearly the whole
of the newspaper Press, high and low, is suborned in
support of quackery, this can be done only by means
of an authoritative inquiry such as, I believe, would
be afforded by a Royal Commission.

I am, Sir, yours truly,

Henry Sewill.

Cavendish Square, October 1, 1907.

A NEW ERA IN MEDICINE.

To the Editor of The Medical Press and Circular.

Sir,—I n the Times of October 1st there appears a
remarkable article under the above heading. It is
rinted in the form of editorial matter, and I do not
now whether the editor is responsible for it, or
whether it is, after all, merely a paid advertisement.
The sub-heading refers to a “Remarkable address at
the opening in London of a West-end home of a
famous Continental spa cure,” but not a word of
any address is to be found in the article. According
to its promoters, this so-called “St. George's Nauheim
Institute has been founded to meet the demand for
progress by both patient and physician,” but who the
patient is, and especially who the physician, the
article does not tell. We are, however, told that
readers of the Times who want to know may learn all
about it by applying at the Institute for a copy of
the “handsome opening Souvenir Book,” a work
which we are further informed “must prove of vital
import to readers who have personal reasons for
desiring acquaintance with the latest methods that
mark this new era in medicine.” If your reporter was
not present at the opening ceremony, I trust that one
of your ablest representatives will be at once
despatched, so that your readers may not remain long
in suspense before they are enabled to take advantage
of “the new era in medicine,” and pass on their
knowledge for the benefit of their patients.

I am, Sir, yours truly,

Rusticus.

October 3rd, 1907.

Oct. 9, 1907.

[*** The article referred to by our correspondent
has appeared in several newspapers besides the* Times.
Although typed as editorial material, it is a cleverly
concocted advertisement, and is paid for as such.—
Ed. M. P. and C.]

CONGENITAL ANOMALIES OF THE EYE.
To the Editor of The Medical Press and Circular.

Sir,—M ay I point out a mistake in Mr. Sydney
Stephenson’s very interesting lecture on “Congenital
Anomalies of the Eye,” in your issue for Septem¬
ber 25th? On p. 331 he says:—“I note that the latest
book on Diseases of the Eye, by Mr. J. Herbert
Parsons, contains the caution not to diagnose pseudo¬
neuritis ‘ unless at least 2 D of swelling can be demon¬
strated.’ ” If he will refer again to the quotation, he
will find that the actual words are :— u Papillitis should
not be diagnosed unless at least 2 D of swelling can
be demonstrated ”—exactly the opposite of the de¬
duction which he has drawn. The sentence would
doubtless have been less ambiguous and more accurate
if I had said that “ Papillitis, in the absence of other
definite signs, such as hasmorrhages, exudates, etc.,
should not . . .” I quite agree with Mr. Stephen¬
son in thinking that there is probably never abnormal
swelling of the disc in pseudo-neuritis.

I am, Sir, yours truly,

J. Herbert Parsons.

27, Wimpo'.e Street, Cavendish Square, W.,
September 26th, 1907. .

“THE INTRODUCTORIES.”

To the Editor of The Medical Press and Circular.

Sir, —It is to be wondered what most of your
readers thought of the Introductories. These effusions
certainly were not very cheerful in their tone, that is,
encouraging to the young freshmen. Dr. Allchin
warned his hearers against the London University.
Dr. Ewart certainly took the view that the life of a
general practitioner is a miserable one, and in any
case a man without means had better keep clear of
doctoring, so far as making a living out of practice
could be relied on. The other lectures were more or
less special, except Dr. Osier’s, and he soared into the
regions of sentiment and high morality. One subject
might have been dealt with, but it was carefully
avoided, and that is the influence of unlimited hospital
treatment upon the great body of general practitioners,
and the extent to which they have suffered. This, of
course, is a subject the hospital man dare not deal
with, and it would be well if it were boldly considered
by the readers of your journal and by the great body
of general practitioners throughout the country.

Yours truly,

A Reformer.

THE NOTIFICATION OF BIRTHS BILL.

To the Editor of The Medical Press and Circular.

Dear Sir, —I have not the leisure to deal with Dr.
Me Walter’s article in any detail which appears in your
last issue, nor do I really think it worth while. I do
not believe that medical men will subscribe to the
ideas contained in the words as I have heard them
expressed, “let the poor little devils die.” But I
would point out that the mere title of the article (“The
Government’s Scheme to Promote the Unqualified
Practice of Medicine ”) is at once a libel on the pro¬
moters of the Act, an untruth, and an appeal to vulgar
passions. It is a libel on the promoters of the Act
because they were single-minded in their object; one
thing only they had in view, namely, to save the lives
of helpless babies who are being slain in appalling
numbers year by year in this country by the inertia
and apathy of the responsible governments, central
and local, of the country. The title is an untruth on
the face of it. It is ridiculous because it is so ob¬
viously untrue. It is just as difficult to point out
how it is untrue as it is to give an algebraical demon¬
stration that two and two make four. And it is an
appeal to vulgar passions because it ignores the
highest and best traditions of our profession, while
appealing speciously and meretriciously to self in¬
terests.

Digitized by LjOOQle

Oct. 9, 1907.

REVIEWS OF BOOKS.

The Medical Pkess. 395

The Government’s Act arises from and follows the
lines of the Huddersfield Act, which originated with
me. I, therefore, am able to speak with some autho¬
rity. I trust that it is hardly necessary for me, a
medical man, to assure my fellow medical men that I
have no desire, and never have had the least desire,
to promote the unqualified practice of medicine. In
Huddersfield the working of the Act cannot possibly
promote the unqualified practice of medicine, because
it is worked by two duly qualified and legally regis¬
tered medical women, as I have stated in Dr.
McWalter's presence.

Faithfully yours,

J. Moore,

Medical Officer of Health.

OBITUARY.

DR. ARTHUR C. HUDSON, J.P.

We regret to have to record the death of Dr.
Arthur Hudson, who died at his residence, near
Avoca, in co. Wicklow, at the age of 71. Dr. Hudson
acted as medical officer in Avoca for 48 years, and was
said to be the oldest dispensary medical officer in
Ireland. He was well-known throughout Wicklow, and
for the last twenty years was a regular attendant at
the local Petty Sessions in his capacity of Justice of
the Peace.

REVIEWS OF BOOKS.

BUCHANAN’S MANUAL OF ANATOMY, (a)

Some months ago, when reviewing the first volume
of this manual, we were struck by the success with
which the authcr, Professor Buchanan, had combined
a systematic and practical Anatomy in one text-book
of convenient size. In it the student, when dissecting
the extremities, can refer to the description and figures
of the bones in the part of the work devoted to
osteology. At the same time he has a guide to the
method and procedure of dissection following the
description of each completed part, and can acquire a
sound knowledge of the subject without referring to any
other book. The advantages of this arrangement in
the manual will at once recommend itself to the
teacher as well as the student.

In Volume II., now before us, we find the same
admirable plan of treatment cf the subject is em¬
ployed. The reader is given every facility to grasp
not only the gross anatomical details but also at the
same time can make himself familiar with the develop¬
mental history and the histology of the organ which
he meets with. The structure of each viscus is fully
described. For instance, in the kidney, the relative
position, size, shape, lining, epithelium and lumen of
the uriniferous tubules are clearly dealt with, and the
minute details of the blood supply are given. The
present Volume II. is nearly twice the size of
Volume I. About the first 300 pages are devoted to
the abdomen, 64 of which deal with the structure and
development of the abdominal and pelvic viscera. The
next zoo pages treat of the thorax. The development
of the heart and great blood vessels, and the foetal
circulation, are described at considerable length. The
anatomy of the head and neck, the nervous system,
the nose, eye, and ear occupy the next 500 pages. An
Appendix contains the Bale nomenclature and a
glossary. The latter particularly will be appreciated
by the beginner.

Vol. II. is particularly well illustrated (363 figures).
Many of these are coloured, especially in the section

(*) “Manual of Anatomy, Systematic and Practical, including Em¬
bryology.” By A. M. Buchanan, M.A., M.D., C.M.. F.F.P.S.Glasg.,
Profeasor of Anatomy In Anderson's College, Glasgow ; Examiner In
Anatomy for the Triple Qualification of the Scottish Licensing Bodies;
Examiner in Anatomy and in Physiology for the Dental Diploma, etc.,
etc. Vol. II. (completion of work) Abdomen, Thorax, Head and Neck,
Nervous System. Organs of SpeoUl Sense, and an Appendix containing
the Bfile Nomenclature and a Glossary. Pp. xt. and 950. Illustrations
363, most It original and In several colours. Demy 8vo. London:
Ballliire, Tindall and Cox, 1907. 12s. Id. net.

dealing with the nervous system, where the various
nerve tracts are picked out in different tints. The
illustrations and diagrams of the microscopic sections
leave nothing to be desired. There are also numerous
figures devoted to embryology. The only regret we
have in regard to this manual is that Professor
Buchanan has not included a brief general account of
the development of the embryo to aid the student in
elucidating particular details.

In conclusion, the many obvious merits of
Buchanan’s work will rapidly ensure its becoming one
of the most popular text-books of the dissecting-room.
In it the examination requirements of the student are
kept constantly in view, and the subject of human
anatomy is made interesting, clear and comprehensive.

TREATMENT OF HIP DISEASE, (a)

This monograph is based upon the author's large
experience in the treatment of hip joint disease. He
follows very closely the methods advocated long ago
by Thomas, but greatly improved on by the author
himself. After defining what is meant by hip disease
and referring to its pathology, the writer goes on ta
speak of rest in the treatment of the inflamed joint.
Rest is to be obtained by the use of a Thomas’s
splint. He then specifies in detail the apparatus
required for measuring in an ordinary typical case.
His method is an improvement on Thomas's, and gives
a certainty of fitting the splint to the patient with far
greater accuracy and celerity. The directions given
are so minute and explicit that anyone can readily
understand and carry them out.

The method of making the required splint is next,
given, and the apparatus required for fitting the splint
is fully described and illustrated. The results
obtained by the author have been uniformly successful,,
and certainly his suggestions are excellent in theory.
Having referred to the treatment of ordinary and
recent cases with flexion and little or no lateral or
rotatory displacement, the writer then goes on to
speak of the treatment of some complications and'
sequelae, especially of cases of old-standing with great
deformity. Those cases, he says, in which the limb
is fixed in extreme flexion can be reduced by treating
them with a double Thomas’s splint, made in the
same way as a single one with two upright stems, set
parallel and at a distance of one inch more than the
distance between the tip of the right and the left
posterior superior spines.

Prophylactic and drug treatment is also referred to,
as well as the operative forms of interference which
may be required in very advanced cases of this disease.
Regarding bloodless surgery Bennie says that it is
“bad surgery, and is a most dangerous operation.
Although this operation has been called bloodless
surgery, it is usually a most bloody one, but you do
not see the blood ; it is effused from the tom structures
covered by the skin. It is more likely to aggravate
than ameliorate the condition.” The work is com¬
pleted by a suitable account of cases actually treated
by the author on the lines laid down by him. We
have read this monograph with considerable interest
as it bears the evidences of much originality of
thought, and shows that the writer knows well his
subject. It is a book with which every surgeon
should make himself thoroughly familiar.

INTERNATIONAL CLINICS, (a)

Volume I. of this quarterly contains the usual
yearly summary of the progress of therapeutics, medi¬
cine, and surgery, in addition t o a series of clinical
lectures on various medical and surgical subjects. The
individual papers are 14 in number, and are well
selected. Dr. Walsh, of New York, writes a most
valuable and practical article on the treatment of
functional heart disease; Dr. Warthin writes on "The

(a) "Rational and Effective Treatment of HIp-Dlsease." By P.
Bruoe Bennie. MA., M.D., B.So.(Melb), Hon. Med. Offloer Melbourne
Hospital for Sick Children, etc. Founded on Experience of numerous
eases In Hospital Practice during 28 years. Compiled by Alex B.
Bennie. M.A., M.B.(Melb.). London: Ballllere, Tindall and Cox 1907.
Price 5s. net.

(a) " International Clinics." Vols. I. and II. Seventeenth Series.
Philadelphia and London ; J. B. Llpplncott Co. 1907.

zedbyGooqle

REVIEWS OF BOOKS.

Oct. 9, 1907.

396 The Medical Press.

Clinical Diagnosis of Enlargement of the Thymus ” ;
Dr. Morton on “ Neurotic Affections of the Joints ” ;
and an elaborate article cn “Disorders of the Um¬
bilicus ” is contributed by Gallant. These, to our
mind, are the pick of the lot, but the remaining ones
are useful as able clinical expositions of the treat¬
ment and diagnosis of many of the every-day con¬
ditions encountered in general practice. The chief
value, indeed, of this journal depends, we think, on
its method of dealing throughout the year with com¬
mon conditions, and laying before the practitioner
succinct and up-to-date accounts of what he is con¬
stantly being cailed upon to treat and diagnose. That
its method is appreciated is proved by the place that
it continues to occupy in medical journalism.

For several years we have been accustomed to say
that the annual summary found in the International
Clinics is the most readable and useful of the
numerous digests of medical progress that are pub¬
lished. This year’s summary bears out that opinion.
It occupies a little over roo pages, and yet a careful
perusal of it convinces us that nothing of importance
has been omitted. At the same time the writers seem
to have made a most careful selection, and to have
eliminated the great bulk of useless writing that
yearly crowds the journals and wearies the reader.
The very brevity of the summary enhances its value,
for a mere glance enables one to gain possession of
The salient points that have engaged medical thought
and investigation throughout the year. As usual, the
surgical summary is somewhat better than the medical
one, because it is written in a narrative style and does
not attempt to summarise all surgery, but only to deal
with the more advancing branches of the science.
Some parts of this section are well illustrated.

Amongst the papers in Volume II. is an interesting
•one by Flexner on “ Experimental Cerebro-Spinal
Meningitis,” in which he summarises the results of his
experiments as published elsewhere. He points out
that in periods of from 14 hours up to two or three
days after injection by lumbar puncture of cultures of
the diplococcus intracellularis into the spinal canal of
monkeys, an inflammatory reaction is produced which
resembles the condition found in epidemic cerebro¬
spinal meningitis in man. In most of the monkeys,
moreover, the nasal mucosa becomes inflamed, and
although the organism has not been cultivated from
the nose, still diplococci resembling it have been seen
in the polynuclear cells of the nasal exudate. This
work seems to foreshadow the possibility of the pro¬
duction of an anti-serum for the disease. Two other
interesting pathological papers appear, one an ad¬
mirable summary of our knowledge concerning the
macroscopic and microscopic characters of normal
and abnormal bone-marrow ; the other a contribution
to the pathology of general infection by the gono¬
coccus. In the Gynaecological Section Cuthbert
I.ockyer writes an instructive article on “Appendicitis
in Pregnancy,” and gives an account of six cases of his
•own. Clogg writes on “Perforated Duodenal Ulcer,”
discussing principally the diagnosis and treatment of
this condition, and pointing out its comparative fre¬
quency. Numerous other papers of interest to both
the specialist and the practitioner are included, but are
too numerous for individual mention. Many will
welcome the opening paper of the Therapeutical
Section. It contains a simple and sufficient statement-
of the theory and principle of vaccine treatment in
infectious diseases.

AUSCULTATION AND PERCUSSION, fa)
The majority of students, it is to be feared, do not
make a study of physical signs as elicited by ausculta¬
tion and percussion, contenting themselves with the
more or less perfunctory instruction they receive in
the wards and out-patient rooms, so that they fail to
grasp the rationale of the methods they employ, and,
memory failing, their powers of observation are left
unnecessarily limited. Yet on their ability to apply
and interpret correctly the methods of acoustic in¬
vestigation depends their skill as diagnosticians in a
whole series of grave affections. Carelessness, or

(a) “ Auscultation and Percussion.” By Samuel Gee. Mi)., K.R.C.P.
Fifth Edition. London ; Hodder and Stoughton. 1907.

want of method, or ignorance may render the observer
blind to the most obvious phenomena, to the detriment
of his reputation and to his ability as a practitioner
of the healing art.

A well-thought-out work like the one before us pro-
vides the student—and, if need be, the neo-practitioner
—with the means of co-ordinating his knowledge and
experience, and enables him to reason out that which
he may fail to remember. Of the work, itself it is
hardly necessary to speak, seeing that it is by this
time a standard treatise on the subject, couched in
language which, if at times a shade archaic, is un¬
usually choice for a technical work.

The history of the subject, as well as the subject
itself, is peculiarly interesting. How signs so obvious
could have escaped the keen observation of our profes¬
sional progenitors must ever remain a matter for sur¬
prise ; but in all probability they had a belter acquaint¬
ance with them than we are apt to believe.

The author is well advised to impress his readers
with the fact that there are other senses than that cf
hearing, and that the stethoscope does not exhaust our
means of perception or dispense with the necessity
or other modes of investigation—in other words, auscul¬
tation and percussion do not cover the whole field of
clinical exploration.

Admirably printed and neatly bound, the work is
one to figure in every medical library. It will well
repay attentive study.

THE DIGESTIVE SYSTEM, (a)

It is often said nowadays that the surgeon is leaving
little or no field for the pure physician, but a book of
this kind tells another tale. At the same time it
remains true that much of the diagnosis ends in sur¬
gery, and the American translator is careful to point
out that many of the diseases included lie on the
borderland of medicine and surgery. The present
work is of considerable value, inasmuch as it presents
in English form a careful and authoritative transla¬
tion of the well-known work, “Die Deutsche Klinik,”
issued under the editorial supervision of Dr. Julies
Salinger. The list of 21 contributors includes the
names of many leading Continental authorities. Among
them may be mentioned Rosenheim, Ewald, Hirsch-
feld, Strauss, Boas, and Statelmann, of Berlin;
Neisser and Ncthnagel, of Vienna ; Hoppe and Seyler,
of Kiel ; Suanboyle, of Bonn ; and Fleiner, of Heidel-
burg. The section upon gallstones, by Neisser, is par¬
ticularly full and interesting, and that upon gastric
ulcer and gastric haemorrhage compact and accurate.
There are 45 illustrations of good quality. The book
has been carefully edited, and Professor Billings may
be congratulated on presenting to English readers a
book that will be invaluable to all physicians.

ON POLYPUS, (a)

The subject under consideration in this monograph
has been much debated and many divergent theories
have been advanced, so that a concise work of real
value is needed in collecting the views of many different
authors and at the same time giving those of the
writer. The following theories are worthy of
mention:—1. That polypi are true tumours. 2. That
polypi are peculiarly modified granulations. 3. That
polypi are almost invariably a symptom of suppuration
in the accessory sinuses of the nose. 4. That polypi
are merely a symptom of disease of the ethmoid bone.
5. That polypi are cedematous hypertrophies of the
nasal mucous membrane, the indirect result of certain
mechanical changes in the mucous membrane glands.
The writer’s own theory is stated in the words above
under the heading 5, and he sums up his remarks as
follows : —

r. Chronic inflammation of the mucous membrane.

2. Dilatation of the glands going on to cystic
distension, caused either (a) through marked inflam¬
matory infiltration of their ducts produced by septic

(a) Diseases of tbe Digestive System." Edited by Julio* L.
Salinger, M.D. (from the Deutsche Klinik). Translated and edl'ed by
Frank Billings, M.D., Professor of Medicine, University of Chicago
London: Sydney Appleton. 1607.

(a) Polypus of the Nose." By Eugene 8. Tonga, M.D. Manchester
Sberratt and Hughes.

Digitized by LiOOQle

Oct. 9, 1907.

MEDICAL NEWS IN BRIEF. The Medic al Press. 397

•discharges, or ( b) through excessive filling of the gland
combined with a partial obstruction to the exit of the
$land contents.

3. (Edematous infiltration of the surrounding tissues,
resulting from the passage of serum through the
capilliary walls, due (a) to increased pressure in certain
capilliaries, owing to obstruction of the capilliaries
into which they lead, (b) to increased permeability in
the capilliary walls, the result of inflammation, and
{c) to the laxity of the surrounding tissues.

4. The formation of folds or projections on the
infiltrated mucous membrane.

5. The increase of oedema in certain of the folds,
formed in the manner described, combined later with
a hyperplasia of the fibrous elements.

6. The formation of flat oedematous structures con-
taining the essential constituents of the nasal mucous
membrane (broad based or sessile polypi), or of
oedematous structures containing the same consti¬
tuents but a greater amount of fluid, and perhaps of
hyperplastic tissue, and each possessing a base which
gradually becomes relatively constricted and stretched,
until it constitutes a pedicle. This connects the
remainder of the structure—which now, through the
influence of gravity and other physical causes, has
"become a globular swelling (pedunculated polypus)—
with the mucous membrane from which it sprang.

The little book adds to our knowledge of the subject
and is worthy of careful study.

NEW BOOKS AND NEW EDITIONS.

The following have been received for review since the publica¬
tion of our last monthly list:—

Sidney Appleton (London).

Minor Medicine : A Treatise on the Nature and Treatment of
Common Ailments. By Walter Essex Wynter, M.D., etc. Pp.
275. Price 6a. net.

Bailliere, Tindall and Cox (London).

Bloodstains : Their Detection and the Determination of their
Source. By Major W. D. Sutherland, I.M.S. Illustrated.
Pp. 167. Price 10s. 6d. net.

Treatment by Hypnotism and Suggestion. By C. Lloyd
Tuckey, M.D. Aberdeen. Fifth Edition. Revised and

Enlarged. Pp. 418. Price 10s. 6d. net.

Nature’s Hygiene and Sanitary Chemistry. By C. T. Kingzett,

F. I.C., F.C.S. Fifth Edition. Pp. 527. Price 7s. 6d. net.
Marine Climates in Tuberculosis. By William Ewart, M.D.,

etc., etc. Pp. 48. Price Is. net.

Preventable Blindness. Bv N. Bishop Harman, M.A.. M.B.
Cantab., F.R.C.S.Eng. illustrated. Pp. 109. Price 2s. 6d.
net.

A. Brown and Sons, Ltd. (London).

Modern Methods for Securing Surgical Asepsis By Edward
Harrison, M.A., M.D., etc. Pp. 125.

Browne and Nolan, Ltd. (Dublin).

Health and Habits. A Course of Easy Lessons, with an Intro¬
duction. By Sir Christopher Nixon, Bart., A.M., M.B., etc.
Pp. 157.

Johx Bale, Sons and Danieisron. Ltd. (London).

Some of the Clinical Aspects of Pneumonia. By Donald W. C.

Hood. C.V.O., M'.D., etc. Pp. 117. Price 7s. 6d. net.

Some Successful Prescriptions. By Herbert Hart, M.D. Pp. 17.
Price Is. net

Light and X-Rnv Treatment of Skin Diseases. By Malcolm
Morris, F.R.C.S.Edin.. nnd S. Ernest Dore, M.D.Cantab.
Illustrated. Pp. 172. Price 5s.

Surgical Applied Anatomy. By Sir Frederick Treves, Burt.,

G. C.V.O., etc., etc. Fifth Edition, revised by Arthur Keith,
M.D., F.R.O.S.. Illustrated. Pp. 610. Price 9s. net.

Cassell and Co.. Ltd. (London).

Insanity and Allied Neuroses. By George H. Savage, M.D.,
F.R.C.P., assisted hv E. Goodall, M.D.. etc., etc. Illustrated
New and Enlarged Edition. Pp. 624. Price 12s. 6d.

■J. A A. Churchill (London).

Pathology, General and Special, for Student* of Medicine.
By R. Tanner Hewlett, M.D., etc. Second Edition. Pp. 585.
Price 10s. 6d. net.

A Short Manual for Monthly Nurses. By Charles J. Culling-
worth, M.D . F.R.C.P. Sixth Edition, Revised and Enlarged.
Pp. 128. Price Is 6d. net.

A Manual for Hospital Nurses and Others engaged in Attend¬
ing the Sick. By Edward J. Domville. L.R.C.P., etc. Ninth
Edition. Pp. 152. Price Is. 6d. net.

Henry Frowde and Hodder and Stoughton (London).

Diseases of the Ear. By Hunter Todd, M.A., M.B., etc., etc.
Pp. 317. Price 6s. net.

Diseases of the Nose. By Ernest B. Waggett, M.A., M.B., B.C.
Pp. 282. Price 5s. net.

A Manual of Venereal Diseases. By Officers of the R.A.M.C.
Pp. 282. Price Us. net.

Henry Fhowde (London).

Travels through France and Italy. By Tobias Smollett. Pp.
352. Prioe Is. net.

Henry J. Olaisher (London). , _ ,

On Acute Pneumonia: Its Signs, Symptoms, and Treatment.
By Seymour Taylor, M.D., L.R.C.P. Pp. 64. Price Is. net.
Humanitarian League (London). . . „ „ ,

How to Reform our Prison System. By H. J. B. Montgomery.
Pp. 20. Price 3d.

William Heinemann (London). „ „ , ,

Metabolism and Practical Medicine. By Carl von Noorden.
Tol. III.. English issue, under the Editorship of J. Walker
Hall. Price, in 3 Vols., £2 12s. Gd. net.

J. B. Lippincott Co. (Philadelphia).

International Clinics. A Quarterly Edited by W T. Longcope,
M.D. Vol. III.. Seventeenth Series, 1907. Pp. 296.

H. K. Lewis (London). . . „ , _

A 8ystem of Radiography, with an Atlas of the Normal. By
W. Ironside Bruce. M.D. Pp. 110. Price 15s. net
Hvsriene and Public Health. By Louis C. Parkes, M.D., D.P.H..
"and Henry R. Kenwood, M.D.Edin., D.P.H.Lond. Third
Edition. Illustrated. Pp. 620. Price 10s. 6d. net.
Macmillan and Co., Lrp. (London)

The Technique of Vagino-Peritoneal Operations. By E.
Wertheim ana T. Mioholitsoh. Translated into English bv
Cuthbert Locicyer, M.D., etc., etc. Illustrated. Pp. 323.
Price 25s. net.

The Prevention of Infectious Diseases. By John C. Mvaii,
M.D., D.P H.Camb.. F.R.S.E. Pp. 290. Price 8s. 6d. net.
George Pulmax and Sons, Ltd. (London).

Ophthalmia Neonatoriuin. By Sydney Stephenson, M.B., C.M.
Pp. 258. Price i2s. 6d. net.

Youxo J. Pextlaxd (Edinburgh). .

Manual of Practical Anatomy. By D. J. Cunningham, M.D.,
etc., etc. Two Vol*. Fourth Edition. Illustrated. Pp. 1,221.
price 21s. net.

Manual of Bacteriology. By Robert Muir, M.A., M.D., L.R.C.P.
Edin., and James Ritchie, M.A., M.D., B.Sc. Fourth Edi¬
tion. Illustrated. Pp. 605.

The Pharmaceutical Society (London).

The British Pharmaceutical Codex : An Imperial Dispensatory
for the use of Medical Practitioners and Pharmacists. Pp.
1,422. Price 12 6d. net.

Sampson Low, Marston and Co., Ltd. (London).

On Stammering, Cleft-Palate Speech, Lisping. By Mrs. Emil
Behnke. Pp. 92. Price Is. net.

Simpkix Marshall, Hamilton, Kent and Co., Ltd. (London).
Self-Synthesis: A Means to Perpetual Life. By Cornwall
Round. Third Edition. Pp. 33. Prioe Is.

Sisleys Ltd. (London).

The Wife: Her Book. By Haydn Brown, L.R.C.P., etc. Pp.
307. Price 3s. 6d. net.

Smith. Elder and Co. (London).

First Aid to the Injured : Six Ambulance Lectures. By Dr.
F. Esmarch. Translated from the German by H.R.H. Princess
Christian. Seventh and Enlarged Edition. Illustrated. Pp.
138. Price 2s. net.

The Health Resorts Bureau (London). „ „ „ „ ~

Wintering in Rome. By A. O. Weisford, M.D., B.C. Second
Edition. Pp. 104. Price 2s. 6d. net.

The Scientific Press, Ltd (London).

A' Text-Book of Mental and Sick Nursing. By Robert Jones,
M D. B.S.Lond., etc., etc., with an Introduction by Sir
Wm.’j. Collins, M.D. Pp. 222. Price 3s. 6d. net.

Nerve Diseases: For Student* commencing Hospittl Practice.
By L. A. Clutterhuck, M.D., etc. Pp. 269. Price 3s. net.
The Sanitary Publishing Co.. Ltd. (London).

The Bacteriological Examination of Disinfectants. By Mr.
Partridge. F.T.O., with Preface by Major C. E. P. Fowler,
D.P.H., F.R.C.S. Price 2s. 6d. net.

John Weight and Oo. (Bristol).

The Re-Educntion of Co-ordination bv Movements, with special
reference to Locomotor Ataxy. Accompanied by Mounted
Charts for the Movement Exeroises. By Arthur G. Dampier-
Bennett, M.R.C.8., L.R.C.P. Pp. 15. Price, Book and Chart,
10 s. 6d. net.

Medical News in Brief.

London Medical Exhibition.

The third London Medical Exhibition, organised by
the “ British and Colonial Druggist,” was opened on
Monday at the Royal Horticultural Hall, Westminster.
Compared with last year the exhibition marks a great
advance; not only is every inch of space taken up, but
the interest upon the part of the medical profession is
greater than in the previous two years. Last year close
upon 5,000 medical men within a radius of twenty
miles from Charing Cross visited the exhibition.
Patent and special foods and beverages are in great
variety. “Equipoise, Limited,” exhibit samples of
furniture which are as much sought after by the ordi¬
nary person as the invalid. Beds, mattresses, chairs,
and other articles are in profusion, among others a
replica of a couch which was specially ordered by the
Queen, and is now in use at Buckingham Palace. The
Hospitals and General Contracts Company have an
interesting show of their aseptic furniture. The Ayles¬
bury Dairy Company explain what can be done to
ensure pure milk. Parke, Davis, and Co., among
many other useful exhibits, have a speciality in the

Digit

Google

398 The Medical Pees*.

MEDICAL NEWS IN BRIEF.

Oct. 9, 1907.

shape of the “Yachtomobile ” first aid case. As its
name indicates, it is suitable either for yachtsmen or
motorists, and contains everything necessary to render
first-aid in cases of emergency, accident, or shock
either on a yacht or motor-car. Messrs. Hearon,
Squire, and Francis have on view many samples of
opium. These include Persian, Chinese, and English
—the latter being most rare and produced in Lincoln¬
shire. They are shown in the raw condition, and also
made up in the form of tabloids, although for the
English product it should be said that it is probably
the only sample of its kind to be found in this country.
The exhibition remains open until Friday.

.Sanatorium for Consumptive Children.

The first British sanatorium for consumptive child¬
ren was opened on October 4th, at Stannington, by
the Duke of Northumberland. The institution is in
the care of the Poor Children’s Holiday Association,
which, managed by Mr. J. H. Watson, of Sidney
Grove, Newcastle, is accomplishing a work that is
deserving of much praise. The Association was
started in the year 1891, by taking some of the little
slum-dwellers to the seaside; and now it has a training
home for girls, a convalescent home, boys’ rescue and
labour homes, and innumerable agencies for the better¬
ment of the poor street children. At Stannington
there is a convalescent home and a farm colony, and a
sanatorium in which consumptive children have every
chance of being restored to health. Mr. Watson’s pro¬
jects have good friends, who appreciate the enormous
value of his labours ; but the Association needs £2,000
to complete the capital cost, and, for the expansion of
the farm colony, £1,000 is required for a new field.
The sanatorium will require at least .£3,000 per annum
to carry out its work. Boards of Guardians and other
bodies have talked about the provision of sanatoria for
consumptives ; but, if they would endow beds in such
an institution as that at Stannington, they would find
the work well done, and save the cost of erecting special
buildings. The parents of the children contribute
towards their support, where they can. But most of
the lads upon the farms are orphans
5heffleld Midwife.

An inquest was held on October 5th at the Jessop
Hospital, Sheffield, relative to the death of a woman
who had died from puerperal fever. The deceased
woman was the wife of a plumber. The inquest was
conducted by the City Coroner. According to the
evidence of the husband a midwife, Mrs. Fetch, at¬
tended the deceased on Friday, September 20th, and
the following five days, but did not visit her on the
26th until fetched. Deceased was then in a very bad
state, and on the following day was removed to the
Jessop Hospital, suffering from puerperal fever. She
died there on October 2nd. It was suggested that the
midwife had not treated deceased properly, and that
a doctor ought to have been sent for sooner. Eliza¬
beth Fetch, the midwife, said she attended deceased
•at her confinement, which was a perfectly normal and
healthy one. Deceased went on well till Thursday,
and on that day witness was fetched. She went, and
owing to the condition of her patient, told the husband
to fetch the doctor, and he did so. She had never
asked him to fetch one before, and he had never asked
her to do so. She had, however, advised the deceased
to have one the day before.—Coroner: But you said
she went on all right up till Thursday. Why did you
advise her to have one? Witness: She had pains in
her head.—Then she did not go on all right? No, sir.
—You advised her to have a doctor the day before?
Yes, sir; but she refused. Witness contradicted her¬
self several times whilst being cross-examined by Mr.
Coath. Asked as to the number of days a midwife
was supposed to attend a patient, she first said seven
days in succession and the tenth day, and then ten
successive days.—Mr. Coath : Did you ever take the
temperature of this woman?—Witness: No.—Do you
take the temperatures of your patients?—No; I don’t
understand the thermometer. Replying to further ques¬
tions, witness first said she had not received com¬
plaints from the medical officer of health as to her
treatment of patients, and afterwards admitted she had.
She also said she could not remember the name of

the disinfectant she was in the habit of using. After
evidence had been given as to the cause of death, the
jury returned a verdict to the effect that deceased had
died from puerperal fever. They also added that they
thought there had been considerable neglect on the
part of the midwife, and that they did not think she
was quite the proper woman to practise.

Tha Carbolic Coefficients of Sanitas-Okol.

Experiments have been made by Dr. Klein with
“ Sanitas-Okol ” to ascertain its carbolic co-efficient on
B. Typhosus (a) under ordinary conditions, ».«., in
watery dilutions, and (b) in the presence of organic
matter—nutrient broth (beef broth and peptone). The
strain of B. Typhosus tested was an active subculture
in nutrient broth (24 hours’ incubation at 37°C) de¬
rived originally from the spleen of a fatal case of
enteric fever, several generations removed from the
original source. In all instances to 5CC. of the dilu¬
tions of Phenol or “ Sanitas-Okol " respectively five
drops of the broth culture of B. Typhosus were added,
and after exposure for the desired time, three loops—
same loop being always used—were taken from the
medicated fluid, and transferred to sterile nutrient
broth in tubes. These were then transferred to an
incubator, and kept for three days at 37°C, after which
time the result was noted. From the experiments it
appears that in the absence of organic matter the car¬
bolic co-efficient of “Sanitas-Okol” is= 20;

90+85

in the presence of organic matter it is 1 ^^ 5 *~^'_ 1 5 °°. = 17.7.

90+85

Death under an Anaesthetic.

Mr. Henslowe Wellington held an inquest on the
body of Robert M‘Donald, aged 47, a pastrycook, who
died in St. Thomas’s Hospital after undergoing an
operation. Robert Greatorex, brother-in-law of the
deceased, complained that the hospital authorities did
not notify the relations that an operation was to be
performed and that a relapse had followed. Dr.
Nightingale, house surgeon at St. Thomas’s Hospital,
said that the deceased had called at the hospital some
days before, and had been informed of the necessity
for an operation, and came to the hospital on Monday
for that purpose. He was asked to communicate to
the relatives the fact that the operation was to be per¬
formed on the following day. He promised to do so,
but apparently did not. The operation was a difficult
one, and ether was the anaesthetic used. It was suc¬
cessfully completed, but later haemorrhage started from
the surgical wounds, and though all that was possible
was done, the haemorrhage continued. It was decided
that nothing more could be done for him without an
anaesthetic, and the deceased was taken to the operation
theatre again. Chloroform was administered, and
under its influence deceased stopped breathing. -Arti¬
ficial respiration was resorted to, and Mr. Adams, one
of the surgeons, endeavoured to massage the heart,
but it was found to be flaccid. In answer to the first
witness the doctor said that the case was so urgent
that there was no time to communicate with the rela¬
tives. Dr. Trevor said that death was due to heart
failure due to loss of blood following on the operation.
The jury returned a verdict accordingly.

Disputed £ 1 oo,oo« Hospital Btqocit

An influential committee of ratepayers in Streatham
have recently circulated a memorial to the Charity
Commissioners with the view of obtaining £100,000
left by the late Mr. Weir to establish a medical institu¬
tion in Streatham parish. The holders of the money,
it is alleged, now propose to hand over practically the
whole sum to the Bolingbroke Hospital, which is in the
Borough of Battersea. The petition says that Streat¬
ham needs the hospital, and that they should not be
deprived of the bequest given to them by the late Mr.
Weir for the hospital and a properly organised am¬
bulance service.

Reuter’s Agency has received from the chief medical
officer of Helsingfors a statement that no cases of
Asiatic cholera have occurred in that town. This
declaration refers to a Reuter’s telegram of September
18th stating that thre* cases of cholera had occurred at
Helsingfors.

D

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Oct. 9, 1907.

MEDICAL NEWS IN BRIEF,

The Medical Press.

399

Pathology In Bristol.

Before the function at the opening of the winter
session at University College, Bristol, when Professor
Gotch distributed the prizes, and delivered a stirring
address on the University question, Professor Walker
Hall gave a demonstration in the Museum of the Royal
Infirmary. This was largely attended by medical men
from the districts around. At 2.30 p.m. there was a
lantern demonstration of microscopical preparations.
This was followed at 2.45 p.m. by an account of
residual opsonins by Dr. J. H. Munro. Dr. J. J.
Lucas related some anomalous cases of tuberculosis—
cases which gave practically no clinical symptoms, or
gave indications of typhoid, or of pernicious anaemia.
Dr. Walker Hall then described some new methods for
the mounting of museum specimens, and for the
estimation of sugar in urine, and fat in fteces.

Entrance Scholarship* at the London Hospital*.

The following announcements were made at the
opening of the Winter Session at the London Medical
Colleges:—

St. George’s Hospital. —The University Entrance
Scholarships in Science have been awarded as
follows:—R. F. Jones, B.A., Pembroke College, Cam¬
bridge, and L. A. Lewis, Edinburgh University, equal,
a scholarship of 60 guineas each, and E. W. M. H.
Phillips, Jesus College, Oxford, scholarship of
50 guineas.

London Hospital. —Price Scholarship in Science,
value £120. —Mr. T. D. Williams. Science Scholar¬
ships, value £ 60.—Mr. N. R. Rawson. Science Scholar¬
ships, value £35. —Mr. J. H. Lloyd. Price Scholarship
in Anatomy and Physiology.—Mr. G. J. F. Jessel
<Univ. of Oxford). Epsom Scholarship (^126).—Mr.

E. H. Henson.

Charing Cross Hospital. —The following Entrance
Scholarships have been awarded :—The Epsom Scholar¬
ship (115 guineas), to Mr. J. E. Ashby ; The Huxley
Scholarship (55 guineas), to Mr. E. M. Morris.
Entrance Scholarships have also been awarded to Mr.
A. E. Hallinan (40 guineas), and to Mr. W. Leslie
(30 guineas). Universities Scholarships of 72 guineas
each have been awarded to Mr. W. R. Thomas and
Mr. C. W. Shepherd, both of the London University.

Middlesex Hospital. —The following Entrance
Scholarships have been awarded :—Arts Scholarship.—
Mr. C. E. Thornton. Science Scholarship.—Mr. W.
Butterfield. University Scholarship.—Mr. W. M.
Penny. Frere Lucas Scholarship.—Mr. A. L. H.
Rack ham.

King’s College Hospital. —The following Scholar¬
ships have been awarded in the Faculty of Medicine:—
Medical Entrance University Scholarship (£s°) —
H. A. Treadgold. Wameford Medical Scholarship
(Arts) (^50).—A. S. Wakeley.

The Forthcoming Tuberculosis Exhibition In Ireland.

An inaugural address in connection with this exhibi¬
tion will be delivered by Professor William Osier,

F. R.S., Regius Professor of Medicine in the University
of Oxford, in the Theatre of the Royal Dublin Society,
Kildare Street, on Friday, October nth, at 8.30 p.m.
The title of the lecture is, “What the Public Can Do
in the Fight Against Tuberculosis.” Admission will
be free.

PASS LISTS.

University of Durham.

At the Convocation held on Saturday, September
28th, 1907, the following degrees were conferred: —
Doctor in Medicine.—Thomas Hartigan, M.B., B.S.,
Durh.; Frederick William Kemp, M.B., B.S., Durh. ;
Wharram Henry Lamplough, M.B., B.S., Durh. ;
Frank Laughton-Smith, M.B., B.S., Durh. ; Frederick
Robert Henry Laverick, M.B., B.S., Durh. ; Morgan
Richards, M.B., B.S., Durh. ; Ernest Charles Young,
M.B., B.S., Durh.

Doctor in Medicine for practitioners of fifteen
years’ standing.—Henry T. S. Aveline, M.R.C.S.,

L. R.C.P.; Edgar Beaumont, M.R.C.S., L.R.C.P. ;
John F. Butler-Hogan, B.A., M.D. (Brux.), L.R.C.P.
and S., L.F.P.S.G., D.P.H. ; Geoffrey Cross,

M. R.C.S., L.R.C.P., I..S.A.; John Cumming,

F.R.C.P. and S., E., L.F.P.S.G.; Ludford Cooper,
M.R.C.S., L.R.C.P.; John Freeman, M.R.C.S.,

L. R.C.P. ; Arthur Hawkyard, L.R.C.P. and S., E. ;
John W. D. Hooper, L.R.C.P. and S. ; Hedley Hill,

M. R.C.S., L.R.C.P.; Llewellyn Lewis, M.R.C.S.,
L.R.C.P.; William M. Palmer, M.R.C.S., L.R.C.P.,

L. S.A.; Arthur W. Read, M.R.C.S., L.R.C.P.,

F.S.A. ; Hugh J. Roberts, M.R.C.S., L.S.A. ; Henry
F. Steele, M.R.C.S., L.R.C.P., L.S.A. ; John F.
Woodyatt, M.R.C.S., L.R.C.P. ; Richard M. West,

M. R.C.S., L.R.C.P.; George C. W. Wright, M.R.C.S.,
L.R.C.P.

Bachelor in Medicine (M.B.).—George E. P. Davis,
L.R.C.P. and S., L.F.P.S.G.; William H. Edgar;
George R. Ellis; Charles W. Greene; Herbert F.
Joynt; Edward P. Joynt; Charles G. Kemp, M.R.C.S.,

L. R.C.P.; Herbert Max Levinson; Hector G. C».
Mackenzie, M.A. ; Stanley D. Metcalfe; Elizabeth

N. Niel; Roland W. Pearson, M.R.C.S., L.R.C.P. ;
James W. Smith; George Walker; Lionel L. West-
rope, L.R.C.P. and S., L.F.P.S.G.; Frank Whitby;
Cuthbert R. Wilkins.

Bachelor in Surgery (B.S.).—George Edward Peckett
Davis, L.R.C.P. and S., L.F.P.S.G. ; WTlliam H.
Edgar; George R. Ellis ; Charles W. Greene; Herbert

F. Joynt; Edward P. Joynt; Charles G. Kemp,

M. R.C.S., L.R.C.P.; Herbert Max Levinson ; Stanley
D. Metcalfe; Elizabeth N. Niel; James W. Smith;
George W T alker; Frank Whitby; Cuthbert R. W’ilkins.

Bachelor in Hygiene (B.Hy.).—George Denholm,
M.B., B.S., Durh.; George P. Harlan, M.D., Ch.B.,
Glas.

And the following received the Diploma in Public
Health (D.P.H.).—-George Denholm, M.B., B.S.,

Durh.; Albert G. W. Pearson, M.B., B.S., Durh.
any's Hospital Medical Acfcsol.

The following Entrance Scholarships and Certi¬
ficates have been awarded :—Senior Science Scholar¬
ships for University Students (^50): J. G. Saner,
Caius College, Cambridge.

Junior Science Scholarships 150): J. F.
Mackenzie, Preliminary Scientific (M.B.) Class;
(^60) R. D. Passey, Preliminary Scientific (M.B.)
Class.

Certificates.—T. J. Bennett, Preliminary Scientific
(M.B.) Class; G. E. Genge-Andrews, Preliminary
Scientific (M.B.) Class; S. Keith, Preliminary
Scientific (M.B.) Class.

Entrance Scholarships in Arts.—(.£100) C. S. L.
Roberts, Cheltenham College; (£25) G. D. Eccles,

Plymouth Technical School and (^25) G. F. Romer,
Malvern College (equal).

The Royal University of Ireland.—The Third Examination In
Medicine.

The following candidates have passed the above-
mentioned examination:—

Upper Pass.—‘Albert V. Craig, “William Dickey,
James A. Hanrahan, ‘Richard W. G. Hingston, David
Horgan, ‘John C. Houston, ‘Edward G. Kennedy,
Ernest W. Kirwan, ‘Patrick J. Lydon, B.A., ‘Michael

G. O’Malley, David A. Rice, Thomas Scanlan, William
S. R. Steven, Alfred M. Thomson, Michael Twohig.
(Those marked with an asterisk had the liberty of pre¬
senting themselves for the further examination for
Honours, which commenced on Monday morning,
October 7th.)

Pass.—David R. Acheson, W’illiam J. Ashby, Percy
M. J. Brett, Daniel Broderick, Francis S. Carson,
Victor L. Connolly, William Doolin, Joseph S. Doyle,
William P. Dunne, B.A., Patrick Hayes, Jeremiah
Holland, Joshua Keyms, B.A., Samuel K. McKee,
William Magner, Thomas P. Magnier, George E. A.
Mitchell, Thomas J. S. Moffett, James M. O’Reilly,
Alexander Patton, B.A., Samuel P. Rea, William
Riddell, John Spence, Hill W. W’hite, Robert Young.
Qassa's Colleys, Cork.

We are officially informed that the King has been
pleased to approve of the appointment of Bertram
Coghill Alan Windle, Esq., M.D., F.R.S., the Presi¬
dent of Queen’s College, Cork, to the Professorship of
Anatomy in the said College, to hold such Professor¬
ship concurrently with his office of President, and of
the appointment of David Thomas Barry, Esq., M.D.,
to be Professor of Physiology in the said College.

zed by GoOgle

400 The Medical Press.

WEEKLY SUMMARY.

Oct. 9, 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled /or The Medical Press and Circular.

RECENT MEDICAL LITERATURE.

Early Diagnosis of Pulmonary Tuberculosis.—

Hammans and Wolman have analysed the records of
1,745 cases of pulmonary tuberculosis met with at the
Phipps Dispensary (Johns Hopkins Hospital Bulletin ,
August, 1907). Out of this number they find that 150
cases may be classed as early, and every one of these
presented either slight changes in the percussion note,
modified breath sounds, or rales. When all three signs
were present, the diagnosis was regarded as complete
by physical signs alone, but in 61 cases further aid in
diagnosis had to be obtained either by examination of
the sputum, by the tuberculin test, or by observing the
further course of the disease. Out of the 61 cases, a
change in the percussion npte was detected in 47 per
cent, j breath sounds were modified in 61 per cent. ;
and rales were heard in 53 per cent. In 24 of the
cases tubercle bacilli were found in the sputum, and
in 24 other cases that did not show bacilli in the
sputum a positive tuberculin reaction was obtained.
The symptom for which many patients presented
themselves was hsemoptysis occurring after a variable
period of coughing, while in 16 per cent, of the cases
haemoptysis was the earliest symptom. As regards the
tuberculin test more value is apparently to be placed
on a negative than on a positive reaction, except when
the positive reaction is borne out by the history, the
symptoms presented, and the physical signs. M.

Tbe Opsonic Index for Streptococci in Scarlatina.—

Banks has investigated the opsonic index for strepto¬
cocci in scarlatina with tha object of attempting to
determine what part streptococci play in the com¬
plications of that malady (Journal of Path, and Bad.,
October, 1907, p. 113). He employed Wright’s method
of determining the index, and made use of four strains
of streptococci, one of which was the strepcoccus pyo¬
genes. The index was taken on different days of the
disease, and during the period of convalescence. He
formulates his conclusions as follows:—(1) In the
early febrile period the index is low : it reaches normal
with the decline of symptoms, but falls again during
the second and third weeks. It again reaches normal
during the fourth and fifth weeks. (2) In fatal cases
with severe angina, the power is markedly subnormal.
(3) The index is low during the presence of such com¬
plications as albuminuria, severe nephritis, and
secondary adenitis. (4) A persistently low index
during nephritis is an unfavourable sign. Fourteen
cases in all were investigated, of which five ran a
fairly normal uncomplicated course. ' M.

Mlcrobic Cyanosis. —Gibson again draws attention to
the condition known as microbic cyanosis (The
Quarterly Journal of Medicine, Vol. I., No. 1, p. 29).
Five years ago Stokvis first called attention to the
causation of cyanosis by intestinal disturbance, and
suggested that some toxin absorbed from the alimen¬
tary tract led to the formation of methxmoglobin.
Later, other cases were recorded, and in 1906 Gibson
reported a case in which there was marked cyanosis
accompanying chronic diarrhoea. Examination of the
blood in this case showed the presence of methasmo-
globin, and some nitrites, and the bacillus coli com¬
munis was obtained readily in cultures made from the
blood on agar. Nitrites also were found in the saliva,
but only in small quantities in the faeces. After treat¬
ment of the case for several months with intestinal
antiseptics, a marked improvement took place. The
cyanosis became much less, the general symptoms
ameliorated, and the blood no longer contained orga¬
nisms. The methaemoglobin also disappeared, but
traces of nitrites were still found. The author believes
that the condition must be regarded as due to a chronic
bacillaemia in which the bacillus coli communis is the
p.ithogenic organism at work. M.

The Parathyroid Glands. —Harnett has examined the
parathyroid glands found at 42 consecutive autopsies
[Trans. Path. Soc. London , Vol. 58, Tart II., 1907).
His anatomical and histological investigations, so far
as they have gone, seem to allow of the following de¬
ductions, which are of interest at the present time,
when so much importance has been attached to these
glands. (1) The activity of the parathyroid increases
as age advances. (2) The parathyroid normally forms
a secretion indistinguishable microscopically from that
formed in the thyroid. In diseases such as myxoedema
and goitre this secretion is formed in greater quantity.
There is as yet no proof that the parathyroid forms
any oth’r secretion besides colloid. (3) There is no
histological evidence in favour of the view that the
gland has a function of its own essential to life, nor
are there any grounds for supposing it to be the organ
specially affected in any diseases. M.

Chronic Valvular Disease of the Heart. —Carr
(Practitioner, September, 1907), in a paper on this sub¬
ject, discusses the difficulty in diagnosis in cases of
adherent pericardium. In chronic mitral valve disease
the diagnosis is often greatly facilitated by the symp¬
toms of failure of compensation, but many cases in
children progress to a fatal termination without the
marked development of the so-called “back-pressure
symptoms.” In Carr’s experience many such cases
have also an adherent pericardium, and it is to this
more than to the valvular lesion that the symptoms
present are due. The ordinary signs of this condition,
as enumerated in books, apply mainly, if not exclu¬
sively, to adhesions between the pericardium and the
chest wall, or mediastino-pericarditis. Carr believes
that in children with mitral, but no evidence of aortic
disease, and a heart so dilated as to give rise to well-
marked precordial bulging, there is very considerable
probability that the pericardial sac is obliterated, even
though no history of pericarditis can be obtained.
The presence of subcutaneous rheumatic nodules, he
also believes, almost invariably indicates the existence
of active heart mischief. K.

Balsam of Peru in Scabies.— Baker (P.A.M.C., Joum.,
September, 1907) gives the result of this treatment,
which has been carried out in sixty cases at the Mili¬
tary Hospital, Arbour Ilill, Dublin. The details of
the treatment were given in the Journal in January
and February of this year by Major Porter. In none
of the sixty cases has there been any relapse, nor has
there been a case of albuminuria though the urine has
been examined at regular intervals after the applica¬
tion of the balsam. Baker considers the preliminary
hot bath, efficiently carried out, as an essential, but
differs from Major Porter in preferring the pure
balsam, while the latter used a mixture of glycerine
and balsam in the proportion of one to three. The
results in the Arbour Hill Hospital have been very
satisfactory, and several patients have been discharged
from hospital cured twenty-four hours after admission.
The drug is expensive, but the short duration of the
treatment more than counterbalances this. K.

Cancer of the Stomach. —Packe (The Med. Chronicle,
July, 1907) brings forward statistics illustrative of this
subject based on the post-mortem records of St.
George's Hospital during a period of ten years—1890-
1900. During this time there were 227 autopsies per¬
formed on cases of cancer of the internal organs, and
of these cases sixty, or 26.5 per cent., were cases of
cancer of the stomach. Cases of cancer of the oeso¬
phagus came next in frequency, and formed 15.9 per
cent of the total, while cancer of the colon gave a
percentage of 15, and cancer of the rectum 7.Q per
cent. From an investigation of these returns Packe
draws the following conclusions:—That primary

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WEEKLY SUMMARY.

The Medical Press. 4 qi

Oct. 9, 1907.

cancer arises more frequently in the stomach than in
any other internal organ. That though cancer in
general is on the increase, yet the increase of cancer
of the stomach is greater proportionately. That males
are more frequently the subjects of cancer of the
stomach than females, the proportion being 1.85 to 1.
The most fatal decade of life for cancer of the
stomach is from fifty to sixty years. In this period
32.01 per cent, of the cases occurred. That cancer
may follow as a late result of gastric ulcer. That 55
per cent, of the growths occur at the pyloric end of
the stomach. That perforation of the stomach occurs
most frequently when the growth is on the anterior
wall. That cylindrical-celled cancer shows a prefer¬
ence for the pyloric end of the stomach, while the
largest number of cases of spheroidal-celled carcinoma
were of the form invading the entire stomach. That
the histological nature of the growth has no effect on
the incidence of metastases or of ulceration. That the
oesophagus is the chief seat of primary cancer growth
in secondary cancer of the stomach, the pancreas fol¬
lowing next in order of frequency. K.

The Starch and Opium Enema. —Ryley (R.A.M.C.
Journ., September, 1907) states that on several occa¬
sions he has seen severe tympanites follow the ad¬
ministration of this form of enema; in one case the
tympanites was so severe that it caused cardiac em¬
barrassment and death. He believes that this con¬
dition is the result of two causes. (1) The opium
causes a paralysis of the rectum which is consequently
unable to expel flatus; (2) the fermentation of the
starch causes a rapid evolution of gas, which fills the
bowel. Ryley has found by experiment that "lien
starch is incubated at the body temperature, mixed
with a little faeces, that large quantities of carbon
dioxide gas are formed. K.

The Cerebral Localisation of Aphasia, and its Classi¬
fication on an Anatomical Basis.— Dana (New York Med.
Record , August, 1907), by means of an ingenious form
of graphic representation, describes the typical
symptoms of the four chief types of aphasia :—(1) The
frontal or fronto-capsular, characterised by aphemia,
with retained ability to read, write and understand ;
(2) parieto-occipital aphasia, characterised by alexia,
with ability to speak, write, and understand, associated
with hemianopsia; (3) temporal or temporo-parietal
aphasia, characterised by anoesia, some mind deafness,
paraphasia, much agraphia and alexia, without hemi¬
plegia, but with some astereognosis, anaesthesia, and
ataxia ; and (4) fror.to-lenticnlar aphasia, the common
mixed aphasia, characterised by aphemia, with much
agraphia, alexia, mind deafness, and deafness with
hemiplegia. The chart by which each case is repre¬
sented includes 22 functions tested and recorded as
“normal,” “slightly impaired,” “seriously impaired,”
or “absent.” In conclusion, a short discussion of each
of the more important of these functions is given, with
the anatomical locations and significance of impair¬
ment. D.

Diet in Kidney Affections. —Hanssen (Nord. Med.
Ark., Stockholm) tabulates the findings in regard to
the metabolism of a number of persons on different
diets. They show that the amount of solids eliminated
in the urine is as large on a strict milk diet as on a
meat diet. The demands on the kidneys are thus as
high on a milk diet as when meat is ingested. Fats
and carbohydrates, on the contrary, made far less de¬
mands on the kidneys, the latter less than the fats. He
confirms the reliability of the “variability test” to
determine the functional capacity of the kidneys. His
conclusions are that a predominant or exclusive diet
of carbohydrates with a little fat is indicated in all
cases in which the functional capacity of the kidneys
is reduced to or below the limits of normal sufficiency.
Milk and meat, providing the same amount of calories,
cause elimination through the kidneys of about the
same amount of molecules, while materially smaller
amounts of solid elements are eliminated through the
kidneys on a diet of carbohydrates with a little fat.
He regards a maximal specific gravity of 1.014, or
1.015 under the “variability test ” of the urine as an
indication that the limits of sufficiency of the kidneys

have been reached, and that meat and milk should be-
restricted. If the specific gravity does not rise higher
than 1.013 or 1.014, or there are signs of retention, then
meat and milk should be entirely, or almost entirely,
suppressed. In case of uremia, nothing should be
allowed but gruels with milk sugar. This takes the
place of milk in regard to diuretic action. D.

Physical Therapy of Headache. —Riedel (Berlin. Klin.
Woe//., 1907) discusses the treatment of headache from
the standpoint of physical therapy. In cases of
hyperemic headache he advises absolute rest, with cold
applications to the head, and hot applications or
friction to the lower extremities. Colonic flushings are
also said to be of value, as well as active purgation.
If the headache is of the paroxysmal variety, cold
applications to the head, for a minute at a time, and
walking in water at a temperature of from 8° to io° C.
for ten minutes at a time, act almost specifically.
Naegel’s manual head-stretching is also warmly recom¬
mended. For headaches of anaemic origin the head is
placed low and the scalp is massaged. Hot compresses
applied to the forehead or the nape of the neck, and
application of warmed cloths around the neck, are also,
valuable. Massage is the most efficient treatment in
cases of rheumatic headache. The hot air douche and
warm applications of various kinds may also be used.
The same treatment is indicated in cases of neuralgic
headache. The author places much reliance on the
intelligent use of massage as a means of relieving such,
headaches, but emphasises the fact that the physician
himself must carry out the treatment, and that it can
not be applied by rule of thumb, as it were. D.

New Infection of Persons with Inherited and Acquired
Syphilis. — (Dermal. Zeit. Berlin, 1907.) Stern’s patient
was a man of 28, who had a primary syphilitic sore,,
with numerous pale spirochetes, differing in no respect
from an ordinary primary infection with syphilis, and
yet the man presented the unmistakable signs of in¬
herited syphilis, or syphilis acquired in early infancy,
with tertiary phenomena. This makes the ninth case
on record, Stern remarks, in w’hich persons with
syphilis in infancy, either inherited or acquired during
the first weeks of life, acquired a fresh infection in
e^rly adult life. He summarises 80 cases of re¬
infection in cases of acquired syphilis, and draws the
conclusion that the re-infection in many instances is
conclusive testimony to the complete cure of the
primary infection. He emphasises the necessity for
teaching patients this, so that those who have had
syphilis in the past may guard against contracting it
anew instead of considering themselves immune. His
experience also indicates that a strong resistant
organism may pass through syphilis with the organs
comparatively intact and escape the dreaded conse¬
quences. The pessimistic idea that a person once in¬
fected is always infected, and immune to future in¬
fection, should be combated, he declares, for numerous
and obvious reasons. D.

Dublin Sanatorium far Consumptive*.

The Dublin Gazette of last week contains the con¬
firmation of the Local Government Board Order
Respecting the Dublin Joint Hospital District, under
which the Lord Mayor, Aldermen, and Burgesses of
Dublin have constituted a Joint Board for the pro¬
vision, maintenance, and management of a hospital to
be used for a sanatorium for consumptives in the
following sanitary districts—County Borough of
Dublin, Balrothery Rural District, Celbridge No. 2
District, North Dublin District, South Dublin
District, and Dalkey Urban District. The Board will
consist of 31 members, and all expenses incurred by
the Board are to be defrayed out of a common fund,
into which shall be paid sums received from the com¬
ponent authorities in respect of the cost of maintenance
of patients and the sums recovered by the Joint Board
from or repaid to the Joint Board by or for patients.

Royal College of Physician* In Ireland.

The annual dinner of the College will be held on
Saturday, October 19th, instead of on St. Luke's Day,
which this year falls on Friday.

402 The Medical Press. NOTICES TO C ORRESPONDENTS. _ OfcT. 9, 1907-

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THE MEDICAL DIRECTORY FOR 1908.

To the Editor of The Medical Press and Circular.

gj R —The amalgamation of various London Medical Societies
under the title of the Royal Society of Medicine necessitates a
irreat many alterations in the forthcoming issue of The Medxcal
Directory, and we shall feel obliged if all Fellows of the Society,
or Members of Sections, will kindly give us at once the necessary
information. We may say that we have now decided to abbre¬
viate the entries to the following:—Fell. Roy. 8oc. Med., or
Mem. Sect. Roy. Soc. Med. , , .

Many gentlemen, in making their returns, have overiooxea
the faot that several of the old societies have ceased to be. Of
course, we have to delete such entries for the future.—Your
obedient servants, The

Dr M. P. K.—O wing to unusual pressure on our space during
the past few weeks, there has been a little delay in the inser¬
tion of papers. We hope to have space for your communication
in our next.

A pacetious correspondent has sent us the following:

SELF-MEDICATION.

One curse of the nation is self-medication,

As now we’re beginning to find;

While symptom* are treated by doses repeated.

The cause, of course, never opined.

Then they find the mistake, for the pain or the ache
Is not quite so easily oured,

And they give up the game, and with sadness exolaim:

No I no 1 it must all be endured I

For everyone gibes at the man who prescribes;

The chemist will suit just as well.

He will always suggest what he thinks is the best.

But the name of no doctor he’ll tell.

Christian Soience they try, but they find bye and bye
It’s not of the slightest avail;

Unless they’re neurotic, it’s all ” Tommy-rotic,"

And they're oertain to find it to fail. A. D.

Mr. J. W. Williams.—T he estimated population of London,
excluding the outer ring, is 4,758,218; that of Glasgow, 847,584;
Dublin, 390,691; Belfast, 370,183; Edinburgh, 345,747. If your
inquiry relates to Greater London for comparison, the official
number is 7,217,941.

JRtetitTQ* of the godelieo, Itedrareo,

Wednesday October 9th.

Medical Graduates’ College and Policlinic (22 Chenies
Street, W.O.).—4 p.m.: Mr. P. J. Freyer: Clinique. (Surgioal.)
5.15. p.m.: Lecture:—Dr. G. H. Savage: The Psychoses of the
Aged.

North-East London Post-Ghaduate College (Prince of
Wales’s General Hospital, Tottenham, N.).—Cliniques:—2.30 p.m.:
Medical Out patient (Dr. Whipham); Dermatological (Dr. G. N.
Meachen); Ophthalmological (Mr. R. P. Brooks).

Thurbdat, October 10th.

ROTAL 80CIETT OF MEDICINX (OBSTETRICAL AND GlNSCOLOOICAI.
Section) (30 Hanover Square, W.).—7.45 p.m.: Specimens will
be shown by Dr. Eden and others. Short communication: —
Dr. A. Reuth: A Case of Csesarean Hysterectomy for Traumatic
Atresia of Vagina, the Patient having previously been Success¬
fully Operated upon for Vesicovaginal Fistula. Paper:—Prof.
W. E. Dixon and Dr. F. E. Taylor: On the Physiologioal Aotlon
of the Placenta.

Medical Graduates’ Colleoe and Policlinic (22 Chenies
Street, W.OJ.—4 p.m.: Mr. Hutchinson: Clinique. (Surgioal.)
6.15 p.m.: Lecture:—Mr. H. Evans: Cysts and Cystic Condi¬
tions of the Neok.

North-East London Postgraduate College (Prince of
Wales's General Hospital, Tottenham, N.).—2.30 p.m.: Gynaeco¬
logical Operations (Dr. Giles). Cliniques:—Medical Out-patient
(Dr. Whiting), 8urgioal Out-patient (Mr. Carson), X-Ray (Dr.
Pirie). 3 p.m.: Medioal In-patient (Dr. G. P. Chappel). 4.30
p.m.: Throat Operations (Mr. Carson). Lecture:—Dr. Forsyth:
Goitre.

St. John's Hospital tor Diseases of the Sein (Leicester

Square, W.O.).—6 p.m.: Chesterfield Lecture:—Dr. M. Dockrell:
Essentials in the Study of Dermatology.

Fridax, October 11th.

Rotal Society or Medicine (Clinical Section) (20 Hanover
8quare, W.).—8.30 p.m.: Inaugural Address: The President (Sir
Thomas Barlow). Exhibition of Cases. The patients will be in
attendance at 8 p.m.

Medical Graduates’ College and Policlinic (22 Chenies
Street, W.O.).—4 p.m.: Dr. St. Clair Thomson: Clinique.
(Throat.)

North-East London Post-Graduate College (Prince of
Wales's General Hospital, Tottenham, N.).—10 a.m.: Clinique:—
Surgical Out-patient (Mr. H. Evans). 2.30 p.m.: Surgical Opera¬
tions (Mr. Edmunds). Cliniques:—Medical Out-patient (Dr.
Auld), Eye (Mr. Brooks). 3 p.m.: Medical In-patient (Dr. M.
Leslie).

Barattate.

Birmingham, City of, Asylum, Rubery Hill, near Birmingham.—
Assistant Medioal Offioer. Salary, £150 per annum, with
apartments, board, eto. Applications to Medioal Superin¬
tendent.

St. James’s Gate Brewery, Dublin.—Resident Assistant Medical
Offioer. Salary, £150 per annum, with furnished apartments.
Applications to the Chief Medioal Offioer, St. James’s Gate.

The Earlswood Asylum, Redhill.—Junior Assistant Medioal
Officer. Salary, £130 per annum, with board, lodging, and
washing. Applications to the Secretary at the Offioes of the
Asylum, 36, king William Street, London Bridge, E.O.

Manchester, University of.—Senior Demonstrator in Physiology.
Salary, £150 per annum. Applications to the Registrar.

Bradford Poor-Law Union.—Resident Assistant Medical Officer.
Salary, £100 per annum, with rations, apartments, and wash¬
ing. Applications to George M. Crowther, Clerk to the
Guardians, Union Offioes, 22 Manor Row, Bradford.

Brompton Hospital Sanatorium.—Assistant Medioal Officer.
Salary, £150 per annum, with board, lodging, and washing.
Applications to the Secretary, Brompton Hospital, London.

Three Counties (Gloucester, Somerset, and Wilts) Sanatorium for
Consumptives, Winsley, near Bath.—Resident Medioal Officer.
Salary, £200 per annum. Applications to the Secretary, at
the Sanatorium.

Newoastle-on-Tyne Dispensaiy.—Visiting Medioal Assistant.

8alary, £160 per annum. Applications to the Honorary Secre¬
tary, Joseph Carr, Chartered Accountant, 26 Mosley Street,
N ewcastle-on-Ty n e.

Valkenberg Asylum, near Cape Town.—Assistant Medical Offioer.
Salary, £250 per annum, free board, washing and lodging.
Applications to Agent-General for the Cape of Good Hope,
100 Vlotoria Street, London.

Albany General Hospital, Grahamstown.—House Surgeon. Salary,
£200 per annum, with board, furnished quarters, and laun¬
dry. Applications to the School Registrar, St. Bartholomew's
Hospital, E.C.

Edinburgh District Asylum, Bangour Village.—Second Assistant
Physioian. 8alary, £120 per annum, with board, apartments,
and laundry. Applications to the Medioal Superintendent,
Bangour Village, Uphall.

West 8ussex County Asylum and Graylingwell Mental Hospital,
Chichester.—Junior Assistant Medical Offioer. Salary, £150
per annum, with furnished apartments, board, attendance,
eto. Applications to the Medical Superintendent.

#irths.

Barlee.—O n Oct. 1st, at 6, Coates Crescent, Edinburgh, the ’wife
of Dr. H. J. W. Barlee, of a son.

Mansell. —On Sept. 28th, at Crofton, West Hill, Hastings, the
wife of H. R. Mansell, M.R.O.S., of a daughter.

JHarriagw.

Atxins—Hiohton.— On Oot. 5, at Christ Church, Brondesburv,
Frederick Durnford Atkins, M B., B.S., M.R.O.8., L.R.C.t,.
son of Frederick T. Atkins, Chelston Manor, Cockington, Tor¬
quay, to Edith Agnes, second daughter of the late Rev.
Edward Hlghton, M.A., Rector of Tarrant-Keynston.

Badoero^v —Oxlet.—O n Oot. 5th, at St. George’s Church, Han¬
over Square, London, George W. Badgerow, M.B., M.R.C.S.
(Eng.), only son of A. H. Badgerow, J.P., of Toronto, to Maud,
eldest daughter of Herbert Oxley, Esq., of 3, Hans Cres¬
cent, London.

Garrett—Hall.— On Oot. 2nd, at the Parish Ohurob, Hamp¬
stead, Raymond Reynolds Garrett, M.R.C.S., L.R.O.P., fifth
son of Lewis B. Garrett, of Maida Vale, London, to JosepbiDf
Bell, daughter of the late Thomas Hall, of Newcastle-on-
Tyne.

Ginner—8hith. —On Oct. 1st, at Holy Trinity Churoh, South-
port, Ernest Wightman Ginner, Esq., M.D., of Cannes,
Franoe, elder son of the late I. B. Ginner, Esq., of Cannes,
to Eiley, younger daughter of the late J. E. Smith, M.D., of
Grimsby and Southport.

Motherwell—Parsons. —On Oct. 5th, at 8t. Peter’s, Bayswater,
Gavin Black Motherwell, Jun., Airdrie, N.B., to Margaret,
only daughter of Sidney Parsons, M.R.C.S., and L.S.A., 78,
Kensington Park Road, London.

jBtathe.

Gallagher.— At Duala, German West Africa, of fever, Dr. John
Gallagher, late Bombay Medioal Service, aged 60.

Jotham. —On Oct 2nd. Helen, eldest daughter of the late George
William Jotham, M.R.C.S., L.S.A,, in her 69th year.
Stoltehfoth.— On Oct. 4th, at Grey Friars, Chester, Henry
Stolterfoth, M.D., J.P., aged 71 years.

oogle

The Medical Press and Circular.

"SALUS POPUU SUPREMA LEX."

Vol. CXXXV. WEDNESDAY, OCT. 16, 1907. No. 16

Notes and Comments.

With the anti-Socialist campaign
Socialism that is at present engaging the

and energies of certain politicians, we

Medicine, have, of course, nothing to do; but
we may, perhaps, pause to ask why
it is that the Socialists who, we understand, advo¬
cate the universal brotherhood of man, seem to
take an almost morbid delight in offending every
party and class in the country. If the world,
socialistically organised, is to be a paradise such
as we look forward to in the millennium, it will,
we take it, not depend for its success on the pre¬
valence of the spirit of bitterness that animates
some present-day Socialists. The medical profession
seems to be a particularly red rag to the Socialists,
and in their organs we frequently find, either in
the editorial or correspondence columns, some
attack, veiled or overt, on medical men. Consider¬
ing that quite a number of medical men are
Socialists, and that the profession itself is the only
one in the land that shares its acquired posses¬
sions freely with those in need, the attitude of the
Socialist spokesman is an extraordinary one.
Perhaps no more striking confirmation of these
assertions could be obtained than by an extract
from the Socialist children’s catechism which has
been sent us. It runs as follows—

“ Have poor people objections to the present
hospitals? ”

“ Yes; they are afraid that the doctors and
students will make experiments on them.”

“Why do doctors make experiments on poor
people?”

“ Because it gives them experience, which they
sell to the rich.”

“Do students practice on the rich?”

“No; the rich will not tolerate it.”

Now, if malignant and spiteful lies
Th Y nrf t * 1 ' s k' n< * are to the rising

* id a** 8 generation of Socialists, we may ex-
10 "* pect it to mature in time into a race
even less regardful of truth and
shame than the people who poison its

young mind with atrocious statements such
as these. The meanest and most sordid
motives are here imputed to the doctors, and they
can have but the effect their authors desire—
namely, to disgust and sicken every honourable
man of the Socialists’ propaganda and methods in
this country. We cannot but feel, however, that
such shameful lies would be disowned by the
philosophical Socialists, who believe in Socialism
as a creed, and set themselves to practice its doc¬
trines of self-abnegation and sharing with the
poor, and who are not Socialists for the sake of
self-advertisement or self-interest. At the present
day the beauty of Socialistic precepts seem about
as much overlaid with undesirable personalities

as the beauty of Christianity was in certain
mediaeval periods.

There are several authorities now
Notification debating the advisability of adopting
of the Notification of Births Act, and
Births Act. one or two which have already done
so. We are glad to see that the aspect
of the Act which is so offensive to medical men
is being represented in most quarters, and last
week, at Battersea, Mr. Burns’ own constituency,
where the adoption of the Act was regarded as a
foregone conclusion, the matter has been ad¬
journed for consideration, in consequence of
strong medical protest- It is greatly to be hoped
that medical men all over the country will make
a powerful effort to impress their views on the
local authority. It must be made plain that there
is no hostility to the principle of the Act, or any
desire to obstruct or hinder the health authorities,
but quite the reverse. But it should be repre¬
sented that the Act, as passed, is most offensive
to the profession, in that they are bound under
penalty to see that their patients perform their
civic duties, and that the character of half-spy
and half-policeman is not one which practitioners
care to undertake. There is no reason why medi¬
cal men should be dragged into the measure at all,
and if this aspect of the Act is presented to local
authorities, and they can be persuaded to represent
it to the Local Government Board, it would be a
very simple matter for a one-clause Bill to be passed
through Parliament next session to rectify this
injustice.

A correspondent in Melbourne has
Melbourne sent us a description from _ the
Hospital Stall Melbourne Argus of the proceedings
Election. that took place at the election of the
■honorary medical staff at the Mel¬
bourne Hospital in August. It is difficult for
anyone living in the antiauated atmosphere of the
old country to understand how anything so dero¬
gatory to professional dignity could take place in
any country at the present day. Apparently the
whole medical and surgical staff was chosen, the
election being by the subscribers, anyone paying
a guinea having a right to vote. According to the
Argus, the scene resembled “a third-rate race
meeting or a Tammany convention.” The street
was crowded with cabs, carriages and motors,
bringing voters to the poll, and the hall where the
polling took place and the approaches were
crammed with professional canvassers, who are on
hire for any election that may be going on.. As
people arrived they were button-holed, cajoled,
and persuaded. Cards were thrust into their
hands, and yells of “Don’t forget Dr.

Dash,” or “Give one vote to Dr. Blank,” made
the place hideous. The candidates were rushing
voters to the tables, and a smart man could, it

Digitized by Google

LEADING ARTICLES.

Oct. 16, 1907.

404 The Medical Press.

And Some
Reflections.

course we
only grieve

would seem, get a supporter from someone else
by dint of a Tittle tact. Nor were the ordinary
amenities of a fair election observed, for hundreds
of ballot-papers were taken out of the room to be
marked, and faggot-votes were created by a special
department, in which people came and paid a
sovereign—whose sovereign nobody cared—and re¬
ceived a vote on the spot. At any rate, nearly
three hundred votes were thus created on the last
day.

Now how far responsibility for such
undignified proceedings rests, with
the management and constitution of
the hospital, and how far with
the medical men concerned, of
are unable to say, and we can
that the fame and honour of
medicine should be so besmirched. Con¬
sidering that honorary hospital posts are supposed,
in theory at least, to represent a form of service
to people so poor as not to be able to pay for medi¬
cal attendance, it can only stultify tne profession
in the eyes of the public if such appointments are
sought with all the vulgarity of public suffrage.
On the other hand, if it is desired by the hospital
to secure the services of the most competent
physicians and surgeons, we can only say that the
method adopted seemed so designed to cater for
the least scrupulous, whatever its results may be
in practice.

It is not a little instructive to notice
v| . .. the way the newspapers are dealing

vmaection w j t j 1 t f, e j atest volume of evidence
Horror. before the Royal Commission on
Vivisection. Naturally, the more
responsible journals give fairly impartial sum¬
maries ; but a shorter and more picturesque way
adopted by others is to drag out a certain passage
or incident which seems to support the views of tne
particular journal, and to paste it large upon its
sheet. Thus the Morning Leader flashed out last
week with an article headed, “ Vivisection Horror.
Official Denials of Obvious Facts.” Now anti-vivi¬
section, anti-vaccination, and anti-medical gene¬
rally as the Morning Leader is, it is certainly not
edited without a sense of humour, and if ever the
weakness of the anti-vivisection case was exposed,
it is by the fact that this “ Horror ” was the worst
thing that could be dished up. In reality, it was
the most hollow farce. The Hon. Stephen Cole¬
ridge was written to this summer by an under¬
graduate at Keble College, Oxford, who said that
his rooms were opposite the University Museum,
and “nearly every day he was harassed by the
piercing yells of a dog in agony.” The gentleman
in question visited the museum, and ascertained
from an “ official ” that vivisection was carried on
there. The letter contained the usual vituperative
remarks about scientists, and several gentlemen en¬
dorsed the complaint. Mr. Coleridge promptly
wrote to Professor Gotch, who replied that no vivi¬
section experiments on dogs had been carried out
in the laboratory during the present year.

“ But,” slyly added the Professor,
And Four “ four puppies were born and kept in
Puppies. the adjoining yard, and the shrill
yelps of these animals when at play
were presumably the sounds heard by your corre¬
spondent.” Needless to say, the young gentleman
who had made himself so supremely ridiculous
was much annoyed at being so neatly and com¬
pletely bowled out, and he descended to abuse and
wild hearsay, calling Professor Gotch a liar and so
on. Really the Morning Leader must be careful,
for what would be left of it but yellowness were it
not for its humour, and what can be said for the
humour of a journal which calls the delighted yells
of four puppies at play a “vivisection horror? ”

LEADING ARTICLE.

THE ALLEGED CRISIS IN THE MEDICAL
PROFESSION.

First of all, let us ask if a crisis is actually at
hand in the medical profession. The answer de¬
pends a good deal upon what is meant by the term
“crisis." If it asserts that the profession, as a
whole, is likely to come to an untimely end in the
near future, and to wither away and die for sheer
lack of sustenance, then the notion may be at once
dismissed. If, on the other hand, it indicates that
the medical practitioners of the United Kingdom
are to-day faced with scanty and diminishing in¬
comes, with increased living expenses, with a
lessened field of work, and with the handicap of
competing hospital and quack practice, there is
truth enough in these things and they undoubtedly
point to a crisis. The phrase, used in the latter
sense, simply expresses the plight of a long-suffer¬
ing profession, whose good nature has been abused,
and whose rights have been violated on all sides.
The crisis is realised more or less in the higher
ranks of the profession, among the consultant and
the specialist. Its more serious effects, however,
are experienced by the general practitioners, for
no profession, however high and noble its ideals,
can hope to survive on any but a sound economic
basis.

Truth to say, the public are themselves greatly
to blame. As a general statement they do not pay
their medical attendants for more than two-thirds
or three-quarters of the service rendered. Obviously
that means a good deal in the case of small in¬
comes, where appearances have to be kept up, and
where expenses are heavy. Read in that light,
the authoritative estimate of the average income of
the British practitioner, at ^200 or £250 a year,
reveals a crisis in itself. It speaks volumes for the
high standard of honour which the public know to
expect from medical men that so poor a profession
should contain so few black sheep. After all
said and done it must be confessed that
medical men have themselves to thank for much of
the mischief. They have no powerful organisation
like the lawyers, to maintain an adequate scale of
fees and to punish promptly all illegal practice.
The General Medical Council enforces an iron
discipline upon the qualified medical man, but, un¬
like the Incorporated Law Society, takes no heed
of the inroads of the unqualified practitioner. In
the latter particular the powers both of the Council
and of the profession are grievously curtailed by
defective medical acts. While these acts carefully
control the education and test the knowledge of
the medical man, they nevertheless permit any
charlatan without the shred of a pretence to medical
training to practice any branch of medicine so long
as he does not style himself a doctor. The reform
of the medical acts, indeed, lies at the root of a
great part of the evils. The State, however, so far
from seeking to advance the status and prosperity
of the deserving class concerned, seldom fails to
seize any opportunity of exacting from it further
gratuitous service, as, for instance, in the Notifica-
ton of Births Act recently passed through
Parliament. In doing this the powers that be have
simply kept to the precedent whereby the death
certificate, another important document, is also

Oct, i 6, 1907.

LEADING ARTICLES.

Thx Medical Puss. 405

exacted without fee or reward. It may safely be
assumed that no Government, however strong,
would venture to impose a responsible duty of that
kind upon the legal profession without fixing an
adequate fee in return.

As medicine becomes more and more an exact
science, and as disease after disease is banished
from our midst, it follows that the field of medical
practice must be correspondingly lessened. What
a vast sum of money the medical profession has
been (quite legitimately) deprived of during the past
ten years by the reduction of small-pox almost to
vanishing point! What is true of small-pox will
one day be true of many other diseases. Neverthe¬
less, so far as one can see, there will always be
need of a certain number of medical men to act
surgically and to advise the individual how to pre¬
serve his health as well as to keep -up public pre¬
vention at the highest possible pitch of perfection.

It has been suggested that the whole medical
service should be brought under the control of the
State. The suggestion seems Utopian, at any rate
in our present stage of civilisation. So far the
State has left the medical man, after a costly and
arduous training, to sink or swim without further
attempt at his protection. Is the State likely to
alter its ways by adopting the rdle of a master?
Not many years ago, by a stroke of its legislative
pen, whole armies of fever-stricken patients were
taken away from the care of private practitioners
and lodged in public infectious hospitals. The
resulting benefit to the community has been, in
part at any rate, at the cost of the medical pro¬
fession. Has the State ever shown any wish to
make good that loss to the medical profession,
even by way of defending their elementary right
against unqualified persons?

It is clearly a matter of supreme importance to
the community to maintain a service of competent
and flourishing medical practitioners. As things
go they are threatened with the atrophy of an In¬
dispensable professional class. The crisis is a real
one and the remedy to a great extent in the hands
of the community.

“THE GRIP OF THE SPECIALIST.”

Under the sensational title of “The Grip of the
Specialist,” one of the young lions of the Nation,
which is our old friend the Speaker rejuvenated,
has been roaring at the growing tyranny of the
medical profession, and reverberations of the roar
have found their way into the leading columns of
the Tribune. Both these excellent papers profess
to shiver at the power which is passing into the
hands of medical men, and we fear, although they
are careful not to commit themselves too definitely,
at the way in which it is used. “ Everywhere
among the educated public we encounter signs of
disquietude, distrust, sometimes of vocable revolt,
against the dominion of the doctor, and the
elaborate professional and business apparatus that
has grown up around him.” Thus runs the “ voc¬
able revolt ” of the Nation, and that of the Tribune
is like unto it. Well, it is always an excellent
thing to have a little outside advice, and we must
not be offended so long as it is for our souls’ good,
but we confess that this “vocable revolt” on the
part of the public has till now not reached our ears,

though there has been some vocability and even
revolt on the part of the medical profession at the
way they have been treated by the public, and in
our opinion there should be a great deal more. The
Nation tells us that most sane laymen “ tremble at
the power of the new priesthood,” and that now
that the Church has lost influence its mystical
authority has devolved upon the medical profession.
“ The mantle of Elijah has fallen on Elisha." Now,
witheut disrespect to the Church we may perhaps
be so bold as to say that it seems to us an excellent
thing that the medical part of its work has been
handed over to a cadre organised and trained
ad hoc, and that the Church has been left free to
pursue its spiritual functions, in which it has
always been considerably more successful than it
has in dabbling in medicine. But knowledge is
power, and whereas the medical man has no more
authority than any other citizen maliciously to
wound or officially to overawe His Majesty’s lieges,
yet he is granted a power to inflict wounds on and
prescribe dangerous drugs for those people who
voluntarily place ihemselves in his hands. A
medical qualification is absolutely valueless except
as a passport to practice, and practice is, or should
be, entirely a matter of personal confidence between
doctor and patient. In other words, a doctor has
no power except over those people who voluntarily
place themselves in his power, and they can remove
themselves from his care whenever they like.
Where the “grip of the doctor” comes in, we fail
to see; anyone who continues in the “grip” of
a doctor he does not believe in is a fool. The
specialist is a particularly dreadful fellow, accord¬
ing to the Nation. “The absolute confidence with
wnich a specialist of repute will impose a long,
painful, and expensive treatment, which other
specialists of no less repute condemn, bewilders and
amazes those new to the annals of modern
medicine.” But his amazement apparently does
not prevent the layman going to the specialist,
even though “ when he (the layman) is taken ill it
becomes a matter of chance whether he is fpreed to
undergo a dangerous operation, is put on novel
and hazardous diet, is sentenced to two months’
close confinement, or to a long term of distant
exile," and yet he dares not refuse the treatment
or take further advice! Really the specialist’s grip
seems to us remarkably weak, and assuming for
the sake of the argument his saturnine character,
he seems only likely to maintain his grasp on those
foolish people who are too weak to enter into
“vocable revolt.” Indeed, we should not feel our¬
selves such villains after all that the Nation says,
if it said but that, but wc consider it utterly un¬
worthy of a journal with traditions of the Speaker
behind it to descend to general innuendo with re¬
gard to medical men receiving secret commissions
from hotel-keepers, chemists, and members of
similar callings. We should think it beneath our
own dignity, if merely out of spite, and without a
tittle of evidence, we suggested that the editor of
the Nation was bribed by politicians to support
their views; but he on his part does not hesitate to
throw out an equally unworthy charge against the
medical profession. To bolster up a weak case
with a vindictive charge is not the type of
journalism we expected from the Nation, to wnose
success in the enterprise before it we have looked
forward with pleasure.

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4 oG The Medical Press

CURRENT TOPICS.

Oct. 16, 1907.

CURRENT TOPICS.

A n unfi t, h a tin Fatalities in London Hospitals.

The question of death under anaesthetics is one
in which both the medical profession and the public
are deeply interested. In spite of many individual
and collective investigations there is still much to
be learnt regarding the scientific side of these un¬
happy accidents. As we have already pointed out
in the columns of the Medical Press and
Circular, it would be an important logical step in
the formal analysis of the situation were one to
secure accurate comparative statistics in full detail
from the various London hospitals. In order to
avoid any invidious criticism the returns would
be made under letter or number, without the pub¬
lication of any names. It seems perfectly obvious
that figures thus presented would indicate useful
lines of further investigation. Another rich field
of data lies in the Coroner's Court. We are glad
to see that Dr. Waldo, the Coroner for the City of
London, is making :.n exhaustive inquiry into the
anaesthetic deaths that take place within his dis¬
tricts, which include the great hospitals of Guy’s
and St. Bartholomew’s. In another column we
publish a short summary of such an inquest held
by him on the body of a woman who died on the
3rd of October at Guy’s Hospital, while under¬
going an operation for exophthalmic goitre.
Chloroform was administered by the house
surgeon, who stated he had given anaesthetics in
some 98 cases, and who admitted he knew the
special anaesthetic risks of that particular operation.
He assumed full responsibility, but later the
surgeon said he himself was partly responsible for
the administration. The Coroner naturally in¬
quired why in a non-urgent case of admitted diffi¬
culty the services of one of the eight staff
anaesthetists attached to the Hospital were not
called into requisition. The authorities of Guy’s
may have some satisfactory explanation to offer, but
meanwhile the public will probably be inclined to
agree with the jury that the present system is to
blame. The matter is in various ways one that re¬
quires careful handling. We all know that medical
men must acquire a knowledge of anaesthetics, but
there is no apparent reason why in a large hospital
juniors should not be kept under constant super¬
vision. What is the use of staff anaesthetists if
they are not required to attend cases of special diffi¬
culty, either at administration or at supervision of
administration?

_ Unvaccinated. Teachers

The educational sea appears to be doomed to
manifold storms. In the London County Council
a fresh disturbance has arisen over a recent resolu¬
tion framed in the interests of preventive medicine.
It was resolved that m the event of smallpox
arising in a school or college any unvaccinated
teacher refusing to be vaccinated within twenty-
four hours will not only be excluded, but will not
be paid any salary during the period of absence.
It seems clear that on moral grounds the teacher,
however much he may be entitled personally to re¬
ject vaccination, must yield to the views of the
majority when the welfare of others is con¬
cerned. While it may be conceded that a school
authority is acting on the lines of commonsense
prudence in excluding an unvaccinated t.eacher from

school during a smallpox outbreak, we faii to see
why such an unprotected person was ever allowed
| to assume a position of the kind. Indeed, it al-
| most seems that to allow unvaccinated teachers to
mingle with State school children is to permit an
open violation of laws that have been formally
adopted by the legislature, with enormous resulting
benefit to the community. The unvaccinated
I school teacher is typical of the restless band of
anti-vaccinationists ever on the look out for some
loophole of e/asion to a most salutary law.

Butchers and Tuberculous Meat.

The war against consumption can hardly be
waged seriously until steps are taken to exclude
tuberculous meat and milk from the national com¬
missariat. Chester, at any rate, is taking the
matter vigorously in hand, so far as cattle are con¬
cerned. The Corporation of that ancient city have
been forced in self-defence to bring pressure on the
farmers attending Chester fairs, and to demand
from the latter a guarantee against tuberculosis in
their cattle. The butchers suggest that the farmer
shall insure approved beasts, and that where a
butcher has a guaranteed carcase seized he shall
be recouped to the extent of two-thirds of the price.
This proposal has naturally caused a good deal of
commotion amongst the farmers, who belong, as a
rule, to a somewhat conservative class. They have
held, so it is reported, a crowded meeting, at which
strong opinions were expressed that compensation
should be paid for condemned carcases out of
public money. Few political economists would
question the principle involved in granting State
compensation for the compulsory destruction of
tuberculous cattle. On no other basis would a law
to that effect be enforced in the United Kingdom.
For a sum costing far -less, say, than the late Boer
war the country could be freed several times over
from tuberculous cattle. Some day this inevitable
reform will be forced upon the community.

Research Scholarships on Effects of Alcohol.

For several generations a kind of scientific or
semi-scientific warfare has been waged over the
question of alcohol and its effects upon the human
body. Mirabile dictu the mass of observations,
chemical, biological, clinical, and pathological
have not yet been reduced to established and
scientific generalisations. Truth to say, the medical
mind is chaotic as regards the desirability of re¬
taining alcohol as a beverage. On the other hand,
most practitioners will endorse the view that
alcohol has a distinct value as a therapeutic agent in
sickness, and perhaps also as a stimulant in various
depressed physiological states. The recent issue of
a manifesto and a counter-manifesto signed by
some of the most distinguished names in the
medical world, however, marks the sharp diver¬
gence of the twentieth century cm so important an
everyday matter as the consumption of alcohol by the
community. The National Temperance League
has taken the practical step of founding research
scholarships for the purpose of investigating the
effects of alcohol. It is to be hoped, however, that
the task will be entrusted to absoluely impartial
scientific investigators, for there is hardly any
sociological matter in which the individual judg¬
ment is apt to be more biassed by personal views
than that of the proper place of alcohol in the
world’s economy.

Google

Digitiz-

Oct. 16, 1907.

PERSONAL.

The Medical Press. 4°7

College Athletics.

It is a matter of some regret that in most
American colleges and universities athletics are
overdone. One of the consequences is that there
Is a strong public feeling hostile to the practice of
athletics, and all such exercises, good and
bad, are likely to come into disrepute. We are
assuming that some athletics are good, and in
this country, for the present at any rate, there
are not many to question the assumption. The
severe discipline undergone by all who really
engage in arduous sport must have moral and
physical effects of some value. As a matter of fact,
the lives of distinguished athletes are, in an insur¬
ance sense, “good,” and old “Blues” are not only
long-lived but healthy. On the other hand, there
is considerable risk in the overtraining that seems
to be prevalent among athletes in America. It is
said that in that country it is impossible, or nearly
so, for a student who wishes to gain scholastic
distinctions to devote any time to games. This is
certainly very different from the state of affairs
in our own Universities, and is very far from what
ought to exist. It is certainly true also that the
abnormal development of muscle to which injudi¬
cious training gives rise is by no means an
advantage to the human economy, and it is
probable that deleterious effects on the blood¬
vessels also result. Under the circumstances, it
is not matter for wonder that some of the pro¬
fessional journals in America have declared a
crusade against athletics at schools and colleges,
and some of them suggest that athletic games
should be put on the same level as gambling, and
strictly forbidden.

The Tuberculosis Exhibition in Dublin.

The Executive Committee of the Tuberculosis
Exhibition, which was opened in Dublin last Satur¬
day by His Excellency the Lord-Lieutenant of
Ireland, are to be congratulated on their initiative in
starting the first exhibition of the kind in the
United Kingdom. In no part of the kingdom,
indeed, is such a lesson so much needed, for in
none is the damage wrought by tuberculosis so
great, and in none are the public health authorities
so lax in their attention to their first duty. The
committee is further to be congratulated on having
brought together a series of exhibits which cannot
fail to give instruction of value, and on the great
public interest which their enterprise has aroused.
It is seldom, indeed, that one sees such a large
and intelligent audience assembled to discuss any
matter affecting public health as that which
listened to Professor Osier’s lecture in the Royal
Dublin Society’s premises on Friday evening. The
practical advice given to him as to the means to
be adopted by the public in fighting against tuber¬
culosis cannot fail to bear fruit. The exhibition
itself is, as may be seen from out description of
it elsewhere, admirably adapted to interest and
instruct the public in matters relating to the pre¬
valence of the disease, and to the methods to be
adopted to prevent its spread. Statistical, patho¬
logical, therapeutic and sanitary exhibits help to
show' the members of the public bodies and others
charged with responsibility for the public health
both the magnitude of the evil and how it may
be met with success. Popular lectures and demon-
■strations serve to explain those matters W'hich are

not obvious in themselves. It is intended that,
when the exhibition has spent a few weeks in
Dublin, it should be taken on tour to the various
large towns of the country, and that every means
be taken to bring its lessons home to the public.

PERSONAL.

Mr. T. J. P. Hartigan will give a course of lectures
on Dermatology at the Hospital for Diseases of the
Skin, Blackfriars, on Mondays, Wednesdays, and
Saturdays at 5 p.m., from October 9th to Decem¬
ber 2 xst.

Dr. Hector W. G. Mackenzie will open a discus¬
sion at the Medical Section of the Royal Society of
Medicine on Tuesday, October 22nd, at 5.30 p.m. The
subject will be, “The Complications in Sequelae of
Pneumonia, and the Possibilities of Treatment by
Serum or Vaccine.”

Dr. MacLennan, of Thurso, was the recipient of
a handsome present on the occasion of his leaving
Thurso, where he has been in practice eight years.

Professor Francis Gotch distributed the prizes at
the opening of the Faculty of Medicine at University
College, Bristol.

Mr. Justice Walton will give the inaugural address
of the Medico-Legal Society’s first meeting at 22,
Albemarle Street, W., on October 29th, at 8.15. Dr.
W. H. W’illcox will give a demonstration on YVounds
Produced by Firearms at the same meeting.

Professor Simeon Snell will give the first post¬
graduate lecture at the Royal Eye Hospital, Southwark,
to-night (Wednesday), at 7 p.m. His subject will be
“Injuries and Wounds of the Eye, Eyelids, and Orbit.''

Dr. Alexander Macphail, Professor of Anatomy at
St. Mungo’s College, Glasgow, was given a compli¬
mentary dinner and a handsome presentation by a
hundred medical men of that town on the occasion
of his relinquishing his appointment for that of
Lecturer in Anatomy at Charing Cross Hospital,
London.

Dr. Laurence Humphry has been appointed
Assessor for the year to the Regius Professor of Physic
at Cambridge.

Dr. E: R. S. Lipscomb has been presented with a
valuable clock on resigning his appointment, hel'd for
twenty years, of Medical Officer to the Starcross
Branch of the Rational Association Friendly Society.

Dr. H. F. Devis has been made the recipient of a
presentation by the employees of the Great Western
Railway at Bristol on resigning the post of Honorary
Lecturer on First Aid, after fourteen years’ work.

Colonel F. J. Lambkin, R.A.M.C., of the Royal
Army Medical College Staff, has been deputed by the
Secretary of State for the Colonies to carry out special
investigations in the Uganda Protectorate.

Mr. Girling Ball, F.R.C.S., has been elected to
the Luther Holden Research Scholarship in Surgery
for the year 1907-8.

Dr. Orr, of Tayport, has been elected President of
the Fifeshire Medical Association for the coming year,
in succession to Dr. Balfour Graham, of Leven.

The inaugural address of the session at the Meath
Hospital and County Dublin Infirmary was delivered
on October 9th by Dr. James Craig, M.D., Physician
to the Hospital.

Dr. David Rice, Senior Assistant Medical Office* -
of the Staffordshire County Asylum, has been
appointed Medical Superintendent of Norwich City.

e

408 The Medical Press

CLINICAL LECTURE.

Oct. 16, 1907.

A Clinical Lecture

ON

ENLARGEMENTS OF THE LIVER, (a)

By W. HALE WHITE,

Senior Physician to and Lecturer on Medicine at Guy's Hospital.

Gentlemen, —It came into my mind, when asked
to deliver this lecture, that we are in our daily life
constantly examining the liver, and therefore it might
not be amiss if this afternoon we discussed some
points connected with its enlargements, especially the
difficulties of appreciating and interpreting variations
in its size.

Sometimes we are, I think, inclined to forget that
in infants and children the liver is relatively larger
than in adults, for while in an adult it is about i-36th
of the body weight, at birth it is only between i-i8th
and 1-24th. More than once I have kr.cwn forgetfuness
of this lead to mistakes.

Feeling the liver is of much greater clinical use than
percussing the area of hepatic dulness, and as a rule
it is easiest to feel the edge of the liver just outside
the edge of the right rectus. It is true that in the
epigastric angle a small portion of the anterior surface
of the left lobe comes in contact with the anterior
abdominal wall, but often in actual practice this can¬
not be felt, for nowhere in the abdomen is it more
difficult to feel through the wall than in that part
formed by the upper quarter of the two recti, for they
are thick muscles, and cannot easily be pushed in from
their attachments. On the other hand, this may be the
only portion of the li\er vhich can be felt, especially
if the ribs are thrown forwards and outwards, as in
emphysema.

With regard to organs resting against the liver, the
fact that its superior surface has on it a slight dep-es-
sion made by the heart is of little clinical importance,
for the diaphragm here is so firm and dense that en¬
largements of the heart hardly ever directly affect the
liver ; but the close contact of the left lobe of the liver
to the lesser curvature of the stomach, and the contact of
the pylorus with the quadrate lobe are of great im¬
portance, for not only may ulcers and malignant dis¬
ease of the stomach grow directly into the liver, but
tumours of the stomach may sometimes be dragged up
and down during respiration, moving with the liver.
For the same reason tumours of the hepatic flexure of
the colon or of the kidney may move up and down
with respiration, as both these organs are adherent
to the under surface of the liver.

Many mistakes have been made from forgetfulness
of the fact that a tongue-like projection of the right
lobe may protrude from its lower right-hand part. This
projection, which is called Riedel’s lobe, is often asso¬
ciated with disease of the gall bladder, such as gall¬
stones, or with tight-lacing, and is commoner in women
than men; but it may be found in quite young
children ; so in some cases, at least, it is a congenital
abnormality. The connection between a Riedel’s lobe
and the liver may be only peritoneal, in which case
the lobe may easily be confounded with a floating
kidney, especially as there may be a band of resonance
between it and the liver. A Riedel’s lobe may also be
confused with almost any abdominal tumour which
occurs on the right side of the abdomen. It rarely
gives rise to any symptoms, but is often associated
with those of gall-stones—why, we do not know. How¬
ever, a Riedel's lobe is not at all common, but still the
lower and outer part of the right lobe of the liver may
be very difficult to tell from a right kidney. I feel sure
that this difficulty is much more frequent than text¬
books would lead us to expect.

Many conditions unconnected with the liver cause an
apparent alteration of it, and these conditions have
often been the cause of mistakes in diagnosis. When

la' Being the Opening Addre** delivered before the North-East
London Clinical Society on October 3rd, 1907, at the first meeting of
the Seesloo, 1907-1908.

the body is wasted and the tissues are lax, the organ
may drop down. I will allude to the condition of
wandering liver presently, but, quite apart from this,
a general weakness of tissues may lead to dropping of
the liver. I have had a strange experience this summer,
for on two occasions I have known men thought to
have cancer of their liver because it seemed enlarged,
and they were very wasted, but the wasting was really
due to diabetes, and the liver, although a little enlarged,
appeared to be much larger than it really was, for it
had dropped considerably. Again, when the liver is
enlarged and heavy, it is very liable to fall, and it
is no uncommon thing to find that the nutmeg liver of
the patient with heart disease, who sits propped up in
bed, has dropped two inches, for it may be ascertained,
even when there is no emphysema, that the upper limit
of the hepatic dulness is lower than it should be, and
then, of course, the liver is not as large as mere pal¬
pation appears to indicate. Again, alterations in the
chest lead to depression of the liver, whicn may be
erroneously thought to be enlarged. Thus, in an
extreme case of fibrosis of the lungs, with adherent
pleura, I have seen the sucking-in of the ribs on in¬
spiration lead to depression of the liver down to the
umbilicus. Again, deformities of the chest due to
rickets or curvature of the spine may lead to great
depression of the liver. With a very large collection
of fluid in the right pleural cavity, the liver may be
depressed, but I would suggest that there is much mis¬
conception on this point, and that depression of the
liver by a collection of pleural fluid is much rarer
than is commonly believed. The reason is that, owing
to its firm attachments, it is not easy to depress the
diaphragm, and the fluid more readily makes room
for itself by compressing the lung and pushing over
the heart. When, however, there is a large amount of
pus in the right pleura, the liver will be more readily
depressed than by simple fluid, for in the case of an
empyaema the diaphragm itself becomes inflamed and
so weakened, and, even with pleurisy, if it affects the
diaphragm, the liver may appear to be a little de¬
pressed, for if the pleural surface of the diaphragm
be inflamed, the pain of moving the muscle prevents
the patient doing so ; hence the diaphragm is kept in a
constant position of inspiration, and the liver being
also constantly in the position of inspiration, appears
depressed. This may be the explanation of the state¬
ment that the liver is depressed in pneumonia of the
right lung.

Talking of pleural leads our minds to pericardial
effusion. We are usually told that extreme pericardial
effusion will depress the liver, but I think this must
be very rare. It certainly is in my experience, and I
should expect it to be so, for the pressure would have
to act through the very firm central part of the
diaphragm. A subdiaphragmatic abscess being below
the diaphragm will, however, depress the liver con¬
siderably.

We may get into difficulties when the liver has been
altered by tight lacing. Often quite a slight degree
will, as is well known, lead to the formation of
furrows on the liver evidently corresponding to the
ribs, but furrows which obviously cannot correspond
to the ribs are sometimes thought to do so. They are
too vertical for furrows due to ribs, and it has been
i suggested that they are due to the fact that the liver is
compressed laterally during inspiration, and expands
j again during expiration. Tight lacing may, by local
I constriction, lead to the formation of such a deep
furrow that part of the liver during life is apparently
separated from the rest. Recently a man was in the
hospital with what was thought by many who saw him
to be an elongated turnout lying transversely in the

Digitized by GoOgle

O ct, i6, 1 907.

CLINICAL LECTURE.

The Medical Pbess. 4 q 9

abdomen, but it was nothing but the lower part of the
liver nearly cut off from the rest by the pressure of a
belt he had worn. The furrow may be so deep that
the blood supply of the isolated portion of the liver is
impaired; then I have seen fatty change confined to
such a part.

The effects of corsets upon the liver as a whole will
depend upon the position of the pressure. Most com¬
monly the liver is forced down, flattened and elongated
from above downwards. The liver thus forms an
apron covering much more of the abdominal viscera
than is natural, but some of the intestines may get in
front of it. The pressure often leads to a transverse
depression across the right hand lower part of the right
lobe, so that a more or less detached piece of the liver
lies over the right kidney, and is, indeed, an artificial
Riedel’s lobe, and may lead to the same difficulties of
diagnosis. When the pressure is by lacing applied
lower down, the liver is pushed up into the chest, and
is thickened in its vertical diameter.

Various abdominal conditions alter the position of
the liver, and the ease with which its size may be ascer¬
tained. Contrary to what might be expected from
some teaching, it is, I think, quite rare for any enlarge¬
ment of the liver to lead to upward extension of the
hepatic dulness. This is what we should expect, for
the mere weight of the enlarged liver will lead to its
falling, and as the resistance of the intestines and ab¬
dominal walls is much less than that of the diaphragm,
it will grow in the direction of least resistance.
Enlargement of the hepatic dulness upwards is best
seen when some local disease of the liver directly im¬
plicates the diaphragm. Thus an abscess of the liver
will grow from the upper surface of the liver, soften
the diaphragm, and extend upwards ; a hydatid will do
the same. From this it follows that when there is an
extension upwards of hepatic dulness, it is a local
extension, forming a dome-shaped addition to the
hepatic dulness. \ery large collections of ascitic fluid,
or very large abdominal tumours, may push the liver
up, and so lead to an increase of hepatic dulness
upwards ; but this is not common, for such tumours
or collections of fluid will more readily cause pro¬
trusion of the anterior abdominal walls and compres¬
sion of the intestines.

When working at the bedside, it is most important to
remember that there are three moderately common
tumours which lie transversely in the abdomen, and
so may be thought to be the lower margin of an en¬
larged liver. They are a stomach affected with
malignant disease, especially when the growth infil¬
trates much of the greater curvature ; malignant dis¬
ease of or impaction of faeces in the transverse colon ;
and the great omentum thickened and puckered up
towards the transverse colon by some form of chronic
peritonitis. Any of these tumours may move up and
down with respiration, for they are all directly or in¬
directly attached to the liver, but their movement is not
usually so extensive as that of the liver should be.
And a band of resonance may sometimes be detected
between the liver and the tumour, or the edge of the
liver may be felt above it. Enlargements of the
pylorus and thickening in connection with a gastric
or duodenal ulcer may be difficult to tell from an en¬
larged gall-bladder, not only from their position, but
because they may move up and down with respiration.

The hepatic dulness may be altered by gas. Thus
it may be almost obliterated by the descent of an
emphysematous lung, and a slight lowering of the
upper margin of the hepatic dulness from this cause
is quite common. Another result of emphysema is
that the lower ribs stand out so far, in a position of
extreme inspiration, that they bring the upper part of
the abdominal wall so far forward that it is often
quite impossible to feel the liver. This state of affairs
is by no means uncommon.

When, as in perforative peritonitis, free gas collects
in the abdominal cavity, it usually gets in front of the
liver, and so may diminish the hepatic dulness ; but
this sign is, in my experience, more often absent than
present in perforative peritonitis. On the other hand,
obliteration of the lower part of the hepatic dulness
by no means always indicates that there is free gas in
the peritoneal cavity, for coils of intestine, or the

colon, may get between the liver and the anterior ab¬
dominal wall. This is of no clinical significance.

As we have been talking about conditions which
push the liver out of place, we are naturally led to a
consideration of a wandering or movable liver. To this
state of affairs the term hepatoptosis is often applied,
and by it we mean a liver which, being unduly dis¬
placeable, leaves its normal position and forms aa
abdominal tumour. It is particularly to be noticed
that a liver displaced by a tumour or any other cause
is not a wandering liver, for it is just as fixed, only
in an abnormal position, as a normal liver; but a
wandering liver can be easily moved about. Further,
as clearness of thought is dependent upon clearness of
expression, we ought, I would suggest, never to use
the unfortunate phrase “partial hepatoptosis.” It has
been applied to a Riedel’s lobe or to pieces of liver
more or less cut off from the rest of the organ by
wearing a band or belt. It should be discarded, for
it has nothing to do with hepatoptosis proper ; but it is
worth remembering that sometimes the part of the
liver cut off from the rest by wearing a band has been
thought to be the whole liver, and has been considered
to be an example of hepatoptosis. Another phrase that
should be avoided is floating liver. The liver, sus¬
pended by its various ligaments, always floats in the
abdomen, and therefore the phrase, floating liver,
does not designate an abnormality. Yet another bad
term is that of total hepatoptosis. Strictly speaking,
that would mean that the liver could be moved about
in the abdomen to an indefinite extent, which is
absurd. So much attention has of late years been
directed to Gl^nard’s disease that there is an impres¬
sion, I think, that a wandering liver is commoner thaa
it really is. It is, I would suggest, very rare. In a
well-marked case, owing to absence of support, the
organ drops and rotates on a transverse axis, so that
the upper diaphragmatic surface comes in contact with
the abdominal wall, and the anterior surface points a
little downwards. The result of this is that a large
amount of liver comes in contact with the anterior
abdominal wall. Such a liver may be felt to be a
large flattened tumour extending down to or below the
umbilicus. It forms a visible protrusion, moves up
and down with respiration, can usually be pushed
back into its normal position when the patient lies
dov/n ; indeed, sometimes on lying down it goes back
of its own accord, only to fall again when the patient
stands up. It is movable laterally, and can with the
hands be rotated round a vertical axis. If it has
dropped far there is hardly any hepatic dulness in the
chest, and the hand may even be passed up betweea
the ribs and the liver. In such a case there is a depres¬
sion at the upper part of the abdomen, and this is very
characteristic. We need not spend more time on hepa¬
toptosis, as it is so rare.

We now pass on to consider enlargements of the liver
proper, for hitherto we have only considered conditions
which appear to make the liver large, but do not really
do so.

When we pass our hand over the abdomen and fed
an enlarged liver, the first thing that naturally arrests
our attention is whether the enlargement is uniform.
Now the diseases which enlarge the liver, but not
uniformly, are hydatid, abscess, growth and syphilis.
The enlargement of both hydatid and abscess—if the
abscess is of the usual variety—is lccal in one part
of the liver, the rest being healthy; but with growth
and syphilis the enlargement is usually of the greater

e art of the liver, although it is very often irregular.

[ydatid and abscess are in this country rare, but, un¬
fortunately, malignant disease is not, for searching
our hospital records shows that, of all persons in
whom at death malignant disease is found, about 50
per cent, have secondary deposits in their liver., and
no organ is more often the seat of secondary deposits.
Therefore it will not be amiss if we first consider some
points about the enlargement due to cancer of the liver.
In the first place, cancer causes the liver to be heavier
than any other disease of it. I have known the liver
weigh 19 lbs., and even heavier weights have been re¬
corded. It is quite true, as the books tell us, that the
nodule of growth may be umbilicated, but it is very
rare for this umbilication to be tangible through the
abdominal wall, but when it is, the fact is, I would sug-

4*0 The Medical Press.

CLINICAL LECTURE.

gest absolutely diagnostic of cancer. So, too, is a very
sudden increase in sizi of a lump in the liver. I have
koown one to considerably increase in size in a single
night. This must, I think, always mean that the
swelling is malignant, for the suaden increase must
indicate haemorrhage into the tumour, and the only
tumours of the liver into which haemorrhage can occur
are those of a malignant nature. If the growth is
breaking down, it may feel soft, and give an obscure
sense of fluctuation; but this is rare, and is more in
favour of abscess or gumma than growth. If the
liver has considerably increased in size in a week, it is
strongly suggestive of growth, for the liver never en¬
larges so quickly as when affected by a rapidly growing
growth. The age of the patient is of importance, for
cancer of the liver is almost unknown at an earlier age
than aa. Before, in a doubtful case, passing an opinion
that a liver is not cancerous, the patient should be
made to take a deep breath, for it is just possible that
a tumour under the ribs may thus be felt. Of course,
if most of the cancerous masses are at the upper part
of the liver, it may be impossible to feel them during
life, but failure to do this is rarely due to the fact
that the cancerous masses are in the centre of the liver,
for in the post-mortem room we hardly ever find can¬
cerous nodules in the interior of the liver if none are
to be seen on the exterior. But we must by no means
away with the impression that lumps can always
felt during life if the patient has malignant disease
of his liver. As pointed out. they may be in the upper
part or they may be on the under surface, or they may
be too small to be felt, or the abdominal wall may be
too rigid, or, again, there are certain rare cases in
which the new growth infiltrates the whole liver, which
is then enlarged and hard, but no nodules can be felt.
We should never omit to feel the umbilicus, for the
growth may spread along the round ligament to it,
and, of course, we ought always to examine for en¬
larged glands over the left clavicle. When we bear
in mind that malignant disease of the liver is nearly
always secondary to malignant disease elsewhere, it is
not surprising to learn that in half the cases in which
in the post-mortem room malignant disease of the liver
is found, it was unsuspected during life, for the
primary malignant disease often kills before the
secondary deposits in the liver have become of any
great size.

Perhaps this is a suitable opportunity to refer to
some difficulties of diagnosis with which I have been
struck. We are often presented with this problem:
Here is a patient with a large hard liver, and he is
jaundiced. Has he malignant disease of it?—for in
many cases the nodules of growth cannot be made out
by palpation. About half the patients in whom during
life malignant disease of the liver is suspected have
jaundice and it is of great importance to bear in
mind that the most frequent cause of long-standing
jaundice is malignant disease. Jaundice in this con¬
dition may vary in depth a little from day to day in
its earlier stage, but when once it has appeared it will
Continue, for it is nearly always due to the pressure cn
the bile duct of a gland in the transverse fissure, which
has become enlarged from the deposition in it of
malignant growth. The skin, slowly and deeply
stained by bile, gradually becomes more and more
green, and -ultimately assumes a peculiar earthy, dark
green tint, which, especially if the patient be aged
and wasted, is almost diagnostic of cancer of the liver.
*There are few things more characteristic in medicine
than to see an aged, grey-haired patient, extremely
wasted, with dry, dark green skin hanging in loose
folds, lying perfectly still, so drowsy that he is more
dead than alive. If we turn down the bed-clothes, the
hver may be seen deform'ng the shape of the abdomen,
and it will be noticed that the sheets are stained yellow
either from urine or sweat. It is excessively rare to get
this green jaundice in any other condition than malig¬
nant disease.

Mistakes have occurred from not remembering that
the evening temperature is often raised to some point
between 99 0 and 101 0 , or even more ; -his may continue
regularly foT weeks, and there may be a leucocytosis
up to 15,000. Only this summer I saw a patient in
whom the characteristic feel of the liver made most
of those who saw him pretty confident he had malig-

Oct. 1 6, 1907.

nant disease of it. But some, arguing from the wide
daily fluctuations of temperature, and the fact that
there was a leucocytosis up to 15,000, thought there
must be an abscess. The liver was explored, and was
found to be affected with growth. In such a case of
difficulty, the absence of rigors would be a point
against pus, and the leucocytosis in abscess of the
liver is usually considerable.

It may be hard to tell between a cirrhotic liver and
one affected with malignant disease if nodules of
growth cannot be felt but the liver appears uniformly
enlarged. If the tangible lumps are large, there is no
difficulty, for, as Sir William Jenner used to teach, if
any of them are bigger than a cherry, the case cannot
be one of cirrhosis, and the increase in the size of the
liver is never so rapid as it may be in growth. It is
only in the case of cirrhosis in which the liver is en¬
larged that difficulty is likely to arise, and in those
cases the jaundice is rarely deep, and, I think, never
green. Ascites is in favour of cirrhosis.

Impaction of a stone in the common duct may give
rise to difficulty, but when there is a doubt the case
nearly always turns out to be one of growth, for it is
much the commoner, and it is rare for the impaction
of a stone to last long enough for the jaundice to
become very' chronic. Usually the stone lying in the
part of the duct which lies in the duodenum ulcerates
its way into the duodenum, and the jaundice passes
away.

Formerly primary malignant disease of the liver was
thought to be much commoner than it really is.
Frerichs gave the proportion of primary to secondary
growths as 1 to 5. Now I think it is thought to be
rarer than it really is. At Guy’s Hospital the propor¬
tion of undoubted primary to secondary hepatic car¬
cinoma is about 1 to 25, and other hospitals show the
same. The reason for this discrepancy is that the older
writers regarded cases of primary malignant disease
of the gall bladder as examples of primary malignant
disease of the liver. There are some interesting facts
about primary malignant disease of the liver: it is
commoner in men than women, although the secondary
form is commoner in women than men. Probably it
will be found that the temperature is more often raised
in the primary than the secondary form, and jaundice
is, if present, usually slight, and comes on late, and
rarely, if ever, becomes dark green. The reason for
these differences is almost certainly that the primary
disease is, as a rule, more rapidly fatal than the
secondary—indeed, it is extremely rare for the primary
disease to last more than four months after the
symptoms have first declared themselves. Mention of
primary disease of the gall-bladder leads me to suggest
that it is much more frequent than is usually sup¬
posed. Dr. N. F. Ticehurst found that among 11,031
post-mortem examinations at Guy’s Hospital, there
were 45 examples of primary carcinoma of the gall¬
bladder, and in 43 of these, or 95 per cent., gall¬
stones were present; in the same 11,031 post-mortem
examinations there were 15 cases of primary carcinoma
of the bile ducts, and in 75 per cent, of these gall¬
stones were present. These figures strongly suggest
that gall-stones are the cause of the cancer, a view
which is supported by the fact that the incidence of
age and sex in the cases of gall-stones and carcinoma
of the biliary passages is tne same in both. Some¬
times a definite history of gall-stone colic precedes the
symptoms of carcinoma of the biliary passages, and
sometimes an examination of the specimen strongly
suggests that the gall-stones preceded the cancer. I
need not trouble you here with the figures, but an
analysis of our cases at Guy’s makes me strongly sus¬
pect that in 20 per cent, of patients who have gall¬
stones, carcinoma of the biliary passages will follow,
and this suggests that gall-stones should be much more
often removed by the surgeon than is commonly done.
Inasmuch as patients who are jaundiced bear opera¬
tion badly, it would appear that the right thing to do
is to remove them at a time when they are not causing
biliary obstruction.

Sarcoma of the liver as a primary growth is exces¬
sively rare, and secondary sarcoma cannot be diag¬
nosed from cancer unless we know that the primary
seat of the disease is sarcomatous.

Syphilis is a very interesting cause of an enlarged

itized by G00gle

Oct. 16, 1907.

CLINICAL LECTURE.

The Medical Press. 4 11

liver. Taking first acquired syphilis, it is only in the
tertiary stage that the organ is enlarged ; it may be
lardaceous, but that produces a uniform increase, and
we are only here discussing irregular enlargements.
These occur because syphilis produces a great increase
of fibrous tissue and gummata. In 20 years at Guy’s
Hospital I find these effects of syphilis on the liver
in the post-mortem room occurred 95 times, and in 23
out of the 95 cases gummata were present, and in
the remaining 72 there was only scarring of the liver
by fibrous tissue. Sometimes scarring and gummata
were present in the same liver. During these 20 years
about 9,500 post-mortem examinations were made,
which shows that 1 per cent, of those who die in a
general hospital have syphilitic fibrous or gummatous
changes in their liver. As the fibrous tissue is so
striking, the phrase, syphilitic cirrhosis, is often used,
but this is a pity, because a syphilitic liver never
resembles one affected with ordinary cirrhosis, for the
new fibrous tissue forms great bands, several of which
usually start from a common point and cut the liver
up into large areas, which consist of perfectly healthy
liver. In alcoholic cirrhosis the areas are never bigger
than a hobnail, and the hepatic cells in the hobnail
are fatty. These great fibrous bands, by their con¬
traction, form scar-like depressions on the surface,
and these may be so numerous and deep as to cut
the liver up into a number of irregular masses, leading
to great deformity of it. Gummata of the liver are
just like gummata elsewhere. They often grow to the
size of a tangerine orange, and then they shrink, so
that they add greatly to the deformity of the liver. A
single gumma is rare; usually two or three are present
in the same liver. But it is clear from this description
that, although the liver in syphilis may be lumpy and
irregular, it is never very greatly enlarged, so con¬
siderable enlargement is a sign of malignant disease.
The swellings in the liver in malignant disease may
alter in size very rapidly; in syphilis the alteration
is slow, although it may be quickened by treatment.
There is no pain in syphilis unless there is some local
perihepatitis over the gumma, and usually there is
not. Pain, on the other hand, is common in malignant
disease. Although jaundice and ascites have been re¬
corded in syphilitic disease of the liver, and have been
associated with either an enlarged gummatous gland
or cicatrisation of fibrous tissue in the portal fissure,
yet such events are excessively unusual. I can remem¬
ber no case in point, so the presence of either jaundice
or ascites is excessively strong evidence of growth as
against syphilis. Then in growth we sometimes get
the umbilicus and the gland over the left clavicle
enlarged. To complete the picture of syphilitic disease
of the liver, it should be added that it is much more
often found in the dead-house than it is diagnosed
during life, and that the association of lardaceous
disease with the scarred and gummatous condition is
very uncommon, but when it exists it may cause a
very large liver. Unless it is remembered that con¬
genital syphilis may produce exactly the same state
of liver as that induced by the acquired disease, mis¬
takes may occur. When this effect of congenital dis¬
ease is first seen, the patient is nearly always between
the ages of 10 and 20 years.

The pericellular cirrhosis of congenital syphilis,
which is the cause of a uniform enlargement of the
liver in infants, and which occurs in almost 50 per
cent, of all the children with congential syphilis, is
of much more histological than clinical interest, for
it indicates that the congenital syphilis is severe, and
many of the infants afflicted die early in life. It is
usually not suspected unless the child has some of the
ordinary signs of congenital syphilis, and if then the
liver is enlarged considering the age, the enlargement
is almost certainly due to syphilitic pericellular
cirrhosis; but once I have known it to be caused by
lardaceous disease

There is not much that calls for special mention
about the enlargements due to hydatid or abscess. It
is, of course, essential to remember that both lead to
a local enlargement of the liver. Growth and syphilis
are rarely confined to one part. However, this last
summer, a boy, aged about 8, has been under my care
for hydatid of the liver, and the organ contained at
least three hydatid cysts; but, fortunately for diag¬

nosis, one in the right lobe was so much larger than
the rest that the enlargement of the liver was at first
local—so much, indeed, that many distinguished mem¬
bers of the profession considered that the child had
an enlarged kidney, for the hydatid was in the lower
right hand part of the right lobe, and therefore «his
case illustrated what I pointed out a few minutes ago
—namely, the difficulty of telling between an enlarged
kidney and the right lobe of the liver. An examina¬
tion of the blood is of great help in the diagnosis of
hydatid, for considerable eosinophilia is present. Ten
per cent, of the leucocytes may be eosinophiles; when
the hydatid is opened the number of eosinophiles falls
quickly. Fluid removed from an exploratory puncture
of the right chest should always be boiled to see if
any albumen is present. I have known forgetfulness
of this lead to a serious result. Some fluid was
aspirated from the right chest; it was assumed to be
pleuritic. The patient was sent into the country for
some weeks. When she came back I put a needle in
again, drew off fluid, and found it contained no
albumen, and so I concluded it was from a hydatid.
Operation disclosed a huge hydatid growing up into
the chest from the upper surface of the liver. Sho
succumbed to the operation, but it is quite likely that
if she had been operated on earlier she would not
have done so. When hydatids or abscesses are small
and in the upper surface of the liver, they may be
detected if the upper margin of hepatic dulness is
very carefully marked out, and a rounded eminence of
dulness occurs on the top of the normal line of dulness.
I have known this to be no bigger than half a crown,
and yet an exploring needle withdrew pus.

As far as my experience goes, the leucocytosis is
always considerable in hepatic suppuration, rigors are
very common, and both they and the rises of tempera,
ture may occur at such regular intervals as to strongly
suggest ague. It often requires a very careful physical
examination, combined with an examination of the
blood, to detect them. I remember a man who used
from time to time to get an attack of shivering and
rise of temperature. Many doctors saw him ; most
thought he had influenza; but careful percussion de¬
tected the abscess, which was successfully opened.

The next enlargement of the liver we have to con¬
sider is that due to cirrhosis. It is usual to describe
two varieties—namely, that in which the liver is large
—the so-called hypertrophic cirrhosis—and that in
which the liver is small—the atrophic; but this is con¬
fusing, for there is an extremely rare condition known
as hypertrophic biliary cirrhosis, which has nothing to
do with ordinary cirrhosis. There is considerable
evidence that first the liver in ordinary cirrhosis en¬
larges, and then becomes smaller. This is what we
should expect, for all forms of fibrous tissue tend to
contract as time goes on; indeed, cases have been
recorded in which cirrhotic livers have become smaller
under observation, and Dr. J. A. P. Price, analysing
142 cases of fatal cirrhosis at Guy’s Hospital, found
that in 80 the weight was over 60 ozs., in 33 the organ
weighed between 50 and 60 ozs., and in 29 it was
under 50 ozs. These figures show the futility of trying
to draw a sharp distinction between hypertrophic ana
atrophic cirrhosis, for it would be difficult to know
where to place the livers between 50 and 60 ozs. in
weight, and these figures strongly suggest that the
liver is at first larger than normal, for the number of
those with a large liver is greater than those with a
small, and naturally we should expect the number of
patients to lessen as the disease went on, for some
would die in the course of it; and that the atrophic
livers are only a later stage of the hypertrophic is
further borne out by the fact that those with large
livers are on the average younger than those with
small, and all supposed differences in the symptoms
are really due to the fact that certain symptoms are
more likely to appear late than early.

Although it is a little outside the title of this paper
to do so, I should like to point out that alcoholic
cirrhosis is an incorrect name for this disease of the
liver, for although the taking of beverages containing
alcohol undoubtedly plays an important part in causing
the disease in many patients, alcohol cannot be the
sole cause, for some patients, notably some children,
who suffer from the disease have not taken any alcohol.

Digitized byGooqle

CLINICAL LECTURE.

Oct. 16, 1907.

4 12 The Medical Press.

It cannot be produced by the administration of alcohol
to animals, and in many parts of the world— t.g
Scotland—much alcohol is consumed, but cirrhosis of
the liver is rare. It is, I think, undoubtedly com¬
moner among the lower than among the middle and
upper classes, and this was the opinion of Sir William
Gull and Sir George Burrows. It certainly may exist
without any symptoms being present during life. Thus
a large cirrhotic liv*r may be detected in the routine
examination for a life insurance, and it is frequently
found in the post-mortem room when it has not been
suspected during life. The symptoms are well known.
Perhaps that least appreciated is the slight pyrexia
that may be present; but, speaking generally, this is
not so high as it mav be in malignant disease of the
liver. It may be very difficult during life, and even
after death, to tell a cirrhotic from a malignant liver,
but facts that will guide us in a local examination are
that hobnails are never umbilicated, are never larger
than a small cheny, and never become suddenly larger.
The irregularity of a liver affected with malignant
disease is usually much greater than one which is
cirrhosed. Cirrhosis of the liver is often regarded as a
local disease of the liver, and it is thought that the
pressure of the contracting fibrous tissue on the portal
vein leads to the ascites; but this cannot be so, for
the fluid in the abdomen usually collects rapidly,
sometimes at the rate of a pint a dav, which would
be very difficult to understand if we believed that the
slowly forming fibrous tissue, by its compression of
the portal vein, was the sole cause of the ascites.
Again, a high degree of cirrhosis may be found in the
post-mortem room in cases in which the disease was
unsuspected during life, and in which no ascitic
fluid existed in the abdomen. Then, again, the
amount of ascitic fluid bears no relation to the degree
of cirrhosis. It is not most evident when the
haematemesis suggests that the portal pressure has been
high, and it certainly is not due to portal thrombosis,
for that is very rare. No obstruction to the portal vein
can be demonstrated after death in cases of cirrhosis.
It seems to me-that th’ correct view to take is a much J
wider one, and I believe that, possibly as a result of
the damage to the liver, or possibly from some other
unknown cause, certain poisons circulate in the blood
©f a patient with cirrhosis. Possibly they are poisons
from the alimentary canal which the cirrhotic liver
cannot destroy. If such a poison is a lymphagogue,
we have the explanation of the ascites, and also of
the oedema of the feet, which is so often seen in
cirrhosis. Probably other symptoms are due to the
poison, such as the coma and delirium which are seen
quite apart from jaundice. The slight pyrexia, wasting
and anaemia may in part be due to the same poison.
Indeed, unless we believe that such a poison exists, it
is difficult to say why cirrhosis should be fatal. The
mere cirrhosis of the liver, I would suggest, does not
matter much so long as the poison does not get into
the circulation, but a person with a cirrhotic liver
is at any moment liable to this ; then he quickly be¬
comes dangerously ill This view is supported by the
fact that when ascites, or coma, or convulsions appear,
the patient is, as a rule, within a few weeks of his
death, although previously it may not have been known
that he is ill. On this view cirrhosis of the liver is
like a granular kidney, for a patient may have this
for years without knowing it, and then suddenly he
becomes uraemic, and is often dead in a few days.

Austin Flint, Watson, Niemeyer, Murchison, Fagge,
and many of the older authors taught (hat the onset
of ascites was of very serious moment, for they said
if it was much the patient died within a few weeks
of its onset. This opinion has been much doubted ;
so, to investigate the point, I took a number of
fatal cases from the records of Guy’s Hospital. In
ten ascites was present, but the patient was not tapped,
but, as far as could be ascertained from the history,
the time from first noticing that the abdomen began
to enlarge till death was on the average only two
months, and the same was true of twelve that were
tapped. Dr. Campbell Thomson and others have col¬
lected cases from other hospitals which quite support
this contention. The onset of swelling of the feet,
and the development of nervous symptoms, both also
indicate that the end is not very far off.

It is quite impossible, in this brief article, to give a
detailed account of that very rare disease, “Hanot’s
cirrhosis,” which has nothing to do with alcohol,
occurs chiefly in children, is very slow, and is charac¬
terised by the fact that the liver and spleen both become
very large. The patient is often stunted in growth,
and the fingers may be clubbed Nor can we say
much about the form of cirrhosis with a large liver
that follows enlargement of the spleen in splenic
anaemia, and constitutes Banti’s disease. Both this and
“ Hanot’s cirrhosis ” are so very rare that they seldom
come before any of us. Some observers claim to have
produced cirrhosis of the liver by ligature of the bile
ducts; but it is doubtful whether this follows if the
ligature of the ducts is performed aseptically, and
certainly if such a cirrhosis exists in man, it must
be quite exceptional, for growths and gall-stones fre¬
quently obstruct the duct, and yet no cirrhosis follows.
Indeed, most physicians doubt whether there is in
medicine such a thing as “obstructive biliary cirr¬
hosis.” Malarial cirrhosis has been described, but it
does not exist. The mistake of ascribing cirrhosis to
malaria has arisen from the fact that many people
with malaria have taken more alcohol than they should,
and the doctor has kindly wanted to whitewash them,
and so has attributed to them malaria cirrhosis which
should have been laid to the door of alcohol. It has
been said that rickets, diabetes, gout, cancer, tubercle,
passive congestion, lead, dyspepsia, and scarlet fever
will all give rise to cirrhosis of the liver, but this is a
misuse of histological knowledge as applied to clinical
medicine. Occasionally, perhaps, a slight increase of
fibrous tissue may be detected by the microscope in
patients dead of these diseases, but this is never enough
to cause the liver to look or feel like a cirrhotic liver;
or are the symptoms of cirrhosis ever present. The
writings on the subject of cirrhosis are most con¬
fusing, but I would suggest that the truth is as follows :
There is a common disease—cirrhosis of the liver. No
distinction should be drawn between hypertrophic
cirrhosis and atrophic cirrhosis, except to express
different stages of the same disease. Hare forms of
cirrhosis are “ Hanot’s cirrhosis ” and that of Banti’s
disease. There is a pericellular cirrhosis which often
accompanies congenital syphilis. Beyond these con¬
ditions there is nothing to which the term cirrhosis of
the liver should be applied. Acquired syphilis pro¬
duces quite a different appearance of hard bands of
fibrous tissue with large areas of healthy liver in
between.

Simple cysts of the liver, innocent tumours and
actinomycosis of it are so rare that we now have only
left uniform hepatic enlargements, and, of these, that
due to backward venous pressure is the commonest,
and is nearly always associated with mitral disease.
This nutmeg liver is often larger during life than it
appears when cut out of the body, for then much
blood has drained out of it. When it is large,
the lower edge may reach to the umbilicus, the hepatic
enlargement often causes much distress from the feel¬
ing of tightness and discomfort of which the patient
complains, and it may be that the difficulty of lying
down which is so common in heart disease is some¬
times due to the direct pressure of the large heavy liver
on the heart. If the heart has failed rapidly, the liver
is often very painful and tender, and then much
benefit follows the application of leeches. In a few
cases an expansile distension can be felt synchronous
with each beat of the heart, if one hand is placed on
the front of the liver and the other behind it. Care
must be taken to satisfy oneself that the pulsation is
expansile, for the dilated and hypertrophied heart may
transmit a jog to the liver at each beat, and sometimes
the abdominal aorta will do the same.

The liver is frequently found in the post-mortem
room to be fatty, but often this change is associated
with cirrhosis, or it does not lead to any enlargement
of the organ, and even when it does the patients may
be so obese that no enlargement of the liver can be
detected during life. Hence fatty liver is not of the
clinical importance that might be thought. Never¬
theless, the soft enlarged fatty liver may often be
detected during life, and successfully diagnosed if
any of the many causes that lead to a fatty liver are
present. It is of considerable importance to detect it,

Oct. 16, 1907.

ORIGINAL PAPERS.

The Medical Press. 4*3

if possible, for those in whom it can be detected are
always in a precarious state of health, and bear opera¬
tions and serious illness very badly.

The liver is affected in half the cases of lardaceous
disease. It may be enormously enlarged, and is smooth
and hard. Lardaceous disease often used to follow upon
prolonged suppuration, but as surgery does not often
allow this nowadays, lardaceous disease is becoming
rare. I have seen the lardaceous liver become much
smaller after the surgeon drained a chronic abscess
connected with the hip. Phthisis and syphilis are much
better treated than they were, and therefore, for both
medical and surgical reasons, we do not nearly so often
see a lardaceous liver as formerly.

The uniform enlargement that follows blocking of
the bile duct is only of clinical interest in the few
cases in which the presence of jaundice and an en¬
larged liver leads to a difficulty of diagnosis between
malignant disease of the liver and an impacted gall¬
stone.

I am afraid I have wearied you, and told you
nothing which is not common knowledge; but as I
said at the beginning, as this is essentially a clinical
meeting, my object has been to quickly pass in review
such features of enlargement of the liver as are of
clinical interest.

Note. —A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture for
next week will be by Professor R. Lepine, M.D., of the
Lyons Faculty of Medicine. Subject: “ Urtxmic Menin
gitis.”

ORIGINAL PAPERS.

SUDO-KERATOSIS.

By R. VV. BRIMACOMBE, M.D.

AsnUtant Physician to the Skin Department, Kensington General

Hospital, and late Pathologist to 8t. John's Hospital (or Diseases
of the Skin.

Sudo-Keratosis (Sweat Keratosis) is the name
I have given to a disease of the skin, involving the
sudoriferous apparatus, and its principal feature is
a keratosis of the sweat duct, mainly at its outlet.
I have considered it of some importance, because
I have not been able to find it in the nomenclature
of skin diseases. The accompanying clinical and
microscopical diagrams, which I exhibited at a
recent meeting of the British Medical Association,
clearly indicate :

(а) the distribution clinically;

(б) microscopically, that the disease is confined
almost entirely to the sweat ducts.

The case which came under my notice was that
of a boy, set. 12, belonging to the very poor class.
He presented a dirty, ragged appearance, and I
have no doubt “dirt” was the principal factor in
the origin of this disease.

Clinical .—The dorsal aspect of the hands only
were affected, the disease limiting itself to the
metacarpal joints (Fig. I.), where no hairs are
present. The papules are mostly discrete, slightly
raised, with a flattened surface and of a semi¬
transparent, somewhat hyaline character. The
centre of the papule was occupied by a black speck,
which gave it a comedo-like appearance.

Microscopical (Fig. II.).—A section of skin
(papule) hardened in alcohol, and stained with
haematoxylin and eosin, shows the lumen of the duct
filled up with a plug of nucleated horny cells,
hypertrophied and comified. The lumen is widely
dilated, and on each side of it and surrounding it
is a layer of hyaline structure without cells. The
hyaline structure also pervades the horny cellular
mass, and binds the horny cells together. The
strata corneum and lucidum are obliterated by the
hyaline layer.

At the top of the plug is ddbris, seen by the

naked eye as a black speck, and the plug itself
contains masses of deeply-stained wandering cells
j (polvnucleated leucocytes). These cells are minus
I their nuclei; they have undergone degeneration,
become dried up and calcified, and show a diffuse
blue staining. Where these cell masses are
located, the channel passing through the nucleated
horny mass is pressed upon, and consequently
1 becomes blocked up, whilst in the intervening
. spaces the channel still remains patent.

Fig. I.

With Zeiss A Ocular II., the plug appeared to
be studded with irregularly-distributed dark pig¬
ment granules, and under the oil immersion lens
the granules at first led one to think a small
micrococcus was present in chains and groups.
Further observation, however, showed that they
were not pigment granules or micrococci, but free
granules without any stain. The sides of the
funnel have become partially denuded of their
stratum granulosum cells, and the granulated

Fig. II.

kerato-hyaline cell showed that the supposed pig¬
ment granules and micrococci were really the
granules remaining from the kerato-hyaline cell,
which cells have become dried off, leaving the
granules free.

The stratum granulosum cells on either side of
the plug are hypertrophied, except at the lower
portion of the plug, where the cells have disap¬
peared and become converted into horny cells, so
that the plug comes into actual contact with the

itized by CjOO^Ic

4 X 4 The Medical Press.

ORIGINAL PAPERS.

Oct. i6 , 1907.

stratum mucosum layer. The cells of the latter
layer are swollen hyaline, and the nuclei enlarged,
with a marked increase in depth of layer, especially
around the dilated duct.

The cells of the papillary layer are also enlarged
and the papillae widened, the capillaries surround¬
ing the duct only are dilated with small celled
infiltration around.

There is a slight increase of spindle-shaped con¬
nective tissue cells in the cutis. Cornification stops
in the epidermis, the epithelium of the sweat duct
in the cutis is merely swollen, the lumen of the
duct moderately dilated and free. There is some
slight swelling of the epithelium of the sweat
glands, together with dilatation of the lumen.

Owing to the hyaline condition of the epidermis
surrounding the duct, although the papillae are
widened, the capillaries dilated, and an inflam¬
matory infiltration is present in the cutis, clinically,
these signs are not present, the papules having a
pale semi-transparent appearance. An interesting
feature in a microscopical specimen is the presence
of epithelial giant cells situated on the right side
of the dilated duct only, and in a large number of
sections examined the left side of the duct was
cfccupied by dilated capillaries and lympathics with
small round-celled infiltration, a few sections show¬
ing commencing epithelial giant cell degeneration.
The cylindrical cells of the papillary layer in rela¬
tion to the giant cells are lessened in number and
development, less deeply stained, and their place
taken by the stratum mucosum cells.

The origin of the giant cells may be traced to
the cells of the stratum mucosum and papillary
layers, which have been left behind or pushed off
from the epidermis into the cutis, or, more pro¬
bably, their development is from the endothelium
of the lympathics and capillaries, on whose site
they occur. The giant cells are grouped, sur¬
rounded and tied together by a capsule of con¬
nective tissue cells, and under the low power are
seen as a definite hyaline patch.

TREATMENT OF TERTIARY
SYPHILIS.

By Dr. M. VON ZEISSL,

Professor of Veneresl Diseases, AUgemelne Krsnkenhsns, Vienna.

Tradition prevails in disease as much as it does in
Art. In the therapy of syphilis old-established notions
have led practitioners to maintain a rigid course of
treatment in syphilis that should have long ago passed
into oblivion with the author. Ricord held that ter¬
tiary—or, better, post-tertiary—syphilis was neither con¬
tagious nor inherited, and that iodide of potassium was
the sovereign drug for this form of the disease, and
that mercury was injurious, and had no effect what¬
ever. It is now some years since I satisfied myself
<1887, I think), by experiments and clinical testimony,
that post-syphilis, as well as primary and secondary,
is transmissible, and that mercury is as efficacious in
the one as the other. Like the trail of the serpent,
one class-book after another hands it down to us that
iodates act more potently in tertiary syphilis than mer¬
cury. This is an error. In the later forms of syphilis
mercury is even more efficacious than the iodides, the
latter being always more protracted than the former.
The mercurial preparations are always more energetic
in all forms of syphilis. Like the application of mer¬
cury, the diagnosis is often misleading by its peculiar
nomenclature. The papules on the iris by many are
called gummata, while this is nothing more than a
papular syphilide corresponding with those on the
body.

This gummatose phenomenon is one of those changes
that seems to exhaust itself or become modified Dy
treatment, as it is now seldom met with in Austria and
other countries where early treatment prevails. The
treatment is usually applied early, and continued ener¬

getically for some time after all symptoms of the dis¬
ease have disappeared, and renewed at a later period
if any other symptoms should present themselves.

In Dalmatia, Bosnia, and Russia, at the present day,
ummata are common, and are received at hospital every
ay, while in Vienna you will rarely meet with one.
This was not always the case with us, as many of the
older physicians know, but it is encouraging to reflect
that the hideous morbid changes that used to deface
cur wards have quite disappeared from our midst.

There is still amongst us a serious result of syphilis
that does not exist in Constantinople, where gummata
are plentiful. With us disease of the central system
is unhappily too frequently the result of the syphilic
oison, which is not found in the Orient, no matter
ow badly neglected the treatment may have been.
This is the experience of Gluck and Diihring, of
Sarajewo and Constantinople. The lecturer saw, while
he was in Herzegovina, Bosnia, and Dalmatia, 370
cases of syphilis which he had to treat, and only four
out of this great number, which were old cases, had
any symptom of either central nerve symptoms or peri¬
pheral phenomena. It would seem from these results
that worry and abuse of alcohol are necessary for the
production of any nerve disturbance in the brain or
spinal cord, which may explain the large number of
resulting nervous diseases met with in France and
other countries, where alcohol is used. Many of these
cases are neurasthenic, and doubtless suffered in the
past from the forced anti-syphilitic treatment usually
practised, where treatment is readily obtained. It is
quite possible that this over-treating may do a great
deal of harm and no good to the disease, but under
the false name of “ preventative ” it is foolishly resorted
to. No such treatment will prevent recurrence, and
no treatment should be commenced until undeniable
syphilitic phenomena appear. Any other proceeding is
injurious. The following may be cited as good
examples of the futility of such heroic treatment as
preventative:—

G. H. was infected, when 24 years old, in March,
190a. On the first appearance of any syphilitic pheno¬
mena, he presented himself at the “Garnison Spital,”
and there underwent energetic treatment. He received
40 inunctions, 10 rubbings, 3 grammes, ten 4 grammes,
and twenty 5 grammes, making a total of 75 grammes
of mercurial ointment. During the same period, which
extended over two months, he took internally 2
grammes of iodide of sodium. During 1902, 1903,
1904, and 1905 he underwent 30 days’ inunction, with
a bathing or drinking cure at the Darkau Hydropathic.
During this interval of preventative treatment none of
the syphilitic phenomena presented themselves, which
I can vouch for, having him under my constant obser¬
vation at the Garnison District, where I was located.
The last inunction was given on May 29th, 1905. On
June 31st he came to the baths for his annual cure,
and told me that he purposed marrying in February,
1906, which I thought a wise proceeding, as the
primary examthemata had appeared in 1902, and
during the long interval no symptom of syphilis had
reappeared. Notwithstanding this satisfaction in my
own mind, I asked him to undergo a short mercurial
treatment before marriage as a precaution against any
recurrence, and on this occasion 30 intra-muscular in¬
jections of succinamid of mercury, with internal doses
of .05 to 5.00 grammes of the proto-iodide of soda and
mercury in pill form. On February 16th, 1906, no
sign of lues was to be observed. He returned from bis
honeymoon on March 21st, and consulted me for an
abrasion on the scrotum which had inflamed the cuta-
enous surface of the penis, where a few weeping
papules were observed. The wife had not menstruated
since marriage, and complained about March 8th cf
pain during coitus. On examination, I found in the
posterior commisure on the left vaginal wall near the
insertion of the labia minora a small infiltration about
the size of a hazel nut, which I removed with a knife.
The inguinal glands were numerous and swollen, and
no doubt remained in my own mind that she had been
infected with the syphilitic virus. On April 19th the
syphilitic roseola appeared, and I at once prescribed
proto-iodide of mercury, 1 gramme, in 50 pills, one
to be taken four times a day. At the same time a
vaginal douche in the evening, followed by the inser-

Google

Oct. 16, 1907.

ORIGINAL PAPERS.

The Medical Press. 4*5

tion of a suppository containing 1 gramme of mer¬
curial ointment. The roseola soon disappeared, fol¬
lowed in June by papules on the mucous membrane of
the mouth, longae, etc., upon which I changed the
treatment to mercurial vasogen inunction. During the
whole of this time she took per-os i| grammes of the
iodate of soda in pill form, and from the beginning
of the pregnancy to the end she took 5 grammes of the
proto-iodide internally, 100 suppositories of 1 gramme
each, and 80 inunctions of 3 grammes each of mer¬
curial ointment. On November 28th a child was born
weighing 3,150 grammes, healthy and strong, and free
from every appearance of syphilis. This year, on
April 21st, the child weighed 7,000 grammes, and no
symptom of syphilis had appeared. The child had
been fed on sterilised milk, as it was unwise of the
mother to feed it, and equally so for the child to be
put to the breast of a healthy nurse. A peculiar
symptom should be noted ; on the second day after
the confinement papules appeared on the tongue of
the mother, which again disappeared after a few
inunctions while confined to bed.

Here we have a man who has taken every precaution
that the science of medicine can suggest to eliminate
by mercurial purgation every trace of that syphilitic
fiend, even up to the very eve of his marriage, and
yet he is able to infect his wife two years after every
symptom had disappeared, and, notwithstanding this
infection, with energetic mercurial treatment a healthy
child is born into the world.

A similar result was obtained in 1905 in the case of
a painter whose wife was infected, became pregnant, |
and was diligently treated with succinamid injection
and given iodide, and a healthy child bom. The child
appeared strong and robust, but in the fourteenth
month whooping-cough developed, followed by inflam¬
mation of the lung, and it died within 15 days. There
is another case demonstrating the fact that we can
treat syphilis quite successfully in keeping it sup¬
pressed, but we are unable to prevent its occurrence by
any protective means we have at our command ; but the
strange anomaly still exists that if pregnancy intervene
a healthy offspring is the result. With these facts
before us, it is useless to attempt the impossible in
eradicating a poison that will occur in spite of the
most persistent treatment. It is therefore better to
guide the local symptoms by treating them as they
arise with mercurial plasters and iodoform bandages
when necessary. When these tertiary results appear on
the forehead as periosteal gummata, with fluctuation,
antiseptic punctures will often check the formation of
abscesses, avoid deformity and a good deal of suffer¬
ing. When necrosis does occur it is always better to
have the loose sequestra extracted. If these be left
until Nature throws them off, the health may suffer,
and the patient become so much weakened that life
may be endangered, but the early interference of the
surgeon will avert this result and hasten recovery. In
many of these cases free mercurial treatment may
modify the gummatose phenomena, and happy results
be obtained. In this class of cases the decoction
Zittmanni, which is a combination of mercury and
sarsaparilla, will be found efficacious. The addition
of calomel or other forms of mercury are quite un¬
necessary if the Zittmanni decoction be made with
fresh sarsaparilla, and not with a fluid extract or
tincture that has been long prepared. A course of
bathing is also a very favourable adjunct in the ter¬
tiary treatment where general disturbances of the nerve
centres are troublesome. Recurrences in the mouth
and throat are readily induced by the abuse of alcohol
and tobacco, which should be forbidden in the ter¬
tiary form.

It is worthy of remark that orchitis syphilitica
seldom passes on to suppuration of the scrotum. If a
hydrocele should occur, it will probably spontaneously
disappear owing to the disturbance in the vascular
system; but when the distention becomes painful it is
better to draw the fluid off. As a rule the swelling
will recede if the part be enveloped in mercurial oint¬
ment in the form of plaster or otherwise. According
to the testimony of Levin, bilateral orchitis will lead
to oligo- or azoospermia. In one case of my own,
destruction of the testis prompted me to
ni-castration, which the patient would not

listen to. The consequence was that one half of the
scrotum necrosed, and after four months’ treatment
cicatrised. A hint might be given to the younger prac¬
titioner that the application of mercurial ointment or
plasters should be carefully done, as gingivitis or
mercurial intoxication may also be induced by this
innocent form, and do considerable damage.

Modern treatment has given rise to a number of new
preparations, such as sajodin jodalbumose, with the
object of making iodine borne easier by the stomach.
These are absolutely tasteless, and have the advantage
of producing no acne. Iodine catarrh is a troublesome
accident producing neuralgia in the trigeminus, which
is seldom met with in sajodin or jodalbumose. When
the catarrh appears it is better to suppress the iodide
in every form at once, and if the soda or potassium
iodide have been used, it is better to vary it with the
newer class of drugs. In very sensitive cases the pill
form is the best, as potassium sodium or iodide, when
given in solution, act directly on the mucous mem¬
brane, inducing the injury we wish to avoid. Pleuro-
dinia of the left side, and oedema of the glottis and
lungs, are also troublesome symptoms of the iodide
poisoning, which may frequently be relieved by the
addition of 0.03 gramme to 00.5 gramme of quinine
to the mixture; this adds to the better digestion of the
drug. It is always better to prescribe iodates after
meals to relieve the irritation of the stomach, and
jodalbumose has been prepared in tablet form, con¬
taining 22 per cent, of the drug, to meet this diffi¬
culty. This seems to act well, as no increase of the
heart’s action has been recorded after its use. Iodide
acne is another troublesome symptom which readily
yields to the combination of cerolin.

Another new drug, named mergal, a mercurial pre¬
paration, has recently been introduced in the form of
capsules containing 0.05 gramme, and gives excellent
results. My own experience is very favourably inclined
towards this preparation since its introduction to the
Austrian clinic.

PHYSICALLY DEFECTIVE CHILDREN
FOR WHOM INSTRUCTION IN
SPECIAL SCHOOLS IS NECESSARY, (a)

By REGINALD CHEYNE ELMSLIE, M.S., F.R.C.S.,

Local Aaslatant Medical Officer to the Education Committee of the

London County Connell; As*latent Burgeon to the Metropolitan
Hospital, London.

It is now eight years since the School Board for
London opened the first “Invalid Centre” for the
instruction of children who, owing to chronic ill-
health or to physical defect, were unfit to mix with
their fellows in the larger schools. The number of
centres has rapidly increased, until at the present time
there are twenty-three open, with accommodation for
1,428 children, and with 1,802 children actually on the
roll—a sufficient number to render a survey of these
children from the medical standpoint both interesting
and instructive.

The schools are dotted about all over London ; each
accommodates from forty to one hundred children,
drawn from a district which may have a radius of one
and a half or two miles, ambulances being used to
collect the children in the morning and to take them
home in the afternoon. A qualified nurse, a cook,
and one or more helpers are in attendance at each
school; in addition to their other duties they prepare
a mid-day meal, for which the children pay. A
voluntary association assists in this catering, and also
provides food at a reduced rate or free m cases of
want.

Children are passed into the school after examina¬
tion by a medical officer, who also periodically sees
all children in attendance. Notes of their histories
and of any changes in their condition are kept in a
case book. They are required to remain at school
until the age of sixteen, unless they are passed to leave
or to return to an elementary school at one of the
medical officer’s visits.

(a) Paper read before the Second International Congress on School
Hygiene, London, 1907.

416 The Medical Press. _ORIGINAL PAPERS.

During the past year I have kept careful record of
the condition of 1,050 children seen and examined by
myself in these schools. As far as possible details as
to the disease or deformity from which they suffered,
the age at which it arose, the treatment which had
been carried out, and the result as shown by the
present condition of the child, were noted. With the
co-operation of the teachers further notes as to the
educational backwardness of the child, the amount of
schooling lost through illness, and any notable devia¬
tions from the average in ability, were taken.

This number (1,050) represents only a small propor¬
tion of the physically defective children in London ;
but having been taken without selection, we may
accept these children as a fair sample of the whole.
From a consideration of them I propose to show—

1. W’hat classes of children are at present being
educated in the London schools for physically defec¬
tive children ;

2. What purpose is being served by educating these
children, what results are being obtained, and
generally whether the system is a desirable one.

The general classification of these children is set
out in the table. The first point calling for attention
is the group of seventy-two children who suffer from
none of the conditions for which these schools are
primarily intended. This group comprises a small
number of semi-blind, semi-deaf children, too bad for
education in an ordinary school, too good for a
special centre for the blind or deaf, and a larger
number of children suffering from no definite illness
or defect whatever. The latter were found to be even
more backward in their school work than were children
suffering from such chronic ailments as tuberculous
disease of the hip or spine. They are a group of
delicate, nervous children, who have missed much
schooling owing to illness ; they are unfit to mix with
healthy children in a large school, and until the
London Education Authority sees its way to the pro¬
vision of special accommodation for them a certain
proportion of them must be found places in the
schools for physically defectives.

Turning to the children for whom these schools are
more specially intended, it will be seen that just about
one half of these are suffering from tuberculous disease
of the bones or joints, the hip or spine being the site
of the disease in the majority of cases. Indeed, it is
for the care and education of those children who
suffer from the more severe forms of surgical tuber¬
culosis that these schools may be said to be primarily
intended. The age at which these diseases usually
arise is of importance. From those cases in which the
history had been recorded the following facts were
made out: —

In tuberculous disease of the spine the disease arose
between the ages of one and five in 72 per cent.

In tuberculous disease of the hip the disease arose
between the ages of two and six in 64 per cent.

In tuberculous disease of the knee and of other
joints the incidence was spread equally over the first
nine years.

These facts agree with such statistics as have been
published from the records of hospitals. They indicate
one great difficulty which is bound to arise in dealing
with these children in schools, viz., that the disease
is already well established, and much deformity has
often arisen, long before school age is reached. I’or
example, of the children with disease of the spine
who were examined, in only about 10—15 per cent,
was the disease considered to be active, whilst 58 per
cent, had very severe fixed deformity of the spine.

Many of the observations made upon these children
are of purely surgical interest; some, however, also
bear very directly on education. In the first place,
the actual mortality from the disease is not high, but
a considerable proportion die from intercurrent affec¬
tions. We may take it, however, that the majority of
thf -Mldren will live to adult life, will then outgrow
the actual disease, but be left with the deformity to
which it has given rise. They will then have to take
their place in the world, and to endeavour to earn
their livings in competition with others who do not
suffer under the disabilities of a fixed deformity, and
of educational backwardness, the result of prolonged
ill-health. Surely, then, our endeavour should be at
one and the same time to prevent or alleviate

Oct. 16, 1907.

deformity, and to carry on instruction during the
periods of illness.

Now, in examining a series of cases of quiescent
tuberculous disease two points stand out at once. The
first is the frequency with which disease which was
apparently cured reappears. A great physician has
said of tubercle in the lungs that it is often arrested,
very rarely cured. The same is true of tubercle in the
bones and joints; over and over again a child with
hip disease remains apparently cured for a year or two,
then some slight accident, a little over-exertion, or
some affection of the general health lights up the
disease afresh, and treatment has to be carried out all
over again. For this reason I am convinced that this
class of children should be kept out of the large
schools, no matter how well they appear to be. To
allow them to mix commonly with their healthy
fellows, to play rough games without supervision,
frequently ends in disaster.

The second noticeable fact is the large proportion
of these children who are left, when the disease is
arrested or cured, with a severe deformity which
seriously affects their prospects in after-life. Now this
is not unavoidable; fully half the deformities follow¬
ing on tuberculous disease are due to three causes
which may be overcome. The first is the commence¬
ment of treatment at too late a stage ; this is remedi¬
able to a certain extent by increasing medical inspec¬
tion, and by training those having charge of small
children to consider any weakness of the spine or
limbs as serious. The second is too short a period of
rest in recumbency during the active stage of the
disease ; and the third, I regret to have to say it, is
meddlesome operative surgery. These last two are
not by any means altogether the fault of the surgeons.
Owing to the absence of special accommodation for
these children most of them have to be treated at the
large general hospitals. Here there is a constant
pressure upon the beds ; there are always more patients
waiting for admission than it is possible to find room
for in a reasonable time. Moreover, some of the
central hospital funds base their grants to hospitals
upon the average length of stay of the patients; so
that the latter have to be discharged at the earliest
possible moment. This rule may be considered
necessary to prevent abuse, but it certainly is not in
the interests of the patients, and it is particularly bad
in its effect on the treatment of children with tuber¬
culous bone disease. They are taken in during some
acute exacerbation of the disease, or for an opera¬
tion, are discharged as soon as possible in a walking
splint with crutches, and are then seen at intervals
as out-patients. It would be almost impossible to
conceive a more thoroughly bad method of treating
them.

One result of this method is that children are con¬
stantly being taken to a fresh hospital, the parents are
dissatisfied with the progress, or perhaps, having
stayed away from the out-patient department too long,
are afraid of receiving a scolding on returning.
Meddlesome operation can be traced to the same
causes. The operations to which I specially refer are
excisions of the hip and knee joints ; these have the
advantage that they sometimes cure the actual disease
right away by removing all the diseased structures.
The surgeon, knowing this, and encouraged by the
success of bold operating in other lines, seizes the
opportunity of curing the patient after only a brief
stay in hospital. The ultimate result several years
after is seen probably at another hospital by another
surgeon, who ascribes it to a bad operation, and
never suspects that many of the excisions that he him¬
self has done have turned out every bit as badly.
Among the cases of old hio disease seen by me,
twenty-five had been subjected to excision, and in
every one of these a weak, flabby joint was left, the
functional result being in every case bad. Similarly
of thirty-four children on whom excision of the knee
had been performed, twenty-nine were left with a
severe deformity. I have no wish to condemn these
operations entirely; in their proper place they both
are of use, but if they are indiscriminately employed
in an attempt to arrest the disease rapidly, not only
are they often unsuccessful in this object, but also
thev often lead in the end to a crippled and useless
limb.

zed by GoOgle

Oct. 16, 1907.

THE OUT-PATIENTS’ ROOM.

The Medical Press. 417

The second group of cases includes children suffer¬
ing from various congenital or acquired deformities,
the latter chiefly the result of severe rickets, from
infantile paralysis, and from spastic paralysis. These
have the characteristic in common that the disability
is of a fixed nature; it may in some cases be im¬
proved by surgical treatment, but it will not become
worse as age advances. These conditions also are
either present at birth, or arise in the first two or three
years of life. Only the more severe cases of such
deformities and paralyses require education in special
schools ; in the slighter cases the children are quite
fit to mix with their healthy fellows. The requirements
of this class of children are (1) constant medical
supervision during the years of growth, to ensure that
they are so treated as to leave them under the least
possible disadvantage; (2) special education to fit
them for the special work which their crippled condi¬
tion will necessitate.

The third class includes children with heart disease,
with progressive forms of paralysis, and with epilepsy,
chorea and some other chronic illnesses. These are
alike in that many of them will never reach adult life
at all, whilst those who do will as a rule not be fit
for any form of manual labour. Their requirements
are similar to those of the last class.

Having shown what children are being educated in
the London schools for physically defective children,
let us consider what the present methods of work are
accomplishing. These schools may aim at one or
other of two objects: —

1. Simply to educate the children as far as possible,
then to turn them out into the world ignoring their
physical defect.

2. To do the utmost to arrest, alleviate or improve
the physical defect, and by improving the child both
educationally and physically to place him in such a
position that he is able to support himself.

In London at present it is the first of these policies
that is adopted, certain additions to it, however, being
made. The additions are: —

1. Supervision in school by a nurse and a doctor,
and occasional recommendation of treatment.

2. The provision of good food.

3. Voluntary aid by the local charitable societies,
which as a rule keep in touch with the children in
school through the managers.

4. Assistance in finding suitable work after leaving
schools through the after-care committees.

These are all very good so far as they go, but those
who assist in carrying them out would, I am sure,
be the first to admit that the results are most unsatis¬
factory. In the first place, the work is voluntary, is
not always systematic, and is carried out by energetic
people, who mean well and work hard, but too often
have an insufficient technical knowledge, and have
no one upon whom they can fall back for advice and
assistance. In the second place, we have no power
over the careless, improvident parents, who are too
lazy or too neglectful to make an effort on behalf of
their own children, and who, perhaps, object to the
offer of the after-care committee to get their boy
apprenticed, because it means that they will lose the
immediate return they might get from his wages as an
errand boy, or in some similar occupation.

The problem of finding suitable work is rendered
more difficult by the backwardness of the children,
nearly all of whom are two standards behind their
proper position, and many a great deal more than
this. . Moreover, the special nature of the work re¬
quired is a further difficulty; the estimate arrived at
upon this point was that only 20 per cent, of these
children will be able to earn their living at any ordi¬
nary form of occupation, 50 per cent, will be able to
work if special skilled work is found for them, the
other 30 per cent, will either not live, or will be
totally unfit to support themselves in any way what¬
ever.

Practically, then, although much good is done in
individual cases, in London at present a large number
of these children are turned out into the world at
fifteen or sixteen to make their way as best they can,
their physical defect being ignored. And although it
may be said that the education authority has done its
duty in educating them, the community at large must
be the poorer by having a number of physically unfit

individuals left upon its hands. Without entering
into particulars of alternative schemes for dealing with
the problem, certain essential points which should be
provided for in such schemes may be named.

x. Three classes of children must be provided for: —

(a) Children with tuberculous disease of the bones
and joints.

(b) Children with fixed deformities and paralyses.

(c) Children with diseases of the heart, lungs, etc.,
of a chronic nature.

2. For children of the first class treatment at the
earliest possible time after the disease shows itself is
essential, and as these conditions arise early in life,
provision must be made for quite young children.

3. Whether the institutions provided are called
hospitals or schools is immaterial; they must serve
both purposes.

4. Technical instruction is essential for the older
children.

5. For certain cases the provision of a permanent
home is desirable.

EXAMINATION OF 1,050 CHILDREN IN LONDON
SCHOOLS FOR PHYSICALLY DEFECTIVES.

I.—CHILDREN FOR WHOM INSTRUCTION 1H SPECIAL SCHOOLS IS
NNCESBARY OK ACCOUNT OF THI PHYSICAL DEFECT.

A. —Tuberculous Disease of \

Boys. Girls. Total. J

1. Spine. 106 80

2. Hip . 100 95

3. Knee. *6 34

4. Other Bones or Joints 8 11

B. —Fixed Deformities or Paralyses.

5. Various Deformities 66 71

6. Infantile Paralysis ... 57 57

7. Spastic Paralyses ... 27 37

C. —Various Diseases.

8. Heart Disease ... 61 59

9. Progressive Paralyses 8 1

10. Various . 22 32

If.— Children for whom Instruction in Spscial Schools is
NOT NECESSARY ON ACCOUNT OF THI PHYSICAL DXFIOT.

D. - Defects of Eye or Ear

only. 9 8 17

E. —Without Special De-

feot. 26 29 55

Totals .. ..536 614 1,050

Children with more than one physical defect were Included under
that defect which was considered to be the most serious.

THE OUT-PATIENTS’ ROOM.

THROAT HOSPITAL, GOLDEN SQUARE.

186 I

195 I 480
80
19

j(about 50 1

315

‘"J (about 30%)

l 978

120-1

4 }

183

(about 20%) )

Foreign Body in the Nose.

By Frank Rose, M.B., F.R.C.S.

Among the out-patients was a little girl, aet. about 5,
who had been brought by her mother on account of a
discharge from the right side of the nose which had
been noticed for about a fortnight; there had occa¬
sionally been a little blood with it. The mother did
not know the cause, but seemed inclined to attribute
the trouble to a blow which she vaguely intimated the
child had had in the playground. On examination, a
thin and purulent discharge was seen issuing from die
right nostril; the upper lip on the same side was red
and excoriated. Mr. Rose pointed out that the case
was certainly either one of membranous rhinitis or
foreign body in the nose; sinus suppuration was ex¬
cluded by the child’s age. Membranous rhinitis,
though possible, was unlikely, he said, because it
nearly always attacked both sides of the nose, though
occasionally it was unilateral. Therefore, the only pro¬
bable diagnosis was that of a foreign body. On sug¬
gesting to the mother that some foreign body had been
introduced into the nose, she denied the possibility.
After wiping away the discharge from the anterior part
of the nose, a dark green body became visible. A blunt
hook was then passed in behind this body, and a boot
button was brought out, much to the astonishment of
the patient’s mother. Mr. Rose laid stress on two
points, (i) That a purulent unilateral discharge, mixed

Digitized by GoOgle

418 The Medical Press.

OPERATING THEATRES.

Oct. 16, 1907.

with blood, from the nose of a young child nearly
always indicated a foreign body; if the discharge were
offensive as well, then the diagnosis of a foreign body
was almost certain. (2) In removing these foreign
bodies, much the best method is to employ a blunt
hook, and not forceps, as forceps are apt to push the
foreign body further and further into the nose, whereas
the blunt hook gets beyond the foreign body and at
once pulls it down. This, of course, would apply to
round, hard objects, such as buttons, beads, etc.,
which are the objects commonly found in children’s
noses.

Foreign Body in the Larynx.

A girl, ®t. 19, came among the out-patients with the
following history: Two days previously, when taking
broth at supper, she felt something stick in her throat,
and had a severe attack of choking. She went to visit
a doctor, who passed a bougie down the oesophagus
without giving the patient any relief. It was then
noticed that she had almost completely lost her voice.
She was able to swallow water and take some toast.
On the next day she again had medical advice, but no
relief was obtained, although an emetic was given. A
foreign body was discovered by the medical man, who
then recommended her applying at the hospital for
its removal. On examination the patient was noticed
to be in no discomfort whatever. The breathing was
natural, there was no cough, and it was only when the
girl began to speak that anything wrong was detected.
Her voice was very weak and slightly husky. On in¬
spection of the larynx it was seen that there was a
foreign body lying inside the larynx in contact with
the posterior wall; a v/hite spot was also visible on
the anterior wall of the trachea below the vocal cords.
The whole larynx was reddened. The pharynx and
larynx were painted with cocaine until they were
anmsthetic, and the foreign body was extracted with
Krause’s forceps without any difficulty. It proved to
be part of the breast-bone of a chicken. It was a thin
plate of bone, triangular in shape, measuring one inch
vertically, its horizontal base being a little more than
three-quarters of an inch. It had been situated in the
larynx as a vertical plane, so as to form a sort of
median partition ; its median upright position explained
why the breathing had not been impeded.

OPERATING THEATRES.

GREAT NORTHERN HOSPITAL.

Pelvic and Subphrenic Abscess.—Mr Arthur
Edmunds operated on an unmarried girl, set. 20, who
ten days previously had been seized with an acute pain
in the epigastrium while she was at work. She was
compelled to go home and lie up, but the pain was not
excessive, and there was no definite collapse. During
the ten days preceding her admission into hospital, her
symptoms were equivocal; the pain continued with re¬
missions, and the abdomen became gradually dis¬
tended ; there was a slight temperature, and the pulse
was quickened. The abdomen at first was generally
tender, but for two days before admission the tender¬
ness had become restricted to the hypogastric region.
On admission she was seen to be well nourished ; her
pulse was rapid—about 120 ; her temperature was about
102 0 ; her tongue was furred. On examining the
abdomen, a large swelling could be felt, extending up¬
wards from the symphisis, but not extending into
either flank. The abdomen, as a whole, moved poorly
with respiration, and was moderately distended. Per
vaginam a swelling could be felt bulging into
Douglas's pouch. It was obvious that the case was
one of intra-abdominal abscess, and the diagnosis,
Mr. Edmunds said, lay between three groups of causes :
In the first place one naturally considered the possi¬
bility of the abscess being due to appendicitis. Here
it seemed probable that the appendix was not at fault,
for although the pelvic swelling was a very large one,
there was not the slightest resistance in the rignt iliac

fossa, and there was no definite tenderness about the
root .of the appendix. It was also a very marked
feature in the case that the pain had commenced in the
upper part of the abdomen, and had never concen¬
trated itself on the appendicular region. There was
no history of previous attacks, so that, on the whole,
it was probable that the appendix was not affected.
The diagnosis then lay between a pelvic abscess which
had been produced in or around a pelvic viscus, and
one which had been infected from a distant organ.
The pelvic origin of the abscess was not very easy to
understand in view of the intact condition of the
vaginal outlet, and taking into account the point of
origin of the pain, it seemed probable that the source
of the trouble was to be sought elsewhere. In giving
an account of her history, the patient had mentioned
that she had had occasional vomiting, but it was only
later in the case that one was enabled to elicit the fact
that she had had slight haematemesis. The abdomen
was opened in the middle line so as to explore the
swelling from above* and it was then found that there
was very little wrong with the appendix or any other
intra-abdominal organ. Towards the pelvis, however,
the intestines were matted together to form the roof of
a large fluid swelling, obviously a big abscess. The
question now arose as to the best method of draining
this. Although it is quite easy, Mr. Edmunds pointed out
to drain an abscess across the peritoneal cavity
it is by no means desirable to do so when the abscess
is so large that any opening into it will be very likely
to flood the whole peritoneal cavity with pus. While
it is quite easy to sponge up a few drachms of pus in
a deep abscess, it is impossible to do so when the con¬
tents of that abscess can be measured in pints, and it
is much safer to drain through the vagina. Accord¬
ingly, the index finger of the right hand was passed
into the vagina with a pair of scissors lying flat along
its palmar surface, and with some little difficulty the
posterior cul-de-sac was opened up. The left hand
was kept in the abdominal cavity, so as to form a guide
to the forceps, which were afterwards passed up the
opening made by the scissors. The blades of the
forceps were then separated so as to enlarge the open¬
ing, and a large drainage tube inserted, the end of
which dipped beneath the surface of a bottle of car¬
bolic lotion. The abdomen was then closed by through
and through sutures of silkworm gut, this part of the
operation being entrusted to an assistant whose hands
had not been soiled by the pus which escaped from
the pelvic abscess. The tube acted well, and the
abdominal wound healed kindly. The pain was re¬
lieved, and the patient’s condition improved. In the
middle of the third week after the operation, however,
she began to have cough and pain in the left hypochon-
drium, which was made worse by any movement or by
drawing a long breath. Signs of fluid manifested
themselves, and a needle was put into the chest, with
the result that pus was obtained. Accordingly, a
portion of the eighth rib was excised and the pleural
cavity opened, giving vent to about a pint of clear,
serous fluid. On further exploration the diaphragm
was found to be pushed up rigid and immovable; this
was obviously due to a collection of pus beneath it. It
seemed necessary, in view of the infective nature of
the case, to drain the pleural cavity as well as the sub-
phrenic abscess. A further portion of rib extending
almost down to the costal cartilage was removed, and
the wound was divided into two by suturing the
diaphragm to the chest wall, and bv drawing the
muscles together around a drainage tube, which was
inserted into the pleura. An opening was then made
into the diaphragm from above, about an ounce of
pus let out, and a drainage tube passed into the abscess
cavity. The patient stood the operation well, and is
now making very good progress. The vaginal dis¬
charge has almost ceased, and the wounds in the chest

Digitized by GoOgle

Oct. 16, 1907.

CORRESPONDENCE.

The Medical Press. 419

wall are healing rapidly. Mr. Edmunds said that in
treating such abscesses various methods could be em¬
ployed, the ideal one being to suture the diaphragm to
the chest wall, allowing the pleural cavity to become
shut off before opening the abscess cavity, but in the
present case it was not possible to do this on
account of the large amount of fluid present; and,
furthermore, the probable infective nature of the
pleural contents made it desirable to drain this cavity,
a method of procedure which has the disadvantage of
exposing the patient to the risk of further infection
from the subphrenic abscess—a risk which, in the pre¬
sent case, has fortunately not been realised.

TRANSACTIONS OF SOCIETIES.

ROYAL SOCIETY OF MEDICINE.

had slight unsteadiness for six years, but had become
much worse after an attack three years ago. There
was slight nystagmus and marked kinetic ataxy. In
the lower limbs the ataxy was chiefly present on
walking.

Dr. H. A. Lediard showed the case of a man with
Diffuse Sarcoma of the Skin. This was most marked
in the head, but extended in the trunk to the waist.
Sir Dyce Duckworth did not agree with the diagnosis,
and advocated treatment by large doses of sarsaparilla.

Mr. Cecil Rowntree showed a male patient with a
large, probably Myxo-sarcomatous, Growth on the right
thigh.

The President then delivered his introductory
address, in which he reviewed the history and work
of the Clinical Society for the forty years of its
existence.

CORRESPONDENCE.

Clinical Section.

First Meeting held on Friday, October vith.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

Sir Thomas Barlow, President of the Section, in the
Chair.

Mr. T. H. Openshaw showed a case of Congenital
Absence of the Fibula in a boy, ®t. 10. The outer half
of the foot and the cuter two toes were also missing
on the same side. There was no similar case in the
family. By means of suitable apparatus the boy was
able to walk perfectly and to play games. Mr. Open¬
shaw also showed a child six months old in whom both
tibia were practically absent. He thought that the scar
so often present in these cases was due to intra-uterine
fracture of the bone. He advised against amputation
of legs with this deformity.

Mr. Douglas Drew showed a girl in whom, after
two arthrectomies for tuberculous disease of the knee,
a movable joint had resulted.

Mr. Drew also showed a case of Congenital Disloca¬
tion of the Patella, which had been cured by operation.

Dr. A. E. Garrod showed a woman, aet. 25, who
presented multiple nodules of rheumatic origin. She
had had rheumatic fever two years previously, but
there was no cardiac lesion. The nodules had been
present for eighteen months, but had softened some¬
what after the use of Bier’s treatment; they were pre¬
sent over the metacarpo-phalangeal joints, elbows, and
knees of both sides and over one shoulder. Dr.
Samuel West had seen several similar cases, and
in some, even the worst, there had been no heart
lesion present. Sir Dyce Duckworth was familiar with
such cases in adults, and had been struck by their long
duration. Dr. Bertram Abrahams had seen four
cases in adults, and was sceptical about their being
always of a rheumatic nature ; in some he had followed
for years no rheumatic manifestations had developed.
He pointed out the remarkable symmetry of the nodules
in adult cases, and their greater discreteness. Dr.
Poynton had seen in children nodules of long duration.
The President agreed with Dr. Garrod’s diagnosis. He
had found the association between nodules and endo¬
carditis less close in adults than in children. They
often lasted over a year in adults.

Mr. F. J. Steward showed a child that had re¬
covered after operation for pyopericardium. An
empyema had previously been opened at the left base,
and the pericardium was opened and drained through
this wound. The pus of both was pneumococcal. Dr.
West had seen recovery from an anterior opening. He
advocated simple incision without thoracotomy.
Mr. R. T. Godlee related a case in which Mr.
Raymond Johnson had successfully drained a pyoperi¬
cardium that was secondary to osteomyelitis.

Mr. T. Hutchinson, jun., showed a case of Fusiform
Aneurism of the Right Carotid Artery in a woman,
“ 3 - There was no syphilitic history. Symptoms
dated back for 18 months. He proposed to perform
distal ligature, as it was impossible to perform this
proximally.

r Dr C. E - Bat ten demonstrated a case probably of
Cerebellar Atrophy. The patient, a man of 62, had

FRANCE.

Part*. Oct. 13th, 1907.

Dilatation of the Stomach.

Dilatation of the stomach is one of the most
troublesome affections that a practitioner has to deal
with. The treatment is medical, but, above all,
dietetic. A proper regime imposed on the patient is of
the greatest importance, for without attention to the
nature of the food medicine can have but an illusory
effect.

The meals should be so arranged that food should
not be introduced into the sto-.aach unless the preceding
repast has had time to digest. In some cases, says
Prof. Lemoine, the organ is very sluggish, so that only
two repasts daily can be allowed, one at 10 o’clock in
the morning, the other at 7 in the evening. Generally
three repasts may be taken, and no drink or food
allowed between the meals.

The dry regime is best suited for these patients, as
liquids distend the stomach ; for the same reason soups
should not be absorbed.

The first repast in the morning should consist of
tapioca, or one or two boiled eggs with a piece of
bread. The two other repasts may be varied in their
composition, but vinegar, sauces and greise should be
avoided, as well as fresh bread. The solid food may
be composed of rice, tapioca, macaroni, roast meat,
salmon, fresh cod, vegetables (well cooked) ; mar¬
malades, jams, all kinds of game, shell-fish, and strong
cheese should be excluded.

The medical treatment should have in view the main¬
tenance of the energy of the muscular system. As a
nervine tonic, phosphate of soda is of a great value
if persevered in for several months :

Phosphate of soda, 4 dr.

Tincture of nux vomica, 40 m.

Syrup of bitter orange, 10 oz.

A tablespoonful an hour before meals

Or, Sulphate of strychnine, 1 gr.

Water, 5 oz.

A teaspoonful in a little water before each meal.

Ipecacuanha in small doses is an excellent stimu¬
lant ; one-grain pill after me tis has been recommended
by Mathieu.

Massage of the epigastrium has been practised by
Dujardin-Baumetz, and with good results, but it re¬
quires to be done methodically, and according to pre¬
cise rules, and by practised hands. However, it can
be replaced by a general massage done each morning
in a bathing establishment after a cold douche. When
the patients cannot take the shower bath, it can be
replaced by rubbing the whole body with a flannel
moistened with a mixture of alcohol and turpentine:

Spirits of turpentine, 2 dr.

Spirits of camphor, 4 oz.

Spirits of lavender, 2 oz.

And an alkaline bath twice a week :

Carbonate of soda, 4 oz.

Salt, 2 lb.

(For one bath.)

Digitiz

420 The Medical Press.

CORRESPONDENCE.

Oct. 16, 1907.

Washing out of the stomach should be reserved
for cases where the distension is considerable, and
symptoms of putridity of the contents of the stomach
exist.

The food that remains incompletely digested in the
stomach accumulates after each meal, and finally
undergoes fermentation, provokes the formation of

f tomaines, and becomes dangerous for the economy,
t is to the absorption of these toxins that may be
attributed headaches, vertigo, neuralgia, hepatic colic,
etc. In such cases antiseptics are plainly indicated—
salicylate of bismuth, salol, betol, naphtol, or
benzonaphtol. Laxatives in the form of purgative
mineral waters (Montmirail, Chdtel Guyon, Rubinat)
should be ordered two or three times a week.

Besides the above treatment, the patients should be
enjoined to suspend all intellectual work and replace
it by physical exercise, manual labour, fencing,
gymnastics, bicycle riding, etc.

Injections of Thiosinamin.

Within the last few months the virtues of
thiosinamin are being spoken of after many years,
during which it had fallen into oblivion. It is now
being employed in sclerous affections, such as pleuretic
adhesions, chronic perigastritis, stricture of the
urethra, the oesophagus, and the affections of the
middle ear (sclerosis of the tympanum).

Two patients were recently treated for stenosis of
the pylorus following gastric ulcer. Every three days
20 drops of a solution of thiosinamin (1/10) were in¬
jected. At the end of three weeks considerable im¬
provement took place. In another case of ankylosis
of the knee, mobility was restored by daily injections
of the same solution, to which was added salicylate
of soda.

GERMANY.

Berlin. Oct. I3tl>, i9o7.

At the Free Society of Surgeons, Hr. Nordmann
showed a case of

Intraperitoneal Rupture of the Bladder.

A waiter was wounded whilst in a state of drunken¬
ness. He had a constant desire to pass urine, and in
the course of 24 hours showed signs of peritonitis. A
catheter was passed, and a large quanitity of urine
drawn off, which was afterwards found to come from
the peritoneal cavity. He concluded that the case was
one of perforated gastric ulcer, and made an opening
into the upper part of the abdomen, but found that
the stomach was whole. He then opened the lower
part, and found a rupture of the bladder. The parts
were united without drainage, and recovery took place.

Hr. Martens spoke on the technique of

Operations for Perforated Ulcers of the
Stomach.

He felt himself bound, he said, in cases of perfora¬
tion peritonitis, when too much time had not elapsed,
to open the abdomen, whether ulcer of the stomach
with perforation could be diagnosed or not. It did
not do to wait for the shock. The patients were given
saline infusions, and were operated on under general
narcosis.

At the operation the aim should be to find the per¬
foration as quickly as possible, and close it. It was
enough to stitch it over; at the most the edges might
be freshened. Omentum was adjusted over the sutures.
It was only advisable to add gastroenterostomy if the
ulcer was situated on the pylorus, and this was nar¬
rowed by the sutures. It only became a question of
jejunostomy when the ulcer was very large, and it
could not be closed by the sutures.

After completing the suture the abdomen was
thoroughly washed out with saline solution, of which
20 to 30 litres were made use of. He kept on with
the washing out until all stomach contents were
washed out.

The abdomen was closed up to a small opening for
drainage, but no tampon was left in. He had had the
leucocytes counted in his cases, but the results obtained
were not constant.

Hr. Federmann, on the other hand, laid stress on

the counting of the leucocytes both for diagnostic and
prognostic purposes, and thought it advisable to leave
out the washing out of the abdomen.

Hr. Korte was of opinion that early diagnosis was
easier than after 15 to 20 hours, when the peritonitis
had become fully developed, and the whole abdomen
equally tender. He had now operated in 20 cases, of
which 6 had died. The prognosis was not so unfavour¬
able if the operation was performed within the first
24 hours. Washing out was unconditionally to be
recommended. It was, without doubt, the most non-
irritating way of cleaning out the abdomen. After
that it was best to close up entirely. It was to the
purpose also to add gastroenterostomy to the closure
of the ulcer.

Hr. Martens related three cases of
Pylephlebitis Complicating Perityphlitis.

One of the cases was remarkable in that thrombosis
of the portal vein occurred, although the appendix was
removed within 40 hours of the commencement of the
attack. In general, however, pylephlebitis was more
rare since the introduction of early operation.

Hr. Korte confirmed what had been said, and had
seen a case in which the patient died of pylephlebitis,
although the operation was performed within the first
24 hours.

Hr. Israel had seen a patient who from an error of
diet had a rigor, and died in three weeks fiom con¬
stantly recurring rigors, jaundice and swelling of the
liver. The autopsy revealed multiple abscesses of the
liver, pylephlebitis, a quite small ulcer on the vermi¬
form appendix, and at the base of it a thrombosed
vessel.

Hr. Engelmann showed a patient with

Acute Inflammation of the Pancreas.

He was admitted into hospital with symptoms of
general peritonitis, great tenderness over the upper part
of the abdomen, which projected forwards, and
showed dulness on percussion. Recovery took place
after clearing out the exudate and drainage of the
bursa omentalis. The next case was one of rupture of
the liver from compression. The torn part was united
by suture. Some time afterwards a subphrenic abscess
formed, which was opened. Recovery took place.

AUSTRIA.

Vienna, Oct, i3th, 1907.

Polyneuritis and Bacterium Coli.

Choroschke has been devoting his attention to
parenchymatous and interstitial polyneuritis, and finds
that many parenchymatous cases have clinically every
appearance of interstitiae. The absence of fever and
the long-continued course of the disease declare it to
be a toxaemia. Whence comes the infection ? he asks ;
and answers—from the bowel; it makes its way into
the urinary tract, which he considers the most favour¬
able for its transmission. The narrowing of the lumen
of the bowel, which produces a coprostasis higher up
from the poison of the bacterium coli, which wanders
from the bowel through the atrophied gastric wall,
and thus makes its way to the bladder by the peri¬
toneum, in which red stripes can be traced in the post¬
mortem room, clearly demonstrates the mode of pas¬
sage. In consequence of the long retention of the
faeces in the bowel, the bacterium becomes more viru¬
lent, and thus easier cultivated in the urinary tract,
where any slight lesion admits of a ready absorption
into the blood. This he considers the real cause of so
many cases of meningitis and myelitis being associated
with the bacterium coli, and from this attack on the
meninges reasons that coprostasis produces polyneuritis,
from which the toxin of the bacterium can equally be
obtained with the same readiness.

Atoxyl in Relapsing Fever.

Glaubermar.n has been using atoxyl for some time
with the best results, but it must be given in larger
doses than the prescribed orthodox quantity. He
treated 30 cases with small doses, but did not obtain
the effects expected. He tried 40 other cases with doses
of 9.0 to 23.0 cubic centimetres of a 20 per cent, solu¬
tion. In seven to fourteen days the fever disappeared.

Digitized by GoOgle

Oct. 16, 1907.

CORRESPONDENCE.

The Medical Press. 421

He considers this a reliable drug in relapsing fever,
shortening the pyrexia by three days.

Origin of Cancer.

At the “ Naturforscher,” Prof. Kelling again ad¬
vanced his theory of the origin of cancer by the im¬
plantation of embryonic cells, which he considers are
taken in as foreign bodies in the nutrition, and under
certain conditions are absorbed through slight lesions in
the mucous membrane. As further proof he exhibited
the blood serum test in carcinomatous patients. This is
conducted with the albumin of the foreign embryonic
cells, where the mixture produces a cloudy condition,
or in others a rapid solution of the blood corpuscles.
In 265 experiments half of them were positive, while
28 of these reactions positively negatived the diagnosis
of cancer, and which were operated on with perfect
success. He disputed Dungern’s results on the ground
of absent control experiments.

Curious Crystal.

At the same meeting Dr. Mayenburg exhibited a
gigantic crystal of the chromate of alum which he had
grown from the size of a pin’s head to half a metre
in the course of 24 years. The small crystal he com¬
menced with was kept in a saturated solution, cold, of
the same substance, and throughout its growth retained
a beautiful octahedral form. The crystal weighed
42.5 kilogrammes, or 85 lbs.

Female Structure.

Prof. Schultze, in his anthropological research,
affirms that the female in structure is more child than
man, and refers to the plastic form of the skeleton and
the formation of the muscular, fatty, and pigmentary
parts, as well as the proportion of the face. The legs
are relatively short, while the body is large. He main¬
tains that the greatest disproportion exists in the head
and body, the female brain being absolutely lighter,
while the child’s is relatively heavier than the male.
The finer skeleton of the face, the form of the lower
maxilla, and the simplicity of the cerebral surface,
are distinguishing features of the female. The small¬
ness of the throat and greater size of the thyroid, lung,
heart, liver and spleen, with different construction of
blood and stomach, are other adjuncts. The cause of
this juvenile condition is not due to any depression by
the male, want of culture, etc., but is rather due to
the phylogenetic progression of the male.

FROM OUR SPECIAL
CORRESPONDENTS AT "HOME.

SCOTLAND.

Teaching of Clinical Surgery in Edinburgh. —A
scheme for the improvement of the teaching of clinical
surgery in the University of Edinburgh has been pro¬
mulgated by the University Court, and will probably
come into speedy operation. It is proposed that the
ordinary surgeons to the Infirmary, except the surgeon
teaching women students, be invited to become Univer¬
sity lecturers on clinical surgery, on condition that—
(1) Each lecturer acts as an examiner on the same
terms as the professor of clinical surgery. (2) As in the
case of other lectureships, 75 per cent, of the fees to
be paid to the lecturer. (3) The University Court pro¬
vides a sum to each lecturer which will cover the salary
of a clinical tutor. At present the students divide
themselves unequally among the different teachers of
surgery, and one of the circumstances which influences
the distribution is the fact that only one of the sur¬
geons, as a rule, is an examiner. Not unnaturally,
this leads to his clinic being unduly crowded, and
prevents the whole clinical material of the hospital
being used to the best advantage. The plan of the
Court is a simple way of remedying this, and it is to
be hoped that it will be accepted by the ordinary sur¬
geons. If it comes into force it will also have the
advantage of shortening the period over which the
examination in clinical surgery extends. Each lecturer
will, of course, receive the whole fees of the extra¬
mural students attending his class, as well as the pro¬
portion of the fees of University students.

Edinburgh Royal Infirmary.—Retirement of Dr.
Alex. James and Mr. Chas. McGillivray. —At the
usual weekly meeting of the Board, a resolution in
appreciation of the services of Dr. Alexander James
was passed by the managers. They “ fully realise, and
highly appreciate, the assiduous and constant attention
he has paid to the patients under his care, and the
great success which has attended his labours, and they
are well aware that his skill as a teacher of clinical
medicine has been shown by the large number of
students who have taken advantage of his instruction
in the wards under his care. By his kindly and con¬
siderate manner to all with whom he came in contact,
by his great ability, and by his unwearied devotion to
duty, he has endeared himself to his patients, his
students, and his colleagues. In parting with Dr.
James, the managers offer him their heartiest good
wishes, and as a testimony of their esteem for him,
appoint him one of the consulting physicians to the
Institution.” A similar recognition was paid to Mr.
C. W. McGillivray for his services as one of the acting
surgeons for the past fifteen years. The managers
appointed him one of the consulting surgeons of the
Institution.

New Physical Laboratory, Edinburgh Univer¬
sity. —At the beginning of the winter session, next
Tuesday, the physical laboratory will be transferred
to the new buildings, which consist of the reconstructed
surgical hospital of the old infirmary. The main walls
of the building have been retained, but the wooden
flooring has been replaced by concrete on steel girders,
running east to west to avoid magnetic disturbances.
On the principal floor is the lecture-room, a library,
and a reading-room. The arrangements for demon¬
strating experiments during lectures are very complete.
Under the lecture table there is a room for manipu¬
lating boilers, gasometers, and other bulky pieces of
apparatus, and the blackboards, etc., slide down into
this room. The lantern is set in a gap in the lecture
table, and its rays are leflected by a mirror on to a
screen which is equally visible to all the students.
Above the ceiling over the lecture table is an attic, the
floor of which has openings for experiments with long
pendulums, falling bodies, etc., and a drop of 45 ft.
can be obtained. The whole department has been re¬
constructed by Sir Rowand Anderson and Mr. Balfour
Paul, architects. They have been advised by Professor
Macgregor, who has made a careful study of the most
recent and complete laboratories on the Continent and
in America.

Consumptive Sanatorium for Ayrshire.— As a
result of a conference between the various local
authorities in the county, the Chairman of the
Glenafton Consumption Sanatorium has offered to
hand over the sanatorium to the countv as a free gift
provided the county give opportunities for treatment
at least as great as the Ayrshire Association does at
present. A report to the Ayr District Committee from
Dr. Macdonald showed that to meet the county’s needs
there would require to be provided 80 beds, which
would involve the enlargement of the present sana¬
torium at a cost of £6,000, and a subsequent charge
for maintenance of about ^3,600. It was agreed to
send down this information to the various local bodies
concerned

Complimentary Dinner to Dr. MacPiiail,
Glasgow. —The occasion of this function was the de¬
parture of Dr. MacPhail from St. Mungo's College to
take up the post of Lecturer on Anatomy at Charing
Cross Hospital. Professor Cleland presided over a
large gathering, and the toast of the evening was pro¬
posed by Dr. Gemmell, and afterwards Sir John lire
Primrose presented Dr. MacPhail with a chronometer,
a dissecting microscope, and a number of books.

BELFAST.

Report of the Medical Officer of Health.—
The report on the health of the County Borough of
Belfast for 1906, just published, is of special interest,
as it is the first report issued by Dr. Bailie, over
whose appointment last year there was so much excite¬
ment. It is only fair to him to bear in mind that he

422 The Medical Press.

CORRESPONDENCE.

Oct. 16, 1907.

was in office for just two and a half months of that
year, and that many details which he might wish to
include in the report were not to be obtained. But
in spite of this, the report shows a very marked im¬
provement on all previous ones, which year after year
have been commented upon in these columns. It is
a well printed and bound volume of nearly 200 pages,
with four maps and eight charts and a good index.
It is, indeed, pretty clear that Dr. Bailie has read and
taken to heart the comments on the former reports.
The report opens with a summary of the vital
statistics for the year 1906, showing a population of
366,000, a birth-rate of 31, a death-rate of 20, a zymotic
death-rate of 2.5, a phthisis death-rate of 2.7, and an
infantile mortality of 143 per 1,000 births. There are
two clear charts giving the total deaths at various
age periods, and the principal causes of death. An
interesting article on the population of the city shows
that according to the Registrar-General’s figures it was
last year 366,000, but according to other calculations
it was as much as 394,000. Calculated from the
number of houses inhabited it was 388,000. The first
four tables deal with zymotic disease and notifica¬
tions, then several tables are devoted to phthisis. A
study of the birth-rate shows that while it has fallen
the fall is only trifling compared with many other
cities. It was 31 per 1,000, as compared with an
average of 31.7 for the previous ten years. The rain¬
fall in Belfast is put at about 36 inches, but this
hardly does justice to the city, for it is taken at the
Antrim Road Water Works, where the fall is increased
by the proximity of the hills. If taken in the centre
of the city, or on the south or east side, it would
probably be decidedly less. Table No. 11 gives the
names of the dispensary medical officers, the popula¬
tion of their districts, and the number of cases of
phthisis, whooping-cough, and measles voluntarily
notified by each during the year. Generally speaking,
the number of cases seems to be about inversely pro¬
portionate to the age of the medical officer! Typhoid
has an article of 29 pages in length devoted to it,
giving a history of a recent outbreak, and its con¬
nection with the milk supply—a very instructive
report already given in some detail in this column a
year ago. Table 15 shows that only nine cases of
typhus were notified, with three deaths, a great im¬
provement on many former years. Scarlet fever was

E revalent, but the mortality was only 2.17 per cent.

iphtheria also was prevalent, and showed a mortality
of 17.6 per cent. Two pages are given to disinfection,
and details of the method and cost are given.
Attention is being paid to books belonging to the
Public Library in houses where infectious diseases had
occurred. The subject of infant mortality is not as
fully discussed as one could wish, and it is to be
hoped that Dr. Bailie will devote much more than
three pages to it in his next report. The rate in
Belfast was 143 deaths under one year old, per 1,000
births, and a table is given showing the rate in a
number of large towns, all of which, except Glasgow,
are worse than Belfast. But we are not informed why
these particular towns were selected, and we notice
that London, Bristol, and Nottingham, for instance,
are not included in the list. About twelve pages are
given to the important subject of phthisis, and the
views expressed are on the whole satisfactory. They
show to a marked extent the influence of the late
Belfast Health Commission, but are none the worse for
that. The card of instructions for consumptives,
which is distributed freely in the city, is re-published
at length, and brief particulars are given of the work
done by the various hospitals in combating the
disease. There are five female inspectors engaged as
health visitors in the city, and of the 13,000 visits
paid by them last year 1,300 were to cases of phthisis.
After a short notice of the water supply, seven pages
are devoted to a consideration of the milk supply and
questions connected with it. The gist of the article is
that far wider powers are needed by the authorities
if they are to deal satisfactorily with the difficult
problem of infected milk. For several years past we
have been asking for particulars as to prosecutions for
adulteration of foods, etc., and now at last we get
them. We find that 1,563 samples of foods and drinks
were taken for analysis, and 67 were found to be

adulterated. There were 61 prosecutions and 51 con¬
victions, the fines amounting to ^85. It is a pity we
cannot have another table giving an estimate of the
profits of undetected adulteration! The seizures of
unsound food are also given, chiefly shellfish and
fruit. Another table gives the number of pigs kept in
the different districts of the city, and it is rather
startling to find that the total is 2,770. The sum¬
mary of the proceedings taken for the abatement of
nuisances and the work done is most interesting, as
is also the account of the public abattoir, in which
58,000 animals were killed and 179 seized as unsound.
Ten pages are given to the work of Professor Symmers
at Queen’s College in examining specimens bacterio-
logically, a work the great interest of which merits
separate notice, as it includes a careful examination
into the bacteriology of the shellfish of Belfast
Lough. The report ends with a good index and maps
showing the localities in which the principal zymotic
diseases occurred. As we said at the beginning, the
report is a marked advance on its predecessors, and
includes almost every point to the omission of which
attention was called in former years. One thing is
still omitted, and that is an account of the working of
the refuse destructor. No doubt this is a concession
to the feelings of some of Dr. Bailie’s former
colleagues on the City Council, who were responsible
for the erection of this costly failure.

LETTERS TO THE EDITOR.

MEDICAL LAW AND QUACKERY.

To the Editor of The Medical Press and Circular.

Sir,—M y letter of last week, in which I called atten¬
tion to the weakness of medical laws as compared with
the Veterinary Act, has drawn forth an interesting
private communication from a distinguished F.R.S.
professor of biology at a British University, from
which I am permitted to publish the appended excerpts.
If the profession propose to fight the battle of medical
law reform with the necessary determination, it may
be desirable sooner or later to discuss the question of
getting proper representation in Parliament. One or
two men with the power and will to make their voices
heard might accomplish much ; and if the sacrifice of
time and income were too great to be conceded gratui¬
tously, it would pay the profession to provide adequate
incomes to members willing to devote themselves to
political life. My friend writes:—“There can be no
doubt that, both in the House of Lords and House of
Commons, there are many men so ignorant of the
whole field of biological science that they cannot
understand the aim or necessity of the education that
the qualified man has to pass through. I believe the
root of the difficulty lies in the system of education
in our higher public secondary schools, in which
science is still stigmatised as ‘ stinks,’ and which turn
out as ‘ educated ’ men boys to whom the whole range
of science is as a closed book. These men go into
Parliament and public life not only ignorant of
science but with an unveiled contempt for us. To
their stupid brains the medical man is a kind of
‘ stinks ’ man, and ought to be treated with contempt.
It is a pity that the medical graduates of some great
University cannot unite to run a candidate for their
seat irrespective of party politics, with a mandate to
look after medical legislation. The doctors who do
get into Parliament are mostly so bound by party ties
that they cannot do much to promote medical Bills.”

I am, Sir, yours truly,

Henry Sewill.

October 12th, 1907.

P.S.—Since writing the above, I have seen in the
Times of to-day the full summary of Mr. Beale, the
Australian Royal Commissioner’s report, to which you
refer in your editorial notes. If a single lay Commis¬
sioner with scanty powers can produce a solid indict¬
ment of quackery such as Mr. Beale has constructed,
what mi^ht not be achieved by a Royal Commission
armed with full powers, including the power to compel
the attendance of witnesses' and examine them on
oath? In the papers of to-day appears also the news
that in Germany there comes into action this month

OBITUARY.

The Medical Press. 423

Oct. 16, 1907.

a law which, if administered with only a part of the
zeal always displayed in matters affecting the welfare
of the people of the Fatherland, will put an end at
once to the traffic in fraudulent quack medicines and
apparatus, and to the illicit practice to which that
traJffic serves everywhere as a cloak. What has been
done in Australia and Germany can be done in these
islands, and it will be done so soon as the profession
unites to carry the matter through with unflinching
courage and determination. H. S.

CONGENITAL ANOMALIES OF THE EYE.

To the Editor of The Medical Press and Circular.

Sir,—M r. J. Herbert Parsons must allow me to thank
him for his courteous correction. What he said in his
recent and admirable work on “ Diseases of the Eye ”
was clear enough. But, unfortunately, some imp of
mischief not wholly unconnected with the printer’s
office changed the “neuritis,” as I originally passed
the word, into the “pseudo-neuritis,” as actually
printed in the columns of The Medical Press and I
Circular. I am glad to find that so competent an
authority as Mr. Parsons is in accord with me in
thinking that probably the optic disc is never abnor¬
mally swollen in pseudo-neuritis. Although it often
appears to be so, I have never satisfied myself that
such is actually the case.

I am, Sir, yours truly,

Sydney Stephenson.

33 Welbeck Street, W., October 13th, 1907.

AN APOLOGY.

To the Editor of The Medical Press and Circular.

Sir, —I write to you to say that, through no fault
of mine, a sensational account of a lecture by me has
appeared in the general Press. I see to-day extracts
from it put together as if it had been an interview.

I cannot describe how profoundly sorry I am that
this discreditable sensation has occurred, and wish to
tender my humblest apologies through your medium to
all members of my profession. I may hold singular
individual views, but I have no desire to ventilate
medical matters through the lay Press.

I am, Sir, yours truly,

Bernard Hollander.

35a Welbeck Street, Cavendish Square, W.,
October 10th, 1907.

[Of course, we publish Dr. Hollander’s disclaimer,
but we think it should be possible to prevent the pub¬
licity which his lectures obtain. As in at least one
lay paper a photograph of Dr. Hollander appeared,
it would seem that his friends are particularly apt to
compromise him in the eyes of his colleagues.— Ed.]

OBITUARY.

E. A. WRIGHT, M.D.Edin., of Huddersfield.

We regret to announce the death of Dr. Edward
Arthur Wright, formerly of Huddersfield, which took
place last week at Clevedon, Somerset. He had
suffered from a painful malady, for which he under¬
went an operation about a week before. The deceased,
who was 58 years of age, was the son of a Cheltenham
clergyman. Entering upon a medical career, he became
M.B. and C.M. of Edinburgh. In 1875 he was ap¬
pointed assistant house surgeon at Huddersfield In¬
firmary. After holding that position for about two
years, he commenced practice for himself, and in 1892
he was appointed one of the honorary surgeons at the
Infirmary, and continued in that position until
April 10th, 1905, when he resigned in consequence of
ill-health, arising partly from injury received in a
trap accident, but mainly from successive attacks of
influenza. In consideration of those services, on
July 28th, 1905, he was appointed honorary consulting
surgeon to the Infirmary.

GEORGE FREDERICK ELLIOTT, B.A., M.D.,
F.R.C.P.

Much regret will be felt at the death of Dr. George
Frederick Elliott, one of the highest esteemed mem¬
bers of the medical profession in Hull. The deceased
gentleman, who had attained the ripe age of 73 years,
died on the 6th inst. The late Dr. Elliott was the
second son of Mr. William Elliott, of Strabane,
County Tyrone, who was a member of the younger
branch of the Elliotts of Cavan. An ancestral head
of this family, Sir John Elliott, settled in Cavan, and
was created a baron at the time of the Ulster rebellion
in 1604. The deceased held the degrees of M.D.
(Dublin), F.R.C.P. (England), and B.A. (Oxford).
Upon qualifying as a physician he entered the Royal
Navy, being attached to the medical staff of the first
branch of the Imperial forces for eight years. Sub¬
sequently deceased held appointments at the Haslar
Hospital and at the Melville Marine Hospital,
Chatham. About forty years ago he came to Hull,
where he rapidly acquired a practice of no ordinary
proportions, for it extended into Lincolnshire. He
was appointed physician to the Hull General Infirmary,
as it was then called, in 1867, and, at the same time,
lecturer on medicine at the Hull Medical School. When
the present Convalescent Home at Withernsea was
opened by Sir James Reckitt, Bart., he was appointed
consulting physician. The late Dr. Elliott took no
part in public life, being of a very retiring disposition.
Deceased leaves a wife, one daughter, and four sons.

The following letter, addressed to the Irish Inde¬
pendent, may be of interest to our Irish readers:—
SIX BROTHERS DOCTORS.

Sir,—I t would appear from your issue of yesterday
that the Earl of Kilmorey, when distributing the prizes
at the opening of the medical school at Charing Cross
Hospital, felt surprised at learning that there are at
present five brothers doctors. I daresay his lordship
will be more surprised to hear that the late Dr.
Macnamara had the pleasure of living to see six of his
sons doctors, all making their mark:—Dr. G. M.
Macnamara, who represents his father ; Colonel John
Macnamara, I.M.C. ; Colonel William Macnamara,
hM.C.; Major M. Macnamara, I.M.C. ; Major Robert
Macnamara, I.M.C., who was appointed lately In¬
spector of Prisons out in India, and though last, not
least, Dr. Joseph Macnamara, who has a very extensive
practice in London. They are a credit to their name
and country.

John Kerin.

Corofin, County Clare, Oct. 3rd, 1907.

The twentieth Congress of the French Surgical Asso¬
ciation was opened in the great amphitheatre of the
acuity of Medicine in Paris on the 7th inst. The
qnestion for discussion was the influence of Rontgen
* a ys on malignant tumours. Many well-known sur¬
geons were present and took part in the discussion.

HENRY STOLTERFOTH, M.A. Camb., M.D. Edin.

We regret to record the death of Dr. Henry Stolter-
foth, which took place at Grey Friars, Chester, on
October 4th, after a protracted illness. The deceased
gentleman was a victim of that insidious disease,
cancer, and had been constantly attended by Dr.
Taylor. By his death Chester has lost one of its
most useful and genial public men. Dr. Stolterfoth
was educated at the King’s School, Cambridge, and
entered Gonville and Caius College, Cambridge, in
1856. He took honours (sen. opt.) in mathematics in
1859, and gained his M.A. degree in 1863. In 1868 he
graduated M.D. at Edinburgh, and was awarded a
bronze medal for chemistry. He then settled in
practice at Chester, and took great interest in public
affairs. In November, 1892, he was unanimously
elected Sheriff, and six years later was installed in the
mayoral chair in recognition of his public services.
During his year of office the question of the amalga¬
mation of Hoole with Chester engaged the attention of
the City Council, and the Isolation Hospital at Sea-
land was opened. As a medical man and member of
the Public Health Committee, Dr. Stolterfoth took a
keen interest in the consummation of the latter scheme.
He was connected with the Infectious Hospital at the
Infirmary ever since its erection—a hospital which, he
once said, had been of incomparable use to the city.
In 1891 Dr. Stolterfoth was elevated to the magisterial
I bench, and in 1900 his colleagues on the Town Council

Digitized by GoOgle

424 The Medical Pkess.

SPECIAL ARTICLES.

Oct. 16, 1907.

conferred upon him the rank of Alderman. The
deceased gentleman was one of the first to come in
contact with the Rev. Charles Kingsley in connection
with the formation of the Chester Society of Natural
Science in 1871. He was a Liberal in politics and
regularly appeared on the party platform, but there
was no element of party bitterness in his nature, and
he was highly respected both by political friends and
opponents alike. He was seventy-one years of age,
and leaves a widow but no family.

SPECIAL ARTICLES.

THE TUBERCULOSIS EXHIBITION IN
DUBLIN.

The Tuberculosis Exhibition, which has been
organised in Dublin by the Women’s National Health
Association, under the presidency of Her Excellency
the Countess of Aberdeen, was opened last Saturday
by His Excellency the Lord Lieutenant of Ireland,
among the others taking part in the ceremony being the
Chief Secretary (Mr. Birrell, M.P.) and Professor
Osier. In declaring the Exhibition open, His Excel¬
lency read the following telegram from His Majesty
the King :—“ I am commanded by the King to express
his good wishes for the success of the Tuberculosis
Exhibition, the first of the kind ever held in Great
Britain and Ireland, on the occasion of its being opened
by you. His Majesty is greatly interested in the
problem of checking the progress of this disease, and
he trusts the Exhibition may be the means of directing
attention of the public to the terrible ravages caused
by this scourge and to the efforts that are now being
made to arrest its progress.”

Prior to the opening of the Exhibition the Con¬
sultative Committee had met in conference, and ex¬
pressed warm approval of the arrangements made by
the Executive Committee, while on the previous
evening Professor Osier, M.D., had delivered an intro¬
ductory lecture in the theatre of the Royal Dublin
Society on the subject, “ What the public can do in the
fight against tuberculosis.” Dr. Osier referred to the
victories that had been won by sanitary service in the
case of typhus, of malaria, and of typhoid fever, and
held out hope for similar results in the case of
tubercle. He said that the ground was prepared for
tubercle by three bad habits, bad food, bad air, bad
drink. He urged as practical measures the re¬
organisation of the public health service, compulsory
notification of the disease, better housing of the poor,
the erection of cheap sanatoria, and care of cases at
home by district nurses.

In the Exhibition the exhibits are divided into four
sections, the first, which supplies statistics showing the
rate of mortality resulting from tuberculosis in
different countries, being in charge of the Registrar-
General. Diagrams are exhibited in this section illus¬
trating the position which Ireland occupies among
different countries with respect to the disease. Some
of these diagrams show that, as compared with
England and Scotland, Ireland’s position is most un¬
satisfactory and discouraging. Thus, it is shown that
whereas the death-rate from tubercle has diminished by
nearly a half in England and Scotland during the past
forty years, in Ireland it has shown a slight increase.
Moreover, in Ireland the age incidence shows that the
disease is most fatal in early adult life, the most pro¬
ductive period from an industrial point of view. The
deaths from tuberculosis in Ireland in 1906 amounted
to 11,756, a figure much in excess of the gross number
of cases of mortality resulting from any other disease
in that year. Of every hundred deaths from tubercle
seventy-six were caused by phthisis. Statistics show
that Ireland holds fourth place with regard to this
disease among the British possessions and foreign
countries. Maps specially coloured to throw into relief
the parts of Ireland where tuberculosis is most
prevalent show that the cities and urban districts are
the most affected. No less interesting is the second
section, devoted to pathology, human and veterinary.
The exhibits in the first branch have been collected by
Professor M'YVeeney, the greatest pathological or

bacteriological expert in Ireland ; and in the Veterinary
Branch the exhibits are provided by the Royal College
of Veterinary Surgeons of Ireland. In this are shown
models prepared by Dr. Bermingham, of Westport,
illustrating tubercle bacilli in the human sputum,
when stained with aniline dyes and strongly magnified.
These models are extremely beautiful for demonstration

P urposes, and will naturally attract much attention.

hey are an excellent representation of the appearance
of the field of a microscope when examining a well-
stained specimen of tubercular sputum. In this section
are also shown slices of tubercular organs, both human
and bovine, together with cultures of the tubercle
bacillus.

The Appliances Section consists of a display of
spitting cups, handkerchiefs, etc. A novel feature is
the display of turf sods, hollowed out to act as spit¬
toons, which can be burned after use. The idea is an
excellent one.

Outside there are sleeping bungalows (models), or
chilets, designed by Messrs. Kennan and Sons, and
also by the contractors for the building of the Ex¬
hibition. There is also a sanatorium in the grounds.
In the village hospital there is a screen, designed by
Messrs. Smith and Sheppard, Dublin, to protect the
body of a consumptive patient when the head is below
the open window and to receive the pure air. The
screen is quite an ingenious thing, for, while it pro¬
vides that the body of the patient may be kept quite
warm, the head and face may be exposed to the sun
and air.

The Literary Section, under the control of Dr. Alfred
Boyd, is of the utmost importance, particularly to mem¬
bers of public health authorities, and to medical officers
of health, since it shows what has been done by muni¬
cipal authorities elsewhere in the campaign again>t
tuberculosis. Most notable is the exhibit from the
borough of Northampton, where, under the executive
control of Dr. Jamas Beatty, the death rate from
hthisis has been reduced to the extraordinarily low
gure of 0.87 per 1,000. There are also tables which
deal with the question of infection, segregation, and
treatment of consumption, while the relations existing
between overcrowding and mortality in the London
district are shown by a series of diagrams constructed
by Sir Shirley Murphy, Medical Officer of Health to
the London County Council. Large diagrams, pro¬
cured by the Public Health Department of Birming¬
ham, show the industrial occupations in the death-rate
from consumption. In that city, and in Sheffield, the
system of compulsory notification—it is voluntary
everywhere else, these cities having got special Parlia¬
mentary powers to enforce compulsory notification—is
dealt with. In Manchester the system of milk inspec¬
tion, as regards city dairies and milk arriving from
the country, is shown by a selection of forms. There
are also exhibits from Dublin, Belfast, Edinburgh,
Bristol, Glasgow, Liverpool, Cardiff, Brighton, and
New York. A number of popular pamphlets dealing
with tuberculosis are shown, and an interesting feature
to those caring for the history of the subject is the
valuable collection of medical works lent by Dr. Kirk¬
patrick.

In the Domestic Section, arranged by Dr. Ella
Ovenden and Dr. Lily Baker, are exhibits of milk
sterilisers, etc., while demonstrations on invalid cookery
are being given each day.

A series of popular lectures is also being given daily,
among the lecturers this week being the Registrar-
General, Dr. Bermingham, Mr. LintargiD, and Pro¬
fessor Lindsay.

The whole exhibition reflects credit on the Executive
Committee, and particularly on the honorary secre¬
taries, Mrs. Rushton and Dr. Alfred Boyd.

THE LONDON MEDICAL EXHIBITION.

The third of the series of Medical Exhibitions,
organised by the British and Colonial Druggist , has
achieved a no less signal success than that of its pre¬
decessors. From the day of its opening, on October
7th, to the last hour of its existence, on October the
nth, it was a centre of attraction for a constant
succession of medical practitioners. The excellence
of the general organisation was well supported by

Google

REVIEWS OF BOOKS. Thb Medical Press. 4 2 5

Oct, i 1907.

the variety and novelty of the numerous exhibits,
which included drugs, foods, instruments, invalid
furniture, and a heterogeneous collection of things
interesting to those engaged in medical practice. In
the present notice it will be possible to mention only a
few of the most important exhibits. So far as genuine
novelty is concerned the first place may perhaps be
allotted to novocain, introduced by the Saccharin Cor¬
poration. It need hardly be remarked that the special
interest attached to this drug is due to its superiority
over cocaine as a non-irritant and non-toxic local
anesthetic. The most important application, how¬
ever, is in the production of spinal analgesia, which
bids fair to revolutionise the field of general
anesthesia for surgical purposes. The adjoining stall
of Meister Lucius and Bruening contained a number
of interesting synthetical and other products, such as
lumenol-ammonium {an antiseptic), holocain, ortho-
form (local anesthetic), and various tuberculins.
Messrs. Brand, as befits a firm of their reputation, had
a stand excellently equipped with invalid soups,
jellies, peptonised foods, and other preparations of the
kind. The International Plasmon Company showed a
series of their well-known products. Cadbury Bros,
were well represented, and the Angier Chemical Com¬
pany were well in evidence with their famous
emulsion, to which they have added a throat tablet.
Mr. George Back held a popular stall, in which he exhi¬
bited samples of his famous diabetes whisky. A pro¬
minent feature was Messrs. Bailliire, Tindall and Cox’s
books, which occupied a commanding position in the
hall; amongst other well-known volumes we noticed
Stewart’s “ Physiology,” Jellett’s “ Midwifery,”
Macnaughton-Jones’ “ Diseases of Women,” Rose and
Carless’ “ Surgery,” and Walsh’s Rontgen Rays.” The
Equipoise Company showed their most ingenious
and handy couches and beds, which are so contrived
as to adapt themselves automatically to the movements
of a patient’s body; they have only to be seen to be
appreciated. Messrs. Fairchild and Co. had a striking
exhibit of their famous digestive products, including
the original trypsin preparations, about which so
much has been heard in the treatment of cancer.
Messrs. Knoll and Co. showed samples of their fine
chemicals, notably styptol (for uterine haemorrhage),
santyl (a non-irritating santal preparation), and the
well-known diuretin. Messrs. Armour and Co. had
an elegantly arranged stall; their pepsin and other
digestive products were shown, together with various
suprarenalin, red marrow, cerebrin, and other organic
drug products, including notably one of thyroid
elixir. Messrs. Christy and Co. had a large and well-
filled stall: amongst its many attractions was the
novelty “Anasarcin,” which is claimed to have an
excelling virtue in cases of dropsy: this firm also
shows a convenient and cheap electric lamp fitted with
mirrors for throat work. Their glyco-thymoline is too
well-known to need more than passing mention.

Messrs. Ingram and Royle showed specimens of the
numerous spa and other waters of which they are pro¬
prietors or agents. Possibly one of the best stalls in
the Exhibition was that of Parke, Davis and Co.,
which it would be hard to beat for the variety, novelty,
and excellence of its exhibits. Space does not permit
us to do more than mention the typhoid agglutino-
meter, a cheap and handy method of performing the
Widal test without a microscope. Their germicide soap
is excellent, and their digitalone, formidine, iodalbin
and petroleum emulsion are deserving of close attention.

Jeyes’ Sanitary Compounds Company had all their
excellent preparations of cyllin, one of the best
modern disinfectants and germicides, well arranged on
a handsome stall. Zimmermann showed such special¬
ties as urotropin, Beta eucain, argentamine, iodol,
and orexin. Messrs. Merck had a number of valuable
pharmaceutical preparations, including iodopin,
dionin, styptican, and veronal. Messrs. Nestis and
Co. showed their Milo food, which is modified by the
omission of starch from their former preparation.
They also have a most excellent product issued under
the name of “Ideal milk in bottles.” Messrs.
Peek, Frean and Co. exhibited their new and admirable
Tillia biscuits. Messrs. Allen and Hanbury had a
peculiarly attractive display of instruments and appli¬
ances, amongst which may be noted the pocket urine

testing cases, and a good syringe for novocain. The
Miol Company exhibited their particular product,
which is a good combination of cod-liver oil and malt;
Bovril lozenges, essences, and invalid Bovril were well
represented, as well as their hardly less important
preparation Virol. Wright’s Coal Tar Soap, a household
word in medicine, was well displayed. Messrs.
Martindale had a very large collection of drugs, pre¬
parations, appliances, and instruments, many of them
of a novel and interesting kind. Their list was headed
by their world-famed “ Extra Pharmacopoeia.” Fried-
richshall water was of course on show, as one of the
oldest and most popular of its class. The Charles H.
Phillips Co. showed their well-known milk of magnesia
and phospho-muriate of quinine compound. Anti-
phlogistine was well to the front in the stall of its
enterprising proprietors, the Denver Chemical Co.
Lastly, Defries and Sons showed the Pasteur and other
modern filters, as well as some good disinfectors.
On the whole the Exhibition may be regarded as a
convenient means of acquiring a good deal of liberal
education in many practical medical matters.

REVIEWS OF BOOKS.

DERMATOLOGY, (a)

This volume includes some thousand pages of
crown octavo size, illustrated by numerous excellent
photographic reproductions. It forms one of the most
serious American contributions to dermatology that
we have seen for some years. On every page it bears
the stamp of scholarly handling and of wide informa¬
tion and practical knowledge. The anatomy and
physiology of the skin, and the principles of its general
etiology, pathology, symptomatology, and treatment
are somewhat fully dealt with. In speaking of the
drug rashes the author remarks that:—“ If these
various rashes can be produced by drugs, it is not
difficult to conceive of analogous eruptions resulting
f-rom other toxic substances.” That view was ad¬
vanced by Walsh in this country at least fifteen years
ago under the name of “Excretory Irritation.” Dr.
Pusey has also advanced that writer’s illustration of the
finding of bromine and iodine in corresponding
rashes and other views. The account of urticaria is
adequate, yet concise, and the author justly states that
diagnosis of the condition is the smallest part of the
problem, the chief difficulty being the determination
of the causative factor. In the discussion of alopecia
areata and universalis, curiously enough we find no
allusion to the relation of that condition with
myxoedema and Graves’ disease. In the brief space
at command, however, it is clearly impossible to take
more than a general survey of so great a mass of care¬
fully collated and edited matter. We may therefore
say that in our opinion this book will be found of
value to all who wish special information in diseases
of the skin. It is written in a clear and pleasing style,
and is thoroughly well edited. A last reference may
be made to the 368 illustrations, which are among the
best of the kind we remember to have seen in any
work upon dermatology

DISEASES OF THE LARYNX. (l>)

This short work is worthy of commendation, as it
is one which can be placed in the hands of senior
students and members of post-graduate classes. The
arrangement is excellent and the drawings are good,
and as the author in the prefaoe says, “the intention
has been to picture the more typical appearances as
an aid to their recognition and diagnosis.” The
illustrations of instruments are useful, as those in
everyday use are portrayed, not as is so often the case
those of a byegone generation. A short but good
account of the newer methods of examination such as
“ Bronchoscopy ” is introduced, and the description
of the commoner operations are lucid.

(a) “ The Principles sod Practice of Dermatology." By Wm. Allen
Pusey, A.M , M.D., Professor of Dermatology In the Unlrerslty of
Illinois, etc. London: Sydney Appleton. 1907. 25s.net.

(6.) “ Dlseasesof the Larynx.” By Harold Harwell, M.B., P R.C.8.
London: Henry Frowde and Hodder and Stoughton.

426 The Medical Press.

Oct. 16, 1907.

WEEKLY SUMMARY.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for The Medical Press ahd Circular.

RECENT SURGICAL LITERATURE.

Post*Operative Results of Prostatectomy. —F. Cabot
gives a series of 62 cases, with four deaths (Post¬
graduate, September, 1907), from his experience of the
operation of prostatectomy. He advises: 1. Never
remove a prostate if there is any question of the
patient’s fitness to resist the shock ; do a preliminary
drainage, suprapubic, and await developments. 2.
Employ local anaesthesia for the preliminary cystotomy
when possible. 3. Never use ether for prostatic
enucleation. 4. Be sure the bladder is completely
drained after the operation, and that the patient leaves
his bed in a day or two for his meals. 5. Choice of
method: perineal route in 20 per cent.; suprapubic at
one sitting 40 per cent. ; Lilienthal’s interval operation,
40 per cent. 6. Perineal route suitable for simple un¬
complicated prostatic hypertrophy (when small). 7.
Suprapubic route in all severe, complicated cases, and
in about one-half of these cases the two stage methods
of Lilienthal should be employed. 8. Cystoscopy is
of value, but prolonged efforts to use it should not be
employed. G.

Congenital Stenosis of the Pylorus. —H. Sheffield
(Postgraduate, August, 1907).—Stenosis of the pyloric
end of the stomach may be complete or partial. In
the first case death is only a matter of hours; in the
second, the child may live, and, if suitably treated,
recover. While complete atresia is very rare, and
almost never diagnosed until a post-mortem examina¬
tion reveals the condition, a partial stenosis is by no
means uncommon. The true stenosis is invariably
due to a congenital narrowing of the lumen of the
pylorus, and is associated with more or less hyper¬
trophy of the pyloric ring. False or spastic pyloric
stenosis is the result of congenital faulty inervation of
the stomach, or of acquired digestive and nervous dis¬
turbance. It is free from primary hypertrophy of the
pyloric ring. Sooner or later secondary hypertrophy
of the muscular and mucous coats of the stomach
occurs in consequence of the increased force required
by the stomach to expel its contents. The symptoms,
as a rule, are definite. After a period of from one to
three weeks’ good health, the infant begins to vomit;
this vomiting increases in severity ; the amount of food
brought back often appears greater than the child had
swallowed, and is free fiom bile. There is pseudo¬
constipation, with scanty concentrated urine. The
child appears to be nearly always hungry, but after a
few mouthfuls of food is seized with colicky pains
and refuses its bottle, only to grasp it again when
some relief prevails. The abdomen is sunken in below,
while the epigastrium is distended. In some cases the
hypertrophied pylorus may be palpated as a distinct
tumour. In the cases of false or spastic stenosis, the
symptoms are much the same, but are not so marked.
This form of disease may, and often does, yield to
medical treatment, the true stenosis, on the other hand,
being always fatal unless treated surgically. The
author believes, in all cases of congenital pyloric
stenosis, if after two weeks’ faithful but unsuccessful
trial of dietetic and medicinal treatment, an operation
should be recommended in bottle-fed children pre¬
senting the usual symptoms of pyloric stenosis, plus
pyloric tumour. In breast-fed infants presenting the
usual symptoms of pyloric stenosis, even if there be
no palpable pyloric tumour present, the choice
between divulsion, pyloroplasty, and gastro-enteros-
tomy depends upon the pathological condition of each
individual case. G.

Primary Cancer ef the Appendix —Hartmann ( Bulletin
de Chir., No. 8, 1907) reports two cases of carcinoma
of the- appendix, occurring in a series of 50 cases
examined for carcinoma, and mentions 40 other cases
of this disease which have been recorded during the

past three years. It seems most probable that car¬
cinoma is a far more common affection of the appendix
than is generally supposed. The growth is usually
very small, and readily escapes notice in the inflamed
appendix unless most careful microscopic search is
made. The cancerous growth in most cases involved
an obliterated part of the appendix. In most of the
cases the growth has been an adeno-carcinoma, and
developed mainly between the ages of twenty and
thirty years. The prognosis of the disease is uncer¬
tain, but cases are recorded in which no return of the
disease had taken place four years after the removal
of the cancerous appendix. G.

Important Change in the Blood and Urine in Appen¬
dicitis. —A. Pisani (Postgraduate, September, 1907) gives
a number of cases of appendicitis in which a careful
examination of the blood and urine had been carried
out. From these he draws the following conclusions:
The necessity for cleansing the intestinal canal by
cathartics, thereby eliminating all causes which tend
to produce any toxins due to putrefactive fermentation
of the food-stuffs. (2) Abstaining from administering
opiates or narcotics to relieve the pain, which mask
the symptoms and cause constipation. (3) The obtain¬
ing of a thorough and accurate blood count, so as to
arrive at a diagnosis whether pus formation exists, or
especially obtaining a radionuclear count of the leuco¬
cytes so as to be able to form some opinion as to
prognosis. (4) Frequent urine analyses, testing especi¬
ally for indican, which would tend to show that putre¬
factive processes exist in the human economy, and that
the disappearance of the same after operation proves
progress of the patient. <5) The total daily output of
urea should be determined daily in all inflammatory
and suppurative processes, to see whether resolution is
taking place, and the rapidity of the resolution, and
when and how rapidly the repair is being effected.

A New Operation lor Mobile Kidney. —Stanmore
Bishop (Brit. Med. Journ., October 5th, 1907) reaches
the kidney through the anterior abdominal wall. The
peritoneum is divided transversely over its lower pole,
and the true capsule of the kidney is also split across
just below the renal pelvis. The capsule is then
stripped inwards and downwards from the kidney,
still, however, remaining attached internally and pos¬
teriorly. The divided edges of the peritoneum are re¬
united. A long silk thread, armed at each end by a
long straight needle, is then taken. One of these
needles is inserted in an antero-posterior direction
immediately below the lower edge of Ihe renal pelvis,
passing through the peritoneum, reflected capsules,
and muscles of the back, and emerging through the
skin behind. The second needle is in like manner
passed at the inner border of the kidnev 1 to ij cm.
lower down. Three or four similar stitches are passed
around and below the kidney in the same way. Each
pair of threads forming a loop is then drawn up
firmly and tied in a groove formed by the division of
the skin between them, so becoming buried. The tying
of the loops draws the incisions between the needles
into a point, so that no suturing of the skin is re¬
quired. The abdomen is then closed. The author has
performed this operation in 10 cases. The first two
relapsed, as a grip of the kidney capsule was not taken
by the stitches. S.

Fracture of the Neck ef the Femur: A New Treat¬
ment. —Gallie (Canada Lancet, September, 1907) says
that the clinical efficiency of the method of treatment
detailed below has been corroborated by observations
made on eight cadavers. The procedure is as follows:
The patient is anaesthetised and elevated on a pelvic

Oct. 16, 1907.

MEDICAL NEWS IX BRIEF.

T he Medical Press. 4 2 7

rest, which does not interfere with the bandages as
they are applied. The surgeon stands beside the
injured hip. If the fracture is impacted, an assistant
forcibly abducts the limb under moderate traction,
breaking down the impaction and only stopping when
an angle of 50 degrees from the normal has been
reached. The surgeon maintains a downward pressure
on the trochanter with the palm of the hand, and
gently lifts it forward, and rotates the limb slightly
inwards. No attempt is made to elicit crepitus. If
the fracture be complete and unimpacted, the assistant
first overcomes all shortening by strong traction,
counter traction being provided by a towel against the
perineum. He then abducts the limb in the same way.
When the surgeon is satisfied with the results of the
manipulations, the bony points are padded, a plaster
spica is applied from the toes to the mammary line.
The plaster is well moulded in by the side of the
pelvis and trochanter, so that displacement may be
rendered impossible. After some days an X-ray photo¬
graph should be taken through the plaster. The best
time for the application of the treatment is imme¬
diately after the injury, unless lacerated tissues require
preliminary treatment. At the end of four weeks the
piaster case may be shortened to allow free movement
of the knee, and may be completely removed in eight
weeks. After this the best routine plan is to use a
light short plaster spica, holding the limb in moderate
abduction. At first the patient uses crutches, and then
.gradually resumes weight-bearing. This plan of treat¬
ment is recommended for all fractures of the neck of
the femur occurring in the young and in adults up to
55 years of age. S.

The Treatment of Weak or Flat Foot.— Whitman
(Med. Record , August 31st, 1907) says that the influence
of modified shoes (raised on the inner side), attention
to posture, and the cultivation of muscular strength
may be quite sufficient to cure milder cases of the
above disability, if the co-operation of an intelligent
patient is assured. Exercises are most important. As
the adductors of the foot have been weakened by in¬
activity, the patient is instructed to invert the foot
voluntarily over and over again. The following exer¬
cise is most important: The patient stands erect,
markedly toeing in, with the weight thrown on the
outer borders of the feet. The body is then raised
on tiptoe with the full extension of the limbs ; then it
is allowed to sink slowly back, the feet during the
descent being gradually inverted, reaching finally the
extreme limit when weight is borne. In most cases,
however, the tendency towards deformity has advanced
so far that it cannot be controlled by the patient, and
a brace is usually an indispensable adjunct in treat¬
ment. Whitman’s brace is made as follows : A plaster
mould of the foot, slightly adducted, is first made.
On the cast from this the brace is fitted. Its inner
margin rises above the astragalo-navicular joint. The
outer side covers the anterior two-thirds of the os calcis
and the cuboid bones, enclosing this joint. The sole part
of the brace extends from the bearing surface of the
heel to the bearing surface of the first metatarsal bone.
The front and outer two-thirds of the sole are not
supported unless there is breaking down of the meta¬
tarsal arch. The author considers that a brace should
not be an agent to supplant developmental treatment,
but one that, by enforcing normal posture, makes such
treatment effective. S.

Skin Grafting by a Modification of the Wolfe-Krause
<Whoie Thickness of the Skin) Method— Young (Glasgow
Med. Journ., October, 1907) describes eleven cases
demonstrating the excellent results obtained in his
modification of the above method of skin grafting.
The grafts are made expeditiously by cutting straight
down to the aponeurotic covering of the muscles. The
whole flap is removed and placed in warm saline. The
fresh wound is forthwith closed completely by suture
and dressed with aseptic care. The surface to be
grafted is now uncovered. If it is a fresh operation
wound, the only preliminary to the application of the
graft or grafts is the thorough checking of haemor¬
rhage. If asepsis of the wounds is not practicable, as
in burns, all necrotic tissue and exuberant granulation
should be removed some days before, and the surface

of the ulcer should be smooth and of a healthy rose-
pink colour. Contrary to the teaching of Thiersch, it
is unnecessary, and probably a disadvantage, to remove
the superficial layers of a granulating surface. The
flap of skin and fat is now placed on the palm of the
hand, and the fat is readily and quickly removed by
cutting it away with a scissors curved on the flat. If
the surface to be covered is large, the flap is divided
into a number of pieces. The wound, when the grafts
have been applied, should be covered with oil-silk or
gutta-percha tissue suitably perforated. This pro¬
tection is not interfered with for several days. The
moist saline dressing outside the protection should be
changed daily. The author calls special attention to
the case of a woman, aet. 70, in whom, although she
was in a practically moribund condition, the grafts
lived and grew peripherally. Microscopic section of
the grafts (obtained post-mortem eight days later)
strikingly demonstrated the greater activity in initial
extension of the stratum lucid um as compared with the
rest of the superficial layers of the skin. S.

The Production of a Filtering Cicatrix in Chronic
Glaucoma. —Felix Lagrange (The Ophthalmoscope,

September, 1907) has devised the following operation
for producing a filtering cicatrix without producing an
entanglement of the iris. Eserine is instilled half an
hour before operation to facilitate the passage of the
knife, and to keep the iris away from the wound. After
cocaine and adrenalin have been well instilled, the
sclera is punctured 1 m.m. from the limbus, and the
counter puncture is made at a corresponding point.
The sclera is divided in the irido-corneal angle. In
finishing the incision, the cutting edge of the blade is
directed backwards, so that the sclera is bevelled “ like
the mouthpiece of a flute,” and a large conjunctival
flap formed. Without injuring the conjunctival flap,
a piece of the exterior lip of the incision is resected
with very sharp, specially made curved scissors.
The iridectomy is now performed in the ordinary way,
i and the conjunctival flap used to cover the wound.
Lagrange has published 27 cases treated by this opera¬
tion, which have been watched for periods exceeding
six months. Of these, four were not followed, and
three remained without result, because he failed to
obtain a filtering cicatrix on account of excising too
small a piece of the sclera. The remaining 20 cases
were good results—the vision having been improved in
twelve and maintained in eight. M.

Medical News in Brief.

Rtyil College of Surgeons of England.

At a quarterly meeting of the Council, held on
Thursday last, Mr. Henry Morris, president, was
elected to give evidence on behalf of the College be¬
fore the Committee which has been appointed by the
Home Secretary on the subject of the “ London
Ambulance Service.” Mr. H. H. Clutton was elected
a member of the Executive Committee of the
u Imperial Cancer Research Fund,” in place of Sir
John Tweedy, retired, and Mr. Edmund Owen was re¬
elected a member of the same Committee. Mr. L. A.
Dunn, surgeon to Guy’s Hospital, was introduced,
and, having made the required declaration, was ad¬
mitted a member of the Court of Examiners.

The Secretary reported the death of Mr. Timothy
Holmes, and lhe Council passed a vote of condolence
to his widow, at the same time placing on record
their appreciation of the services rendered by Mr.
Holmes to the College in the conscientious discharge
of the several duties which for many years had de¬
volved upon him. The Council also expressed their
deep regret at the death of Professor Charles Stewart,
and their sincere sympathy with his widow and family
in their bereavement. The Council further expressed
their sense of the great advantages which the College
had derived from Professor Stewart’s rare knowledge
of all branches of science represented in the Museum,
and recorded their appreciation of the zeal and ability
which he displayed in performing the duties of Con¬
servator of the Museum during the past 23 years.

Digitized by GoOgle

428 The Medical Pees*.

MEDICAL NEWS IN BRIEF.

Oct. 16, 1907.

The following candidates were admitted Members of
the College: R. Jamison, M.A., St. Bart.’s; R. J. P.
McCulloch, Toronto and Lond. Hosp. ; C. H. Mont¬
gomery, Toronto; D. G. Pearson, Cambridge and St.
Bart.’s; and A. J. Turner, Durh. Univ. and London
Hosp. The president reported that he attended the
centenary celebrations of the Geo'ogical Society of
London as the representative of the College, and had
presented an address of congratulation on behalf of
the Council. The report to be presented to the
Fellows and Members at the annual meeting, which
is to be held at the College on Thursday, November
aist, was considered and adopted.

Death* under Anaesthesia.

A verdict of death by misadventure was returned
on the 14th inst. by a coroner’s jury in the case of a
married woman, 29 years of age, who died at Guy’s
Hospital on October 3rd, whilst undergoing an opera¬
tion (tying the inferior thyroid arteries) for exoph¬
thalmic goitre. Chloroform was administered by the
house surgeon, and ten minutes after inhalation com¬
menced the patient turned colour and died, directly
after the surgeon, Mr. C. J. Symonds, had made his
incision. The heat was somewhat dilated and fatty.
Both the surgeon and the house surgeon admitted that
the case was one of recognised anaesthetic danger. The
Coroner of the City of London, Dr. Waldo, pointed
out that, in spite of that fact, the chloroform was
entrusted to the house surgeon, who had administered
anaesthetics in 98 cases only, instead of to one of the
eight anesthetists attached to the hospital. The ques¬
tion raised was one of system. Whilst recognising the
necessity of medical men being trained in the adminis¬
tration of anesthetics, he maintained that all cases of
known gravity should be entrusted only to anesthetists
of long experience. The jury found that the chloro¬
form was administered with reasonable skill, consider¬
ing the limited experience of the administrator. They
appended a rider recommending that in future opera¬
tive cases of a serious nature anaesthetics should be
administered either by a staff administrator or under
his immediate supervision. They also recommended
that full statistical returns of all anaesthesia cases
should be kept at Guy’s Hospital.

(lraat Northern Central Hospital, London, N.

An attempt is being made at the hospital to utilise
the exceptionally large amount of clinical material
which is available for the purpose of teaching and
study. A course of clinical lectures has been
arranged, the second of which will be given on Friday,
October 18th, by Mr. Arthur Edmunds on “ Some
Practical Points in the Diagnosis and Treatment of
Appendicitis.” In addition to this, the wards and
out-patients’ department are open to students and prac¬
titioners of medicine, and demonstrations are given at
regular hours. The hospital contains 160 beds, a
double set of operating theatres, and accessory rooms,
and all the equipment of a first-grade modern hospital.
The opening of two new electric railways with stations
at Holloway Road and Highgate respectively has made
the hospital one of the most accessible in London ;
and this fact, combined with the abundance of
material for study, should make the hospital of much
more than local importance.

A Medical Motorist.

At Ongar, on October 5th, Dr. Butler Harris was
summoned for motoring at an excessive speed. The
police evidence was to the effect that defendant drove
his motor-car at 30 miles an hour. Defendant abso¬
lutely denied that he was going at 30 miles an hour,
because his car was incapable of doing it. On the dav
in question he attended a patient at Coopersdale, and
hearing that someone had been seriously injured at a
farm fire at Stanford Rivers he hurried forward, but
found that this was not so. He protested against
medical men being pilloried in this manner. This was
the fourth time within the last three years that he had
been before the Justices for motor driving, and only
on one occasion—when the case was dismissed—had
there been any allegations of reckless or inconsiderate
driving. If the police continued to pillory him in this
way it would make the continuance of his country
work almost an impossibility, because there was pro¬

bably no day upon which he did not go at the rate
of 23 or 24 miles an hour on some part of his journey.
He objected to the method of timing adopted by the
police. Drivers heard nothing of the matters until two
or three days had elapsed, and were therefore unable
to prepare a defence. The Chairman, Mr. Tyndale
White, said there was nothing in the Act to exempt
medical men, although, personally, he sympathised
with them, and wouldn’t mind them going 60 miles an
hour—he would only be too pleased. The Bench
much regretted having to fine defendant £3 and costs,
4s., but they had no alternative.

Supt. Laver said these motor traps were set in conse¬
quence of complaints, and the proceedings were taken
by order of the Chief Constable.

City Medical Officer’* BereaveoMata.

Mrs. Collingridge, the wife of Dr. Collingridge,
of Penrith, was found in her room dead from prussic
acid poisoning. Mrs. Collingridge had only been
married three months, and lately had apeared strange
in her manner. As she did not appear yesterday
morning her bedroom door was burst open, and Mrs.
Collingridge was found dead. A bottle that had con¬
tained prussic acid was by her side, death having
taken place several hours earlier.

Dr. Collingridge, who is the son of the medical
officer for the City of London, is at present in a
fever hospital, and Mrs. Collingridge, senior, died
suddenly at Morland only a fortnight ago. The lady
who was found dead yesterday was a daughter of
Professor Klein, of Twickenham, and had arranged
to meet her husband on his discharge from hospital
to-day, and travel south with him. When he went
into the hospital, suffering from scarlet fever, she
went to her home, but returned to Morland on Satur¬
day. On Monday and Wednesday she visited her
husband, and on Thursday evening she appeared to
be in good spirits. At the inquest the jury found a
verdict of “Suicide during temporary insanity.”

Royal Academy of Madldoe la Ireland.

At the annual stated meeting of the Royal Academy
of Medicine, held on the nth inst., the following
officers and Councils were elected for the coming
.year:—President, J. Magee Finny; General Secretary,
James Craig; Secretary for Foreign Correspondence,
Sir J. W. Moore.

Medical Section.—President, The President, R.C.P.
(Joseph M. Redmond); W. J. Dargan, H. C. Drury,
T. P. C. Kirkpatrick, J. A. Matson, T. G. Moorhead,
A. R. Parsons, G. Peacocke, F. C. Purser, W. J.
Thompson, W. A. Winter.

Surgical Section.—President, The President, R.C.S.
(Sir H. R. Swanzy); C. A. Ball, Alex. Blayney, Sir A.
Chance, G. J. Johnston, R. C. B. Maunsell, Seton
Pringle, J. B. Storey, E. H. Taylor, W. Taylor, W. I.
de C. Wheeler.

Obstetrical Section.—President, E. H. Tweedy; J. S.
Ashe, Paul Carton, Gibbon FitzGibbon, M. J. Gibson,
H. Jellett, F. W. Kidd, R. D. Purefoy, J. Spencer
Sheill, A. J. Smith, Sir W. J. Smyly.

Pathological Section.—President, A. R. Parsons;
H. C. Earl, L. G. Gunn, W. G. Harvey, H. C.
Mooney, T. G. Moorhead, J. F. O’Carroll, A. C.
O’Sullivan, J. A. Scott, A. H. White, J. T. Wigham.

Section of Anato ny and Physiology.—President,
A. F. Dixon, A. Fraser, H. M. Johnston, E. L’E.
Ledwich, E. P. M'Loughlin, W. H. Thompson.

Section of State Medicine.—President, W. R.
Dawson ; A. E. Boyd, T. P. C. Kirkpatrick, F. C.
Martley, J. A. Matson, G. S. R. Stritch, W. A. Winter.
Westminster Hospital.

Under the chairmanship of Mr. A. H. Tubby,
M.S., F.R.C.S., a highly successful annual dinner of
the Past and Present Students of the Westminster
Hospital took place at the Trocadero Restaurant on
Thursday, October 3rd. In proposing the toast of
“The Westminster Hospital and Medical School,” the
chairman pointed out the satisfactory working of the
arrangement made with King’s College for the teaching
of the preliminary subjects. In these days, when the
diminution in the numbers of medical students in
London compelled the larger hospitals to put forth
every effort to attract men, it became increasingly diffi-
I cult for the smaller schools to keep up their numbers.

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Oct . 16, 19 07.

PASS LISTS.

Tn r Medical Press. 429

The Dean, Mr. Paton, in his reply, urged upon all
Westminster men the necessity for individual effort in
support of the school. It was in the power of the old
students, much more than in that of the staff, to secure
new students. Dr. Allchin, in proposing the toast of
“ The Guests,” said the presence amongst them of Pro¬
fessor Halliburton and Professor Thompson was
eloquent of the happy relations now existing between
Westminster and King’s College. The health of the
“ Old Students ” was proposed by Dr. Hebb, and
acknowledged by Dr. Macnamara.

Meath Hospital, Dublin.

The opening meeting of the session at this hospital
was held on Wednesday last, when Dr. James Craig
delivered the inaugural address. The President of the
Royal College of Physicians presided, and the meeting
was addressed by, amongst others, the President of the
Royal College of Surgeons, Dr. J. M. Finny, Sir John
Moore, and the Provost of Trinity College. Dr. Craig,
whose address we hope to publish in a later issue, dealt
with “The Choice of a Medical Career and Medical
Ethics.”

The Treatment of Lunatic*.

At the meeting of the Hampstead Board of
Guardians on October 10th, a letter was read from the
Commissioners in Lunacy saying that they had seen in
“The Times” a report of the inquest on the body of a
man who died in the observation ward of the Hamp¬
stead Workhouse after having been there 17 hours,
seven of which were spent in a strait jacket, without
being seen by a doctor. The Commissioners presumed
that the guardians would hold an inquiry into the
circumstances, and they would be glad to be informed
of the decision at which the Guardians might arrive.
A letter was also read from Mr. Walter Schroder, the
deputy coroner, stating that at the inquest the jury
added a rider to their verdict to the effect that they
considered it very desirable that every patient should
be seen by the medical officer upon admission, or as
soon after as possible, and that in no case should a
strait jacket be applied without the authority of the
medical officer. Mr. Schroder added that he had also
sent a copy of the rider to the Local Government
Board. Mr. H. C. Russell, the master of the work-
house, said that after the inquest be instructed the
lunatic attendants to notify the medical officer imme¬
diately of the admission of any patient to the obser¬
vation ward. It was resolved to refer both communi¬
cations to a committee of the whole board for
consideration and report.

London County Connell Scholarship*.

The London County Council will be prepared to
award, in January, 1908, not more than six scholar¬
ships to students in midwifery. Candidates must be
between the ages of 24 and 40, and must be resident
within the County of London. The value of each
scholarship will be ^25, and the course of training
provided will extend over a period of six months.
Forms of application may be obtained not later than
Saturday, November 19th, from the Executive Officer,
L.C.C. Education Offices, Victoria Embankment,
W.C., from whom further information may also be
obtained.

PASS LISTS.

University of Glasgow.

The following candidates have passed the second
professional examination for the degrees of M.B. and
Ch.B. in the subjects indicated (A., Anatomy; P-,
Physiology ; M., Materia Medica and Therapeutics) :—
Archibald Aitchison (M.); William Shanks Alex¬
ander, M.A. (A., P.) ; John Allan (A., P., M.) ;
Andrew Clark Anderson (A.) ; James George Anderson
(A. P.) t William Anderson (A. P. M.) ; Edgar Barnes,
M.A. (A.) ; Arthur Munby Bayne (A. P.) ; Emile
Augustine Cameron Beard (P. M.) ; Douglas Morris
Borland (M.); John Adam Gib Burton (A. P.) ; James
Cairns (A., P., M.); John Allan Munro Cameron (A.,
P., M.) ; James Lang Cochrane (A., P., M.) ; David
Rutherford Cramb (A.); Charles Duguid, M.A. (M.) ;
Thomas Scoular Fleming (P. M.); George Fletcher,
M.A. (A.); Edward George Glover (M.) ; Robert
Dunlop Goldie (M.) ; Joseph Graham (M.); John
Granger (M.); John Gray (P. M.); William Howat,
M.A. (A., P. t M.); William Howie (P.) ; James Walker

Jones (A., P., M.) ; David Neilson Knox (M.) ;
Alexander Leishman (A. P.) ; William M'Adam, M.A.
(M.); William Charles Macartney (A.); Donald
M'Dougall (M.); Donald MTntyre (A.); Thomas
Mackinlay (M.); Donald Mackinnon (M.) ; William
Alexander Maclennan (P.); Campbell Macmillan (A.,
P., M.); John William M‘Nee (M.); Thomas Marlin
(M.) ; William Aubrey Layard Marriott (A.); Donald
Meek (A. M.) ; Angus Millar (P.); Hyacinth Bernard
Wenceslaus Morgan (M.); Findlay Murchie (A. P. M.) ;
Frederick Lewis Napier (A.) ; William Nicol (A.) ;
Clark Nicholson, M.A. (A., P.) ; John Robertson (A.,
P.); William Wilkie Scott (A.); William Alexander
Sewell (M.); Alexander Hunter Sinclair (A.); James
Stewart Somerville (A. M.); Richmond Steel (M.) ;
Arthur Ford Stewart (M.); Robert Sweet (M.) ; Aidan
Gordon Wemyss Thomson (M.); Charles Hermann
Wagner (A., P., M.); William Samuel Waterhouse
(M.) ; James Brown Whitfield (M.); Henry Joseph
Windsor (A., P., M.); William Richard Wiseman,
M.A., B.Sc. (A., M.); David Yellowlees (M.) ; Douglas
Young (M.); John Young (M.). Women.—Christina
Barrowman (A.) ; Florence Ann Gallagher (A.);
Euphemia Adamson Hay (A., M.); Jeanie Douglas
M‘Whirter, M.A. (A., P.) ; Margaret Muir (A.);
Ethelwyn Mary Walters (M.); Marion Aitken Wylie,
M.A. (A., P.).

The following have passed the third professional
examination for the degrees of M.B. and Ch.B. in the
subjects indicated (P., Pathology; M., Medical Juris¬
prudence and Public Health) :—

David Anderson (M.); Thomas Archibald (M.);
William Hunter Stirling Armstrong (P.); John
Atkinson (P.); Alexander Ballantyne, M.A. (M.);
John Blakely (M.); James Nimmo Brown, M.A. (M.) ;
William Barrie Brownlie (M.); John Cameron (M.) ;
Matthew Ignatius Thornton Cassidy (M.); Donald
Clark (P.); Donald James Clark (M.); Alexander
Beck Cluckie (M.) ; James Cook (Coalburn) (P. M.);
Walter Dawson (P.); Thomas Scott Forrest (M.);
William Leonard Forsyth (P.); John Fotheringham,
B.Sc. (P., M.); Robert Dunlop Black Frew (P., M.);
William Ernest Gemmell (M.); Alexander Thomas
Arthur Gourlay (M.); Edward O’Driscoll Graham
(P.); Thomas Harkin (P.) ; John Mitchell Henderson
(M.) ; John M'Lean Hendry (P.); James Hall Hislop
(P., M.) ; William Alexander Hislop (P. M.) ; Walter
Hermann Kiep (P., M.); James Towers Kirkland
(P.) ; William Leitch (P., M.); Daniel Conway
M'Ardle (P.); Frank Crombie Macaulay (M.); Robert
M‘Carlie (P.); Joseph Glaister M‘Cutcheon (P.);
Alexander Macpbail Macdonald (M.); William
M'Kendrick (M.); Murdo Duncan Mackenzie (M.) ;
Francis William Mackichan (M.) ; William Campbell
Mackie (M.); John James Mackintosh (P., M.); James
M’Millan M'Millan (P., M.); Allan Macpherson (M.) ;
Murdo M'Kenzie M‘Rae (P.); Andrew Maguire (P.,
M-) 5 Frank Needham Marsh (M.); William Aikman
Muir (M.) ; Charles Sutherland M‘Kay Murison (M.) ;
Watson Noble (P., M.) ; Ralph Montgomery Fullarton
Picken, B.Sc. (M.); Richard Rae (M.) ; Henry Nimmo
Rankin (M.) ; Hugo Given Robertson (P., M.) ; Allan
Semple (P., M.); James Brown Sim (M.) ; William
Stevenson (M.) ; Hugh Cochrane Storrie (M.) ; David
Taylor (M.); Walter Telfer (M.); Arthur Turnbull,
M.A., B.Sc. (P., M.); Hugh White (M.) ; David
M'Gruther Wilson (P.); John Alexander Wilson (P.,
M.); John Youngson Wood (M.) ; Hugh You lg (M.).
Women.—Margaret Baird Sproul Darroch (M.) ; Olive
Robertson (M.) ; Winifred Margaret Ross (M.) ; Jeanie
Hinshaw Stewart (M.).

The following passed with distinction in the subjects
indicated :—

Second Examination—In Anatomy—William Howat,
M.A. ; Alexander Leishman. In Physiology—John
Allan Munro Cameron; Jeanie Douglas M'Whir ter,
M.A. In Materia Medica and Therapeutics—Edward
George Glover; John Granger; William M’Adam,
M.A. ; John William M‘Nee; Hyacinth Bernard Wen¬
ceslaus Morgan.

Third Examination—In Pathology—Arthur Turn-
bull, M.A., B.Sc. In Medical Jurisprudence and
Public Health—Matthew Ignatius Thornton Cassidy ;
Francis William Mackichan; Ralph Montgomery
Fullarton Picken, B.Sc.

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D

43° The Medical Press. NOTICES TO CORRESPONDENTS.

Oct. i6, 1907.

NOTICES TO
CORRESPONDENTS, ffc.

ttr Correspondents requiring a reply in this column are par¬
ticularly requested to make use of a Distinctive Signature or
Initial, and to avoid the practice of signing themselves
“ Reader,” " Subscriber,” " Old Subscriber,” eto. Much oon-
fusion will be spared by attention to this rule.

SUBSCRIPTION S.

Subscriptions may oommenoe at any date, but the two volumes
eaoh year begin on January 1st and July 1st respectively. Terms
per annum, 21s.; post free at home or abroad. Foreign sub¬
scriptions must be paid in advanoe For India, Messrs. Thacker,
Spink and Co., of Calcutta, are our officially-appointed agents.
Indian subscriptions are Rs. 15.12.

ADVERTISEMENTS.

Foe One Insertion :—Whole Page, £5; Half Page, £2 10s.;

Quarter Page, £1 5s.; One-eighth, 12s. 6d.

The following reductions are made for a series:—Whole Page, 18
insertions, at £3 10s.; 26 at £3 3s.; 52 insertions at £3, and
pro rata for smaller spaces.

Small announcements of Practices, Assistancles, Vacancies, Books,
Ac.—Seven lines or under (70 words), 4s. 6d. per insertion;
6 d. per line beyond.

Reprints.— Reprints of artloles appearing in this Journal can
be had at a reduoed rate, providing authors give notioe to the
Publisher or Printer before the type has been distributed. This
should be done when returning proofs.

Scotsman. —No official figures are furnished, but it is said that
the Royal College of Physicians of London and the Royal College
of Surgeons of England receive yearly about £12,000 in examina¬
tion fees between them; of this amount ubout £8,000 goes to
the examiners.

M. T.—We believe Southwark is the only London borough that
favours oompulsory notification of tuberculosis. At n recent
meeting of the Borough Oounoil the matter was dealt with.
They then decided to make it a compulsorily notifiable disease.
The Progressives argued that the new order would result in
many men having to give up their employment, especially in
view of the new Workmen's Compensation Aot.

Seaside.— Yes, even shrimps are preserved with boracic acid.
A shell-fish dealer was summoned at 8outhport only the other
day for selling potted shrimps oontaining an exoess of boracio
acid. For the proseoution, it was stated that the pot of shrimps
oontained 107.6 grains of boracio acid to the pound. It was
stated that the Corporation intends to proseoute in all cases
in which the amount of boraoio acid as a preservative exceeds
30 grains to the pound. For the defence, it was stated that the
defendant had purchased the shrimps from a wholesale potter,
who, owing to the soarcity of shrimps at Southport, had bought
them at Manchester and had potted them exactly as received.
The Bench inflicted a fine of 20s. and oosts.

Occupation. —The total number of cases of poisoning and of
anthrax reported to the Home Offloe under the Factory and
Workshops Aot during August was 58, there being 48 cases of
lead poisoning, 2 of merourial poisoning and 8 of anthrax. In
addition to the above, 17 oa'ses of lead poisoning were reported
among house painters and plumbers. During the eight months
ended August, 1907, the total number of cases of poisoning and
of anthrax was 376, as oompared with 484 in 1906. The number
of deaths during the same period was 28, as against 36 in 1906.
In addition there were 104 oases of lead poisoning (including 26
deaths) among house painters and plumbers in the first eight
months of 1907, as oompared with 111 (inoluding 26 deaths) in
the first eight months of 1906.

dfoetirtga of the go a e to , %ntvccte t &t.

Wednesday, October 16th.

Roial Microscopical Society (20 Hanover Square, W.).—
8 p.m.: Papers:—Mr. A. A. O. E. Merlin: (1) Note on a New
Prismatio Microscope Ocular; (2) On Ghost Images seen in the
Secondaries of Ooseinodisous Asteromphalus.—Mr. A. Letherby:
Systematio Exposure with Transmitted Light in Photomicro¬
graphy.

Medical Graduates' College and Policlinic (22 Chenies
Street, W.O.).—4 p.m.: Mr. A. H. Tubby: Clinique. (Surgical.)
5.15 p.m.: Lecture:—Dr. B. Abrahams: The Post-Influenxal
Heart.

North-East London Post-Graduate College (Prince of

Wales's General Hospital, Tottenham, N.).—Cliniques:—2.30 p.m.:
Medical Out-patient (Dr. Whipham); Dermatologioal (Dr. G. N.
Meaohen); Ophthalmological (Mr. R. P. Brooks).

Thursday, October 17th.

Medical Graduates' College and Policlinic (22 Chenies
Street, W.C.).—4 p.m.: Mr. Hutchinson: Clinique. (Surgical.)
5.15 p.m.: Lecture:—Mr. H. Evans: Cysts and Cystic Condi¬
tions of the Neok.

North-East London Post-Graduate College (Prince of

Wales’s General Hospital, Tottenham, N.).—2.30 p.m.; Gyneco¬
logical Operations (Dr. Giles). Cliniques: —Medioal Out-patient
(Dr. Whiting), Surgioal Out-patient (Mr. Carson), X-Ray (Dr.
Pirie). 3 p.m.: Medioal In-patient (Dr. G. P. Ohappel).
4.30 p.m.: Lecture:—Mr. J. Canflie: Recent Discoveries in
Tropical Medicine.

8t. John’s Hospital tor Diseases op the Sxin (Leicester
Square, W.C.).—6 p.m.: Chesterfield Lecture:—Dr. M. Dookrell:
Eczema (its Varieties, Symptoms, and Causes).

Friday, October 18th.

Society tor the Study op Disease in Children (11 Chandos
8 treet, Cavendish square, W.).—5 p.m.: Cases will be shown by
Mr. 8. Stephenson, Dr. Chisholm, Mr. G. Pernet, Mr. L. Ham-
jflery, Dr. Inn^msad, and others. Paper:—Dr v E. C. Williams -

On the Simulation of Some of the Symptoms of Primary Amau-
rotio Idiocy by a Cerebral Tumour.

Medical Graduates' College and Polyclinic (23 Cheaiet
Street, W.C.).—4 p.m.: Mr. H. W. Dodd: Clinique. (Eye.)

North-East London Post-Graduate College (Prince of
Wales's General Hospital, Tottenham, N.).—10 a.m.: Clinique: —
Surgical Out-patient (Mr. H. Evans). 2.30 p.m.: Surgical Opera¬
tions (Mr. Edmunds). Cliniques:—Medical Out-DatienC (Dr.
Auld), Eye (Mr. Brooks). 3 p.m.: Medioal In-patient (Dr. M.
Leslie).

Central London Thboat and Eae Hospital (Gray’s Inn Boad,
W.C.).—3.45 p.m.: Demonstration:—Mr. C. Nourse: Larynx.

^ppoitttnums.

Carltlk, Oliver, l.R.O.P. and 8. Edin., House Physician and
Pathologist at the Infirmary, Sunderland.

Chapel, K., M.B., B.S.Edin., Certifying Surgeon under the
Factory and Workshop Act for the Rothwell Distriot of the
county of Northampton.

Cuxlipfe, E. N., M.D.Viot., M.B., B.S.Lond., M.R.C.P.Lond.,
Honorary Consulting Physician to the Colne Cottage Hospital.

Cunningham, Richabd G„ M.B., Ch.B., Senior House Surgeon
at the Infirmary, Sunderland.

Dodds, Thomas Geoboe Boswall, M.D., B.Ch.Edin., Medical
Officer to the Starcross (Devon) Branoh of the Rational
Association Friendly Society.

Fitzoerald, C. C., L.R.O.P. and 8. Edin., L.F.P.S.Glasg., Junior
Assistant Medical Offloer at the Hope Hospital Union In¬
firmary, Salford.

Granger, Henry, M.R.C.8., L.R.C.P., Resident Medioal Officer
at the Royal Victoria Hospital, Bournemouth.

McLean, Mcbdo, M.A., M.B., Ch.B.Edin., Honse Surgeon at the
Infirmary, Sunderland.

fetmacB.

Brighton, Hove, and Preston. Dispensary.—Honse 8urgeon.
Salary, £160 per annum, with furnished rooms, ooals, gas,
washing, and attendance. Applications to O. Somers Clarke,
Hon. Secretary, 113 Queen's Road, Brighton.

North Riding Lunatio Asylum, Clifton, York.—Junior Assistant
Medical Officer. Salary, £150 per annum, with furnished
apartments, board, washing, and atteidanoe. Applications to
the Medical Superintendent.

Woodilee Asylum, Lenzie.—Medical Officer. Salary, £150 per
annum, with board, lodging, eto. Applications to Dr. Man,
Medical Superintendent.

The Finsbury Borough Council.—Medioal Offloer of Health.
Salary, £600 per annum. Applications to G. W. Preston,
Town Clerk, The Town Hall, Rosebery Avenue, E.C.

City of Birmingham.—Assistant Medioal Offloer of Health.
Salary, £250 per annnm. Applications to the Chairman of
tho Health Committee, Oounoil House, Birmingham.

Carlisle Non-Provident Dispensary.—Resident Medical Offloer.
Salary, £150 per annum, with apartments (not board). Appli¬
cations to the Hoh. Secretary, Mr. G. A. Lightfoot, 23, Castle
8 treet, Carlisle.

Edinburgh Distriot Asylum, Bangour Village.—Seoond Assistant
Physician. Salary, £120 per annum, with board, apartment*,
and laundry. Applications to the Medioal Superintendent,
Bangonr Village, Uphall.

Newcsstle-on-Tyne Dispensary.—Visiting Medioal Assistant.

Salary, £160 per annum. Applications to the Honorary Secre¬
tary, Joseph Carr, Chartered Accountant, 26 Mosley Street,
N ewcastle-on-Ty ne.

^Births.

Fawcett.—O n Oct. 9th, at High Park, Roacres, Ireland, the wife
of Edward Fawcett, M.D., of a son.

Thompson. —On Oot. 5th, at Tntshill, Chepstow, the wife of
Cecil C. B. Thompson, M.R.O.S., L.R.O.P., of a daughter.

JHarmgtB.

Huston—Young. —On Oot. 9th, at the Parish Church, Great
Stainton, Frederick Hunton, M.D., of Sedgefleld, to Eleanor
Mary, daughter of the late William Joseph Young, J.P-.
D.L., of Wolviston. Hall, Stockton.

Moore—Ravenscropt. —On Oot. 9th, at tho Parish Church,
Ewell, Surrey, John William, vonngest son of the late R. H.
Moore, F.R.O.8., Dnblin, to Violet Hastings, only daughter
of the late Honble. W. H. Ravensoroft, C.M.G., of Ceylon.
Mulkern—Voule8. —On Oct. 8th, at 8t. Mary's Church, Woot-
ton, Bedfordshire, Hubert Cowell Mulkern, M.D., second son
of Alfred Courtney Mulkern, to Florenoe Emily, only daugh¬
ter of the late Lanrenoe Francis Voules.

Robinson—Ward. —On Oot. 8th, at Swanage Church, Gerald C.
F. Robinson, F.R.C.8., son of Gerald Robinson, Esq., to
Helen Margaret, elder daughter of Lient.-Colonel A. C.
Ward, late R.E.

Veblino-Brown—Hair. —On Oct. 9th, at 8t. Peter's Church.
Belsize Park, N.W., Charles Richard Verling-Brown, M.D.,
Lond., of 8utton, Surrey, elder son of the late Charles Brown,
of •' Carnarvon,” Bournemouth, to Jane, younger daughter
of J. Hair, Esq., of Hampstead.

Deaths.

Dredge.— On Oct. 8th, at Melrose, GlMtonbury, Captain J. A.
Dredge, I.M.S., 8taff Surgeon at Bangalore. (Accidentally
killed out riding.)

Elliott. —On Oot. 6th, at Hull, George Frederiok Elliott, *-D-
F.R.C.P., England.

Heath.— On Oot. 4th, Edward Alfred Heath, M.D., of 34, Ebory
Street, London, and Shore ham, Kent, aged 68.

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The Medical Press and Circular.

-SALUS POPULI SUPREMA LEX. -

Vol. CXXXV. WEDNESDAY, OCT. 23, 1907. No. 17

Notes and Comments.

Southend is emerging ignomini-
Defeat ously out of its contest with its

of medical officer of health. As the

Southend. result of the attitude of loyalty to
their colleague taken by medical men
generally, the advertisements issued by the South-
end Town Council only elicited four replies from
applicants for the post, and not one of these was
suitable. Considering that when Dr. Nash was
originally appointed a few years ago there were
forty-eight applications, most of them presumably
from qualified men, it cannot be said that there is
no cohesiveness in the profession when a question
of principle is at issue. Whatever the unfortunate
dispute has or has not done, it has at least shown
that there is now a fairly well organised esprit de
corps among medical men, and that this spirit is
a factor to be taken into consideration by public
bodies who try to play fast and loose with their
medical officials. On that let us at least congratu¬
late ourselves, for in the case of medicine it is as
true as ever it was, that united w-e stand, divided
we fall. We do not envy the Health Committee
of Southend their position, for they themselves are
aware of Dr. Nash’s value and uprightness, and
yet, acting under the orders of the Council, they
have to find a successor to him in face of a prac¬
tically unanimous boycott by the medical profes¬
sion. At present matters stand thus. Finding no
suitable man can be obtained for the post, the Health
Committee were bound at the last meeting to recom¬
mend that Dr. Nash should be re-appointed for
another year at the proper salary, namely, £600 a
year, and of course this proposal was very distaste¬
ful to the Council, especially to those members who
had come into conflict with Dr. Nash through their
own sanitary shortcomings. Needless to say, the
recommendation was opposed in every way, but it
had perforce to be carried eventually, the only
modification being that the period of re-appoint¬
ment was shortened to nine months.

Now this period, it seems to us, is
The Need quite long enough for the Question
for to be thoroughly investigated by the
Inquiry. Local Government Board. The
health of Southend and the efficiency
of the health administration of the whole country
is bound up in its settlement. Mr. Burns, with his
long experience of local authorities, and Dr. Mac-
namara, by his recent declarations, are both fully
alive to the unsatisfactory and anomalous position
in which health officers are placed by the insecurity
of their tenure, and they must know that in the
result hundreds of wrongs that need righting are
untouched, because the very man who could tackle
them is unable to act without risking the loss of
his livelihood. The Southend case would make an
admirable subject for a public inquiry by the

Board, because it contains the elements which com¬
pose all difficulties of the kind, plus a medical
officer of more than usual enterprise, and one who
preferred his duty to soft words and ineffectiveness.
If the Local Government Board leave things where
they are, it is possible that the Council will be able
to secure a medical officer at the end of the nine
months, and the present fight will be in vain. On
the other hand, if they hold an inquiry now, and,
being satisfied as a result that Dr. Nash has been
punished for doing his duty, intimate that they
will not sanction any variation in the terms of his
appointment, Southend will serve as a lesson to the
rest of those sanitary authorities who set personal
interests above public ones.

As a matter of fact, at the moment
Cheltenham a similar fight is engaging the
and Council of Cheltenham. Dr. Gar-
its M.O.R rett, the medical officer of health of

that borough, is an energetic and
well qualified man, who has raised the reputation
of Cheltenham as a health resort to a high level.
L’nhappily, his care for the town has brought him
into collision with the butchers, or certain butchers,
whose slaughter-houses he has opposed, and with
other parties whose private interests are not coinci¬
dent with those of the public. Now, it is as
inevitable that a conscientious medical officer of
health should find himself in collision with private
tradesmen as that a conscientious policeman should
occasionally find himself under the painful necessity
of injuring the feelings of Bill Sykes; human
nature being what it is, there will always—this side
of the millennium—be bad landlords, erring trades¬
men, and incorrigible rogues. A medical officer
who did not find any nuisances to abate would be
as slack or incompetent as a policeman who found
.no thieves, but whereas society congratulates the
policeman on his success, the medical officer
(usually) gets kicks. The Cheltenham Town
Council is being asked to reduce Dr. Garrett’s
salary by ^100 a year as a reward for his energy
and competence, and while we hope thev will have
nothing to say to so monstrous an injustice, we
may, with some confidence, point to Southend as
an example of what may happen if they give way.
Happily, however, in the case of Cheltenham the
Local Government Board have the last say in the
matter.

Icl on parle
Fran;ais.

The line between legitimate and
illegitimate advertising by medical

men is so delicate a one that till
the end of the chapter there is likely
to be an Infinity of disputes with re¬
gard to it. Whereas there are, unfortunately,
members of the profession who stretch the elastic
boundary to breaking-point, it cannot be denied

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43-2 The Medical Peess.

LEADING ARTICLES.

Oct. 23, 1907.

that there is in some quarters a hyper-sensitiveness
with regard to prominence attained by professional
brothers. The important point to remember about
medical rules is that they are laid down for the
benefit of the public, and that medical etiquette is
made for the man, and not man for etiquette. An
amusing example of this hyper-sensitiveness has
just occurred in Saxony, where the Medical Council
of that State has decreed that it is derogatory to the
dignity of medical men for one of them to indicate
on his door-plate that he can speak English and
French ! Now, to a patient in a foreign town it may
certainly be a deciding factor in selecting a doctor
that he can speak the patient’s native language,
but who can say that such a reason is not per¬
fectly legitimate? It must be convenient to
foreign visitors to a town to know which doctors
can be expected to understand them when they
explain their symptoms, and which ones can
merely, with strained sympathy, ejaculate “Ach”
or “Ja.” We can imagine that the General Medi¬
cal Council would not smile if it became the
fashion to adorn the dining-room windows in
Harley Street with white letters announcing “ Ici
on parle Fran^ais,” or “American Understood,”
but it would certainly be comforting for a man
taken with abdominal pain in Naples to see
“English spoken” on Signor Baccelli’s plate.

The recent German legislation pro-
German Legis- hibiting advertisements of quack
lation and its medicines has caused some flutter-
Consequences. ing in the dovecotes of the gentle¬
men who live by that obnoxious
trade. The Advertising World describes the legis¬
lation as grandmotherly, because it considers the
German people the best educated in the world, and
therefore able to “act with intelligence and dis¬
crimination.” It seems to us that they have just
given a signal proof of this ability by prohibiting
advertisements which appeal solely to the ignorant
and fleeceable members of • the community. A
correspondent of that journal, Mr. Robert Glass-
pole, of Coventry, writes to the editor an interest¬
ing and significant letter objecting to the com¬
ments made by him on this legislation. In the
course of this letter Mr. Glasspole says: “ I do
not hesitate to express the opinion that sooner or
later something will be done in this country, having
the same object as that held in view by the Ger¬
man legislators when they made their law affecting
patent medicines. Lest it should be thought that
my argument is disinterested, I might say that I
am myself an advertising man, and happen to
know how, in some of the most notable instances,
the copy issued (including the testimonials) is
originated. As tending to show that I am not
alone in my opinion, even amongst those con¬
nected with advertising, I should mention that
in the advertisements of one of the most progres¬
sive advertising agencies in this country, there
appeared not long ago the announcement that con¬
tracts for patent medicines would not be accepted.”
It is particularly striking that such strong and sane
views should be held by a gentleman who is an
advertising man himself, and we are thankful to
know that there is at least one agency which will
not lend itself to the duplicity and frauds of the
quack medicine trade.

The retirement of Professor Politzer,
Retirement of Vienna, is an event of consider-
of able interest, for he is acknowledged
Politzer. generally to be one of the pioneers

of otology, and he has undoubtedly
the highest international reputation of any prac¬
titioner of that branch of surgery. Professor
Politzer owes much of his success to his ingenuity
and to his manual dexterity. The latter he ac¬

quired in his early days as a painter, an art in
which he earned no little skill and renown, and
his originality of thought and method after devot¬
ing himself to otology are known all over the
medical world. For thirty-six years he has been
professor at Vienna, and it was only the other day
that he brought out his enormous work on his
speciality. The good wishes of many sufferers,
and of all his medical colleagues, will follow him
into his well-earned retirement.

LEADING ARTICLE.

THE ADMINISTRATION OF ANAESTHETICS
IN HOSPITALS.

The points recently raised by the City of London
Coroner, Dr. F. J. Waldo, have clearly enough
an important bearing on the administration of
anaethetics, as regards both the public and the
medical profession. An inquest, as most of our
readers are aware, was held on the body of a
woman who died at Guy’s Hospital some ten
or fifteen minutes after the administration of
chloroform was commenced by a house surgeon.
The patient was suffering from exophthalmic
goitre, and the operator had just made the first
incision, when the patient vomited slightly, or
attempted to vomit, and then ceased breathing.
It appears that the operation was performed at the
day and hour usually fixed for such procedures, so
that there was ample time to make the necessary
preparations and to secure the attendance of one of
the eight staff anaesthetists attached to the hospi¬
tal. As regards this particular occasion, both the
surgeon and the house surgeon admitted in evi¬
dence that they recognised that operation in cases
of exopthalmic goitre involved special anaesthetic
difficulties. There is no need in these columns
to dwell upon the peculiar risks involved
therein in the position of the neck, the occasional
pressure upon the trachea, the hypersensitive
nervous mechanism concerned, and the frequently
enlarged thymus. The point to be considered,
however, is whether, with all these facts in view,
any system can be countenanced which permits a
house surgeon, whose experience is limited to
some ninety or one hundred administrations, to give
the anaesthetic, in spite of the fact that more
experienced anaesthetists are available. At the
inquest the house surgeon accepted all responsi¬
bility, but it may be doubted whether the public
or the medical profession would approve such an
assumption. Legally, we believe the responsibility
rests with the operator, and in this particular case
the surgeon said he was ready to accept part of the
responsibility. The Coroner thereupon naturally
pointed out that a man who was undertaking a
difficult operation could not be expected at the
same time to superintend the anaesthetic. The in¬
quest thus centres upon the system in vogue at
Guy’s, and, for that matter, at many other
hospitals throughout the kingdom. It is often a
matter of convenience to the surgeon and to the
hospital surgeons to have an anaesthetic administered
on the spot by one of the resident staff. In many
small institutions and country places it is abso¬
lutely the only course open to the operator. Nor
in any big hospital would it be possible in a large
number of surgical casualties to call in the sen-ices
of a special anaesthetist. On the other hand, if

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Oct. 23, 1907.

CURRENT TOPICS.

The Medical Press. 433

there be any virtue at all in specialism in the
administration of anaesthetics, not to mention
staff appointments of that kind, it seems abun¬
dantly clear that special anaesthetists should
attend all difficult operations where due notice can
be given. The education of the student can be
equally well, or probably far better, conducted by
practical demonstration or by supervision than if
he be left to his own unaided resources. It is of
course necessary to instruct medical students in
the administration of anaesthetics, which they are
called to administer in after life under many varied
circumstances, at times involving the assumption
of the highest possible degree of direct personal
responsibility. But while the necessity for a prac¬
tical training must be freely admitted, it may,
nevertheless, be a matter of question whether this
or that given system of training is not open to
improvement. In many ways the question of
anaesthesia is of as much direct importance
to the success of an operation as well as to
the safety of the patient as the actual surgery
which is involved. From this standpoint we
venture to doubt whether sufficient importance is
attached to the subject of practical anaesthetics in
the medical curriculum. So far as the after career
of the medical practitioner is concerned, we have
little hesitation in saying that he would be better
equipped for the battle of professional life by a
sound education in anaesthetic administration than
by the study of technical experimental physiology
and other highly specialised branches of scientific
work having a more or less indirect bearing on
medical practice. So far as Guy’s Hospital is con¬
cerned, wc have no doubt that the authorities will
take immediate steps to review the situation and
to introduce any alterations in the present system
that may appear necessary or desirable. An insti¬
tution of that standing is so far above suspicion
that no reasonable person would blame the authori¬
ties were any administrative defect shown to exist.
At the same time, it must be borne in mind that
all human organisations are fallible, and that with
increasing knowledge and experience reforms are
necessary from time to time if they are to keep
abreast of the progress of knowledge and ex¬
perience. In our opinion, the time has arrived
when, in the interests of the community, an
authoritative Government enquiry is demanded into
the whole question of anaesthetics and their ad¬
ministration. We further think that such a
Commission, to be of real value, should be con¬
stituted not solely of medical men, but of men
eminent in science generally, of lawyers, and of
others of acknowledged intellectual standing, in
conjunction with a few medical men. Compara¬
tive statistics of all large hospitals should form an
important feature of the evidence before such a
Commission.

THE DEADLOCK AT THE ROYAL BRISTOL
INFIRMARY.

The conflict of opinion that has arisen between
the staff and the Board of Management of the
Bristol Royal Infirmary shows little sign of settle¬
ment. In its essence the dispute becomes one of
the right of a medical charity to say what outside
duties may or may not be undertaken by its
honorary medical staff. There is obviously some¬
thing to be said on both sides of the question. If

the Board finds its medical staff performing outside
duties of such a nature as to interfere with the
attention due, in the first instance, to the patients
of the Royal Infirmary, it has clearly a right to-
expostulate and, if necessary, even to revise the
terms of an appointment the duties of which are
perfunctorily performed. We are glad to believe,
however, that such a hypothetical case would be of
the very rarest occurrence in the medical profession.
Any physician or surgeon finding his energies un¬
duly drawn upon by an auxiliary appointment
w'ould naturally resign, not less as a duty to him¬
self than to his colleagues and to the medical
profession outside the walls of the hospital. It
would be useless to attempt to disguise the fact
that plurality of appointments is open to serious
abuses. Perhaps one of the greatest objections is
that the pluralist, while holding a position to which
he is personally unable to do justice, is, at the same
time, excluding one of his own cloth from the
higher things that undoubtedly attach to hospital
life. So far as the Bristol Royal Infirmary is con¬
cerned, the medical staff have acted with com¬
mendable firmness and moderation. The new
regulations passed by the governors—but not yet
confirmed—provide that no member of the full staff
shall hold any other professional public appoint¬
ment except professorship or lectureship at any
university, college or school; further, that only
consultant or special practice shall be permitted.
The medical staff accepted the latter clause, but
have refused to acquiesce in the former, and have
intimated that, in the event of its being retained,
they will have reluctantly to send in their resigna¬
tions. It would be a matter of profound regret
were the outcome of these attempted changes to
end in so disastrous a fashion. After all said and
done, the services of the medical staff are purely
honorary, and it is surely for themselves to regulate
their own professional lives. While it is quite
reasonable and, indeed, salutary that the governors
of a charitable institution should be able to satisfy
themselves at any moment that the work of the
hospital is being conducted in the best interests of
the public, we can by no means agree with the
arbitrary and unconstitutional interference with the
extramural rights of their honorary staffs. For
the present the matter is in abeyance, but it will
come up shortly for a final decision by the governors
of the Bristol Royal Infirmary. It is impossible to
think that the governors, without overwhelming
evidence of the necessity of such a step, will
estrange and eliminate their present staff by adopt¬
ing rules that are condemned by the whole of the
local medical practitioners, and thus reverse a
policy under which the Bristol Royal Infirmary
has for many generations faithfully and honourably
discharged a great public responsibility.

Medical Slclcneas and Accident Society.

At the usual monthly meeting of the Executive Com¬
mittee on the nth inst., the investment of about
£7,000, the surplus produced by the Society’s opera¬
tions through the summer, was arranged. The rate
secured was 3! per cent., and this leaves a large
margin over the rates assumed when the business of
the society has been valued. The funds of the society
now amount to over £215,000, of which £14,000 is
treated as an investment reserve to cover any fall in
the price of the Stock Exchange Securities held by the
society, or any losses that may be incurred in any
other manner.

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434 The Medical Press.

CURRENT TOPICS.

Oct. 33, 1907.

CURRENT TOPICS.

The Alleged Dearth of Medical Men.

As a general statement, there seems little doubt
that there has been for some years past an increas¬
ing difficulty in finding men to take junior resident
posts in hospitals and other medical institutions.
The rush of applicants, however, for adequately-
paid appointments is just as great as ever, and the
obvious deduction is that advantage has been taken
of an overcrowded and disorganised profession to
cut down salaries below a fair standard. A Man¬
chester practitioner has recently written to a local
newspaper, stating that not long ago he adver¬
tised for an assistant in his practice, and received
no fewer than ninety-three replies, of which eighty
came from suitable persons. We do not say
what salary he offered, but we may infer that
it was adequate to the purpose, judging from the
result. The same correspondent appended an
analysis of forty-four posts offered in a leading
medical journal for medical men, the average re¬
muneration being £90 per annum, with board and
lodging. He remarks that, rather than spend
1,000 on educating a son of his to enable him to
earn £90 yearly, it would be better to make him
a bricklayer, as he might then perhaps live in
comfort on such an income. The protest is vigo¬
rous, but is In itself hardly likely to contribute
materially towards reform, unless, indeed, it
suggests to hospitals which fail to secure residents
that they should henceforth offer an adequate
salary. The medical profession will never be able
to secure fair remuneration until it is protected
against the unfair competition of quacks and
quackery; nor, it may be remarked incidentally,
will the public safety and the national stamina be
safeguarded until this elementary precaution be
taken by the legislature.

Spotted Fever as a Test of Local
Sanitation.

The gospel of disease prevention could hardly
find a finer text than that afforded by the recent
report of the Local Government Board for Ireland
upon “ spotted fever" in Belfast. Dr. Clibborn,
the inspector, attributes the outbreak to an infected
coalheaver working on one of the ships from the
Clyde. From the visit of that single patient
sprang an epidemic of 233 cases, of which no fewer
than 154 were fatal. This occurrence shows the
enormous importance of an efficient system of port
inspection. Although it would be a counsel of
perfection to attempt to exclude all cases of minor
infection, yet it is nevertheless possible to insist
upon proper reports from the ship authorities, and
a compulsory medical examination of all persons
who are obviously ill. But the lessons of the Bel¬
fast outbreak by no means end with the necessity
of port sanitation. The fact stands out in high
relief that the disease establishes its foothold in
filthy houses, and is propagated by actual human
contact. Although there is much to be learnt
with regard to the specific microbe of “ spotted
fever,” we know that it cannot live long enough
outside the human body to be propagated in dust,
furniture, bedclothes, and so on. The moral is
obvious. This terrible disease can flourish only in
communities which permit the continuance of
plague spots within their walls. As with some
other communicable diseases, “ spotted fever ”

could gain no grip in any district kept up to a
reasonably high pitch of sanitary perfecton. Viewed
from this standpoint, the extent and duration of
an outbreak of the malady in question may be re¬
garded as a kind of test imposed by Providence
upon the sanitation of any given locality.

Some Medical Aspects of the Shrewsbury
Railway Accident.

Once again the British public has been startled
by a terrible accident to an express train. It seems
likely that it will never be known why the train
ran into a dangerous curve at such excessive speed,
but the probable explanation appears to be that
the brakes failed to act. The tragic fate that has
overtaken so many of our fellow-countrymen sug¬
gests that it would be well to raise some obvious
medical considerations at the present moment.
The necessity of periodical inspection of the engine-
men and guards has been often insisted upon in
medical journals. One has only to reflect on the
terrible consequences that may result from a
momentary lapse of reason or attention on the part
of an engine-man or a guard, to realise the need
of full sanity of mind and body. Perhaps one of
the points upon which the medical profession could
insist with most advantage is that concerning the
long hours of railway-men. It is absolutely im¬
possible for an habitually over-worked man to keep
his attention concentrated continuously upon his
work. It is the momentary oblivion of the driver or
the signalman that does the mischief. Parlia¬
ment might do worse than appoint a medical com¬
mission of enquiry into the hours of railway-men,
or, at any rate, a commission in which the pro¬
fession of medicine would be strongly represented.

Army Reform and the Medical Profession

In the scheme for the reform of the Territorial
Army, which was foreshadowed by Mr. Haldane
in his speech at North Berwick last week, a re¬
ference was made to the assistance which
he hopes to get from the medical profession.
So far as can be made out from Mr. Haldane’s
brief sketch, it is intended to reorganise a medical
force for the Territorial Army on lines similar to
those on which the Royal Army Medical Corps
runs for the Regular Army. This Territorial
Medical Service will be wanted, in time of war,
not only to treat wounds but to secure sanitation
and health preservation. The various medical
units which are necessary will be raised, as
far as possible, within the areas in which the
divisions are formed. Outside these units
the co-operation of experts in preventive medicine
will be invited, whose advice will be asked in
time of war, should troops be massed in their
neighbourhood. Undue demands will not, how¬
ever, be made on their time, and there will be
nothing in any part of the scheme to interfere
with the civil occupations of those taking part in it.

It is, of course, impossible to criticise Mr. Hal¬
dane’s scheme until we know something more of
it in detail. At the same time, there is no doubt
that it is a good intention to interest members of
the medical profession throughout the country in
national defence, so that they may prove of use
in the event of war. Mr. Haldane may be assured
of the active support of members of the profession
in the carrying out of any sound scheme.

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Oct. 33, 1Q07.

PERSONAL.

The Medical Press. 435

Milk Contamination.

It is not long since that our countrymen stood
aghast at the horrors of the American tinned meat
factories. It now appears that they may have their
fill of that sort of thing without going across the
Atlantic ; indeed, by simply turning to the milk can
at their own doors. A London milkman was re¬
cently charged on a warrant with selling unwhole¬
some milk. The Westminster Medical Officer of
Health deposed that the milk seized from prisoner
had a number of black smuts floating on its surface :
the fluid smelt offensively, and there was a large
quantity of filthy material at the bottom of the can.
This sediment was found to contain a large quantity
of vegetable and other debris, consisting of hairs—
some human and others belonging to small animals
—pieces of human skin, and other most objectionable
matter. The refuse apparently came from a dirty
stable or the street, and it may be conjectured that
some of it was due to dipping out the milk with a
dirty can. The milkman cynically suggested it was
due to the fog, but that defence did not save him
from a sentence of six months’ hard labour.
This heavy punishment should act as a warning to
the milk trade. The patience of the public must
soon be exhausted, and fresh legislation will be de¬
manded to stop the noisy carts of the milkmen, their
adulterations, and their traffic in milk of tuberculous
cows, all of which constitute offences of a nature
that would not be tolerated for a moment in the case
of other tradesmen.

Specific Cruelty in Divorce.

The legal interpretation of “cruelty ” is somewhat
elastic and fanciful, a fact that to some extent indi¬
cates the insufficiency of the existing law. The
communication of venereal disease to a wife has
happily long ago been included within the category
of cruelty. Moreover, the advance of medical
science has now made it possible to produce absolute
evidence in the shape of bacteriological proof of the
existence of both syphilis and gonorrhoea. From a
recent judicial utterance it may be gathered that the
mere fact of specific infection of the kind mentioned
constitutes a sufficient ground for divorce, apart
from any further question of legal cruelty. Mr.
Justice Bucknill, however, in the course of the
recent hearing of a painful case of the kind from
Nottingham, made an important judicial utterance
upon the subject. After commenting upon the present
state of the law, he added that, in his opinion, it
ought to be made a criminal offence for a man
wilfully to communicate a specific disease to his
wife. The Medical Press and Circular goes a
good deal further than that, and maintains that it
ought to be made a criminal offence for any man
knowingly to communicate a venereal disease to a
woman, or vice-versa, on the absolutely clear and
definite principle adopted by the legislature in the
case of ordinary specific communicable diseases.
Why punish a man for spreading small-pox but not
the wanton dissemination of syphilis ?

The Sheffield Infirmary Appointments.

We learn that the Sheffield Guardians propose to
appoint as Medical Officer of the hospital a gentle¬
man with greater experience, who will be able to
take full control of the medical work. There will

be two junior officers as before. They do not pro¬
pose filling the position of visiting surgeon and
visiting physician vacated by Dr. Wilkinson and Dr.
Arthur Hall. But that will not prevent the Hos¬
pital Committee calling in outside aid whenever it
is required for surgical operations. The new Medical
Officer will be paid a salary of £300. It is under¬
stood that the Local Government Board representa¬
tives who recently visited the Workhouse Hospital
fully approve of these changes.

PERSONAL.

H.M. the Queen has sent a donation of 600 guineas
to the London Hospital.

Dk. Borger has been appointed personal physician
to the King of Siam.

Mr. A. H. Lees has been appointed to a Research
Studentship in Medical Entomology at Cambridge.

Mr. Rushton Parker has resigned his post of senior
surgeon to the Liverpool Royal Infirmary, his term of
office having expired.

Mr. Nathan Strauss, of New York, has offered a
pasteurising plant to the cities of Dublin and Liver¬
pool, in connection with their scheme for reducing in¬
fantile mortality.

Mr. Joseph Montagu Cotterill, M.B., C.M.Edin.,
F.R.C.S., was unanimously elected President of the
Royal College of Surgeons, Edinburgh, on Wednesday
last.

Mdme. Zola has presented to the Assistance
Publique of Paris her house and grounds at Medan as
a convalescent home for infants. Dr. Mery has been
appointed physician to the establishment.

Dr. Koch, who has been examining the causes of
sleeping sickness, left Mombasa for Germany on
October 15th. His investigation camps in Uganda
have been taken over by the colonial authorities.

Mr. Victor Thomas Ellwood, of Merchant
Taylors’ School, has been elected to the Medical
Scholarship instituted at Pembroke College, Oxford
University, by Dr. Theodore Williams.

Dr. T. Sangster Greig has been the recipient of a
handsome testimonial from the staff of the West Ham
Infirmary. Dr. Greig has been Acting Medical Super¬
intendent of the Institution for some time, and has
failed to be elected to the post permanently.

The friends and pupils of Dr. Hallopeau are sub¬
scribing for the presentation to him of a medal,
executed by M. Chaplain. The list is open till
November 10th, and all subscribers of twenty-five
francs will receive a replica of the medal.

Dr. Edward W. Hope, Medical Officer of Health for
Liverpool, and Professor of Public Health in the
University of Liverpool, delivered an address on
“Some present problems of public health administra¬
tion ” at the inaugural meeting of the York Medical
Society last week.

Dr. Edgar Byass, of Cuckfield, who, for health
reasons is leaving the district, has just been presented
with a handsome parting gift of /417, together with a
bound list of the subscribers. The Byass family have
been associated with medical practice at Cuckfield for
over 100 years.

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456 The Medical Press. CLINICAL LECTURE._ Oct. 23. 1907-

A Clinical Lecture

ON

UREMIC MENINGITIS, (a)

By PROFESSOR R. LEPINE, M.D.,

Of the Lyons Faculty of Medicine.

Is there such a thing as uraemic meningitis?
Pericarditis, as a complication of uraemia, is fre¬
quently observed, and whether it be a direct effect
of the toxaemia or, as some hold, invariably the
result of infection, the fact remains that the renal
subject offers a favourable soil for its evolution.
One thing is certain—vie., that pericarditis be¬
comes more frequent the nearer the approach of
the uraemic state. Theoretically, therefore, I see
no obvious reason why the meninges should not
sometimes be affected like the pericardium.

I have not been able to find anything in medical
literature bearing cm the question, but three cases
which have recently come under my observation
suggest the possibility of such a relationship, and
this I propose to discuss in the light of the informa¬
tion they afford.

The first patient was a labouring man, aet. 65,
who had for some time previously been suffering
from arterio-sclerosis, and was re-admitted in
March with well-marked symptoms of kidney
disease, and, in particular, general anasarca.
Subjected forthwith to the dechloridation treatment,
his state did not improve, and early in May he
became delirious. He was still passing a fair
quantity of urine (about four pints), but this was
highly albuminous, and the elimination of methy¬
lene blue was greatly below normal. Little by
little the urajmic condition became more marked,
consequent upon the gradual failure of the heart.
The pulse, which had been bounding (without any
double murmur), became weak, and he died on
May 31st, without either convulsions or coma.

Post mortem, the kidneys weighed 83 ounces.
The cortex was much atrophied, and the large,
flaccid heart, more dilated than hypertrophied,
weighed 20 ounces. The meninges over the con¬
vexity of the hemispheres were thickened, and were
milky white except at one spot two or three inches
square, which was bright red. The meninges
were easily stripped from the subjacent grey
matter, which was healthy, with the exception of
a small patch of softening in the temporal con¬
volution. The central parts of the brain were quite
healthy.

No trace of tubercle was discovered in any of the
organs or tissues, or cicatrices suggestive of healed
tuberculosis.

The patient was reported to have been of sober
habits, so that the thickening of the meninges
could not have been due to alcohol. Its existence
might be secondary to the renal condition, for
during his two months’ sojourn in hospital no
other cause had intervened. To this acute process
and the toxaemia the delirium was no doubt due,
for the patch of softening did -not appear to have
plaved any part in its production.

Case 2 was that of a woman with kidney
disease who developed delirium and sundry menin¬
geal. symptoms, and in whom, post mortem, the
meninges were found to be of a bright red colour.
She was aet. 45, and was brought to the hospital
by neighbours, who knew very little about her

(«) Delivered at the Hotel Dleu at Lyon*.

history. She was very thin, had a vacant look,
and could not be got to speak. She appeared, how¬
ever, to understand to some extent what was said
to her. There was no stiffness, and Kernig’s sign
was absent. The reflexes were exaggerated.
Pulse 116, some rhonchi in both lungs. The urine,
withdrawn by catheter, was of normal colour and
albuminous. Lumbar puncture gave issue to a
clear fluid. An enema brought away a large
motion, without any improvement in her state.

The next day the heartbeat was 128, with a ten¬
dency to gallop. The urine, mostly passed in¬
voluntarily, was darker and contained 17 per cent,
of urea and the merest trace of albumen. There
was some difficulty in swallowing, the face was
turned to the right, the pupils were sometimes
contracted, or at other times normal, the left being
the larger. Respiration was noisy, but regular;
the abdomen was soft. Examination of the urine
on the 16th showed a marked diminution of phos¬
phoric acid in proportion to the urea. A second
lumbar puncture gave issue to fluid under moderate
pressure (whereas on the previous occasion the
pressure appeared to be high). Nothing particular
was found therein. Post mortem, the atrophied
kidneys weighed 3$ ounces, while the heart weighed
12£ ounces. There was some cicatricial tissue in
the apex of one lung that was probably of
tuberculous origin. The cerebral meninges were
much injected over the convexity, and several con¬
volutions presented a bright red colouration. The
cerebral ventricles were not dilated. No trace of
exudation.

Case 3 was that of a young woman, aet. 30,
admitted on May 12th. She was restless and
delirious and had visual hallucinations. The rectal
temperature was 104° F. Dr. Rome, w’ho had been
attending her, gave us the following particulars
Her father, a chronic inebriate, died of ethylism at
the age of sixty. She had lost a sister of menin¬
gitis at twenty-two. No tuberculosis in the family.
She was spare, but healthy, was of sober habit’s,
and lived a regular life. She had lost her mother
five months before, and since that time she had
become irritable, and for two months had suffered
from headache. The actual attack had set in eight
days before admission, with shivering that obliged
her to keep to her bed. She remained in bed the
following day on account of a “ stitch " in the side.
The temperature was high and the dyspnoea very
pronounced. Dr. Rome was called in on the nth,
when respiration was rapid, there was slight dul-
ness. at the right base, with tubal breathing and
crepitant rales. Pulse 130. Consciousness dulled.
Violent delirium all night, and next day she was
brought to the hospital.

At this stage the breath signs were barely
audible at the right base, and the two symptoms
that attracted our attention were the delirium and
the retraction of the abdomen. No stiffness, no
Kernig’s sign, no exaggeration of the reflexes.
Pulse 130.

On the 13th she was calm but unconscious.
Some stiffness of the neck was noted and Kernig’s
sign was well marked. Lumbar puncture gave

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Oct. 23, 1907.

ORIGINAL PAPERS.

The Medical Press. 437

exit to a perfectly clear fluid, under a certain de¬
gree of pressure, containing a few lymphocytes
and an occasional polynuclear cell. The physical
signs at the right base had disappeared. The
abdomen was still concave. Temperature barely
99.5° F. It fell the next day to 98° F., with a slow
pulse. The patient vomited for the first time, and
became comatose. Death took place on the 15th.
Post mortem, the kidneys were found to be the
seat of chronic nephritis and weighed 7^ ounces.
The heart weighed ii£ ounces. There was general
congestion of the viscera. At the apex of one lung
a few white spots were seen, which, however, did
not look like grey tubercles. There was no trace
of past tuberculous mischief.

The meninges were intensely red, with marked
congestion of the cortex. Nothing was found at
the base of the brain.

Careful examination of the apices of the lungs
revealed nothing pointing to tuberculosis. The
kidneys presented the characteristic lesions of vas¬
cular origin. A certain proportion of the arteries
presentecf somewhat advanced lesions of arteritis
and periarteritis. The case, then, was one of
Bright’s disease, with what appeared to be inflam¬
matory redness of the meninges, limited to the
convexity, without exudation or tuberculous
granulations.

It is to be noted that this patient, on admission,
presented a herpetic eruption on the lip. I have
already pointed out that the broncho-pneumonic
lesions did not present the histological appearances
of the tuberculous process, and Ehrlich’s diazo-
reaction, which is ahvays positive in tuberculosis,
proved negative here.

The existence in the second case of old-standing
lesions pointing to past tuberculous disease of the
apex may suggest a tuberculous origin of the
meningeal congestion, but these lesions gave one
the impression of being quite “dead,” and the low
temperature militated against any such hypothesis.
Lastly, a close examination of the meninges failed
to reveal the slightest trace of granulations.

I do not, of course, pretend that tuberculous in¬
fection is necessarily associated with the presence
of granulations. The nature of a given lesion is
to a certain extent independent of the anatomical
characters which it displays. This is an unques¬
tionable fact upon which, in respect of tuberculosis
as it happens, Prof. Poncet has very properly in¬
sisted of late. But for the above reasons it appears
to me highly improbable that there was anything
tuberculous in either of the two female patients
just referred to. I may add that the rapid course
of the malady, the freedom from disease of the base
of the brain, and the absence of any meningeal
reaction in the cerebro-spinal fluid, are points to be
borne in mind.

To sum up, the first patient presented marked
thickening of the meninges over the convexity,
apparently due to the uraemia. In the two others
the symptoms pointed to meningitis, and recent
lesions were discovered. Unfortunately, owing to
circumstances beyond our control, no histological
examination of the meninges was made, so that we
are not in a position to speak authoritatively as to
the exact nature of the intense congestion found on
the convex surface of the meninges and on certain
areas of the cortex.

In spite of very careful examination of the
cerebro-spinal fluid in the two cases, we w r ere
u-nable to obtain unquestionable evidence of menin¬
geal inflammation, either because there was not
free communication between the perivascular
sheaths and the main cavity of the arachnoid—in
which event the absence of a “cup” in the fluid
does not prove the absence of a reaction in the
sheaths, or because acute uraemia does not deter¬
mine any reaction.

It should be noted that pericarditis is but rarely
met with in acute uraemia. It is possible that the
urasmic poisons, which are of endogenous origin,
are less irritating to the tissues than exogenous
poisons.

As a matter of fact, the nervous lesions hitherto
mentioned by writers in connection with acute
uraemia do not appear to have been manifestly
inflammatory. Dr. Castaigne says : “ Most fre¬
quently we find generalised or circumscribed
oedema, sometimes congestion of the brain and
meninges, with sub-arachnoid ecchymoses, which
appear to be rather the effect than the cause of the
uraemic accidents.”

I do not know whether genuine inflammatory
lesions have been found to be the basis of the
auricular troubles in renal patients. As to the
retina, I am aware that in renal subjects it is
often the seat of exudation, and a special renal
variety of retinitis has been described, but we
do not find white patches in the early stages of
uraemia.

In the absence of further information, therefore,
I hold that inflammatory lesions are only produced
in chronic uraemia. The meningo-eclamptic sym¬
ptoms are acute disturbances, so that we must not
be surprised to find that they are not dependent
on frankly inflammatory lesions.

We must, indeed, not bind ourselves to the data
afforded by pathological anatomy, and, to speak
frankly, the symptoms are much more dependent
on the distribution than on the nature of the
morbid process. This is why we must learn to
think physiologically, and not anatomically, as we
are so often tempted to do. I do not pretend that
the nature and intensity of the lesion are devoid
of importance, for it is clear that the destruction
of an organ must abolish its function, but so long
as a lesion is not too advanced, and is, Ala rigueur,
curable, we must pay special attention to the
functional disturbance, for that, after all, consti¬
tutes the disease.

NOTE. —A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture for
next week will be by H. Oliphant Nicholson, M.D.,
F.R.C.P.B., Assistant Physician to the Royal Maternity
Hospital, late Obstetric Physician to the New Town Dis¬
pensary, Edinburgh. Subject: “ The Prevention of Fever
in the Puerperium.” _

ORIGINAL PAPERS.

SOME MEDICAL" ASPECTS OF
SPINAL CURVATURES.

By GEORGE W. F. MACNAUGHTON, M.D.,
M.R.C.P., F.R.C.S.E., etc.,

Phyalclan, Kensington General Hospital.

When briefly considering these conditions, one
may affirm that kyphosis, to a greater or less
degree, is present as a natural state in the two
extremes of life—in the infant, before the spinal
muscles acquire power to assume and maintain the
upright position; and in the aged, where the
anterior margins of the intervertebral discs, be¬
coming atrophied and inelastic, permit the natural
tendency of the flexor muscles to prevail over the
extensors. At other times, excluding rickets and
Pott’s disease, this antero-posterior curvature takes
place in the cervical and upper dorsal segments in
osteo-arthritis, in many cases of cardiac disease,
especially where pain is a feature, in lung fibrosis,
and chronic bronchitis, and more decidedly when
accompanied by asthma.

Lordosis of a moderate degree is more frequently
met with than kyphosis, but presents less medical
interest. In persons with a pronounced lumbar

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43^ The Medical Press.

ORIGINAL PAPERS.

Oct. 23, i9°7-

forward curve, the head is generally large, the
figure rounded and of medium height, with an
abdomen disproportionately prominent to its cir¬
cumferential measurement, while the hips arc
broad. The disabilities attendant thereupon arc
backache after walking a comparatively short dis¬
tance, and in swimming on the breast the lower
half of the body, being deep in the water as com¬
pared with the position of the thorax, progression is
hindered. Further, the legs, by being upon a still
lower plane, lack force in the kick and in their
return to position, and thereby lose a considerable
power of propulsion.

Scoliotic changes occurring in early life and the
consequent deformities present a surgical rather
than a medical aspect. The converse, however,
obtains in those cases attributable to occupation,
postures, and debility, and which have their advent
between the ages of twenty and thirty years, or
even later. In these the amount of curvature
apparent upon examination is no real index to the
severity of the patient’s distress. Just as the inci¬
dence of a rapid, though moderate, flattening of
the arch of the foot in the adult is followed by
numbness, heaviness, and pain in the leg upon
reasonable exertion, so does slight lateral curvature
present a number of indefinite and desquatous
symptoms, or these occipital and vertex headaches
—visceral crises, more frequently intestinal than
gastric, localised and diffused neuralgias, along
with temporary trophic alterations, such as swelling
of the hands, form a series indicative of spinal
irritation, and frequently classed as hysterical or
neurasthenic. When one considers the continual
effort required of the central nervous system in
maintaining the tone and relative positions of
muscles, and the inherent strain upon these,
which, in the presence of even a slight scoliosis,
sustain, at a disadvantage, the erect position of the
body, then it is justifiable to conclude that many
cases of neurasthenia are the consequence of lateral
curvature. Moreover, a number of the cephalal¬
gias, particularly those which arise from attempts
at reading, are due to that irritability of the
sensorium which accompanies curvature, and not
to defects in the visual organ.

During empyema, and occasionally phthisis,
scoliosis occurs as an accommodative process.
There are other physical signs of medical import,
however, and, of these, changes in the apices of the
lungs are perhaps the most deserving of attention;
thus, to whichever side the curve in the dorsal
region be inclined, the scapula of that side projects
backwards, and the entire shoulder passes forwards
and upwards, while anteriorly, the supra and infra-
clavicular areas become prominent. On the other
side of the thorax the changes in configuration are
exactly the opposite, and the parts above and below
the clavicle become flattened and depressed. Besides
these abnormalities to be observed on inspection,
the breath sounds on auscultation are altered, so
that in the retracted regions the breathing is harsh,
vesicular, or broncho-vesicular. The percussion
note is impaired; and, notwithstanding that the
fremitus is but little modified, the ensemble is like
to early consolidation of the lung, and may be
readily mistaken for it.

Although not attributable in any wise to the cur¬
vature which goes with marked right or left
handedness, it should be noted that many persons
of middle age, who are occupied in the finer mani¬
pulative movements, such as art and penmanship,
show the walls of the arteries in the arm most
employed to be thickened, and the veins more
prominent than those of the opposite limb. This
fact should be remembered when estimating the
blood pressure of the individual.

POSTOPERATIVE INTESTINAL H
OBSTRUCTION.

By R. J. JOHNSTONE, B.A., M.B.,
F.R.C.S. Eng.

AisUtant Gynecologist, Royal Victoria Hospital, Belfast -.'.Burgeoo
Belfast Maternity Hospital.

Post-operative intestinal obstruction is a con¬
dition which is not very commonly met with. It
occurs on an average after about 1 per cent, of
abdominal operations, and is said to be more fre¬
quent after vaginal hysterectomy than after other
operations. I lost one case of vaginal hysterectomy
from this cause four years a^o; since then 1 have
not encountered it again until this year, when the
following two examples of the condition occurred
in my practice.

Case /.—Isabella McD., set. 34, was admitted
to hospital on March 30th, 1907. She had been
married eleven years, had borne two children, the
vounger eight years ago, and had had no mis¬
carriages. Her menstruation was regular—of the
four-weekly type, lasting about three days, and
not excessive. She had noticed an abdominal
tumour nine years before admission, which had
grown gradually larger. About five years ago she
| had an attack of pain over the tumour, which re-
1 curred at first about every five months, and then-
with rapidly decreasing intervals, until the attack
coincided with each menstrual period. The pain
lasted, as a rule, two or three days. She was sent
into hospital by Dr. Kennedy for an attack of more
severity than usual, from which she had suffered
for a week before admission.

On examination, she had all the signs of a large
myoma, extending up to the costal margin, with a
localised dry peritonitis. Her temperature on ad¬
mission was ioo.^° F., and her pulse 120. After
four weeks’ rest in bed and expectant treatment,
her temperature was normal in the morning, but
still rose to 99.5 or thereabouts in the evening.
Her pulse had, however, come down to 86, and I
thought it right to remove the tumour.

Accordingly, on May 1st, I performed a supra¬
vaginal hysterectomy. 1 found verv extensive
adhesions to the omentum, and as there was a
good deal of haemorrhage from its surface after
these had been separated, I tied off and removed
the major part of that organ. The tumour was
adherent, by its posterior aspect, to the root of
the mesentery, but was separated with less trouble
than might have been anticipated. The abdominal
cavitv was well flushed with normal saline, and
left full of the fluid when the incision (a ten-inch-
one) was closed in three layers.

The patient’s temperature that evening was 99.5,
and her pulse 120. She had a morphine hypo¬
dermic to auiet her through the night. Vomiting
continued during the next day, and she was given
a powder containing bismuth and sodium bicarbo¬
nate without effect. I ordered her a soap-and-
water enema that evening, which acted well but
did not check the vomiting. On the third day
after operation she was still vomiting at intervals,
though her pulse had come down to 100, and her
temperature to normal. Next day her pulse went
up again to 110. She was given a turpentine
enema which moved her slightly, but she still con¬
tinued to vomit. On the fifth day after operation
distension of the abdomen began to make its
appearance, and as her pulse had risen to 128, and
the vomit was becoming rather fjecal in appear¬
ance, I re-opened her abdomen under chloroform
and ether. Distended and injected bowel at once
presented itself, and, on following this up, the
obstruction was seen to be caused by a recent
adhesion of the gut to the omental stump, causing
a kink. The intestine distal to this was quite
collapsed. I freed the adhesions, and buried the

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Oct. 23, 1907.

ORIGINAL PAPERS.

The Medical Press. 439

omental stump in the peritoneal flaps of the
abdominal wound. There was a large quantity of
dark and rather foul-smelling serum in the abdo¬
minal cavity, which I washed out with plenty of
saline before closing the abdominal wound in
layers.

The operation was done at five in the evening,
and gas could be seen passing into the collapsed
portion of the gut before the wound was closed,
yet faecal vomiting continued till eight the next
morning. Shortly after flatus was passed, and
vomiting ceased. The bowels moved of themselves
about five in the evening, twenty-four hours after
operation. One or two stitch abscesses developed,
otherwise convalescence, though slow, was un¬
eventful.

My second case Sarah P., aet. 38, was also
married, but had had no children and no mis¬
carriages. She could fix no date for the time when
she first noticed her tumour. The symptoms com¬
plained of were pain in both sides of the abdomen
for two or three years, frequent and painful mic¬
turition, and constipation which had lasted for
three weeks. For these she was sent into hospital
by Dr. Hunter, of Dunmurry, who assisted me at
the operation. Menstruation was four-weekly in
type, lasted five days, and was profuse. She had
all the signs of a large fibromyoma of the uterus,
occupying practically the whole abdomen.

Her temperature rose to 99.8 on the evening of
admission, -but dropped to normal for the three
days following, and her bowels were well moved
by'white mixture. I operated on August 8th—four
days after admission—and removed a large myo¬
matous uterus with a good deal of difficulty, as it
was adherent over almost its whole surface to
omentum and intestines. To get at the posterior
adhesions I had to bisect the tumour, and even
with this help the operation took two hours. The
patient’s condition afterwards was very bad, but
by dint of repeated saline and brandy enemata and
injections of adrenalin she pulled round, and went
home to Dunmurry three weeks and a half after
operation. Although the wound healed by first
intention, her temperature rose at intervals to be¬
tween ioo° and ioi° from the seventh day after
operation to the eighteenth day, which is of interest
in the light of the sequel.

She left hospital on August 30th, apparently well,
though, of course, weak, and shortly after Dr.
Hunter tells me that the lower end of the scar
irave way and commenced to discharge thin pus.
On September 23rd, almost seven weeks after
operation, Dr. Hunter was summoned to see her,
and found her vomiting incessantly, and with such
an alarmingly bad pulse that he did not expect her
to live through the night. He gave her morphia
hypodermically, and, as she was a little better
next morning, asked me to see her with him. I
found her still vomiting, with a pulse of 140 and
some distension, and, as the surroundings were
not favourable for operation, recommended her
removal to hospital as her only chance, which she
willingly consented to.

I re-opened the abdominal wound that afternoon,
after curetting the suppurating sinus which still
persisted in its lower end, and found a very interest¬
ing state of affairs. Distended bowel at once
presented itself, which was studded with recent
tubercles. An adhesion was present between a
caseous focus in the omentum and the small intes¬
tine, causing a kink. This was freed, and the
caseating area removed. Several thin stringy
bands running in various directions, and binding
down intestine beneath them, were cut away; and,
lastly, three or four coils of gut, which had be¬
come adherent to one another, and had caused con¬
siderable narrowing of the lumen of one of them,
were freed from each other. A considerable

amount of ascitic fluid was present. Convales¬
cence was delayed by the skin failing to unite at
the seat of the sinus, but otherwise the case went
on well; the patient’s pulse came down, her general
condition rapidly became good, and the bowel func¬
tions were re-established the next day, and have
given no trouble since. What her prospects are in
the future, with an undoubted tuberculous peri¬
tonitis, is, of course, very doubtful. It will be
interesting to see whether laparotomy in this case
has the beneficial effect which it certainly does
produce at times in this type of disease.

These cases are worth recording, as post-opera¬
tive ileus is a condition which, after being for
many years the bugbear of the pioneers in abdo¬
minal surgery, now receives little attention either
in text-books or in journals. There is no doubt
that modern aseptic technique, and better judg¬
ment in choosing the time for operations, have
done much to minimise the risks; still, abdominal
operations of all kinds are now so frequent that it
is rather a matter of surprise that more accidents
of the kind are not reported.

I would like to emphasise the insidious charac¬
ter of the onset of symptoms in my first case. The
main, in fact, the only symptom at first was
vomiting. This was continuous with the usual
post-anaesthetic vomiting, which may last for
twenty-four hours or even longer, especially where
the operation has been prolonged and morphia has
been given afterwards. The danger-signal was
the continuance of the vomiting after the second
day. Two motions had been procured by the ad¬
ministration of enemata, so that symptom Was
negative. The points which, to my mind, esta¬
blished the diagnosis were distension, most marked
in the lower half of the abdomen, and the rising
pulse-rate, and when these appeared I resolved to
operate at once.

In the case which I referred to at the beginning
of this paper, and which I lost, the symptoms were
still more equivocal; recurrent attacks of vomiting
were succeeded by intervals during which the
bowels acted and everything seemed to be right,
until when the symptoms of obstruction became
declared and permanent the patient was too far
gone to be s^ved. The obstruction in that case
was a kink due to an adhesion to the wound in the
vagina, and had evidently been relieved from time
to time by the bowel becoming straightened out.

My last case is an exceedingly interesting one.
This patient had absolutely no history of any
trouble whatever, until the pains due to inflam¬
matory changes in the tumour first appeared. At
the operation there was no sign of tubercle in the
peritoneum, and yet a caseous focus must have
been broken down in the manipulations necessary
to separate the adhesions, with the result that the
infection was spread over the serous lining, and an
acute tuberculous process set on foot. Such cases
add another risk to abdominal surgery, but one
which, I hope, the operator will not often be called
on to encounter.

It is of interest to note that the abdomen in each
of these cases was filled with saline before being
closed, which is supposed to be a preventive against
the formation of adhesions. It is more than a
coincidence that each case had suffered from
active adhesive peritonitis before and almost up to
the date of operation; but, on the other hand,
in how many similar cases does one operate with¬
out any untoward result? The “abdominal facies”
which one expects in acute obstruction was con¬
spicuously absent, both patients being rather
flushed and feverish-looking. I have met with
this complication on the three occasions which I
have narrated, in a total of upwards of 200 abdo¬
minal sections. I hope that these cases may be of
interest, and possibly of some help, to other

ized by GOOgle

44 ° The Medical Press.

surgeons in dealing with a condition which is, in
my experience, a rather insidious, but a very real
danger after operation, although, if the diagnosis
be made early and the proper treatment—viz.,
opening the abdomen—carried out before it is too
late, the results, even in the most debilitated
patients, are surprisingly good.

HAEMORRHAGIC RASHES, («)

By GEORGE PERNET.

Assistant to Skin Department, University College Hoepital, London.

Haemorrhagic lesions of the skin, using the term
haemorrhagic in a wide sense, are visually spoken
of as petechiae, ecchymoses and vibices. In a
general way petechiae apply to small punctate
spots and ecchymoses to larger ones. They axe
bilateral in distribution, multiple, more or less cir¬
cular, but may be irregular ; of a bright red tint in
the early stages, varying in shade with time, much as
the play of colours so grossly exhibited by a sub¬
siding black eye. Ecchymoses may become confluent
and give rise to large livid patches and areas. Again,
petechiae may pick out the pilo-sebaceous apparatus.
Haemorrhagic spots are sometimes raised, especially
in erythema multiforme conditions. In vesicular and
bullous eruptions, when the onslaught is severe, the
contents of the vesicles and bullae may be haemorr¬
hagic. A very fine haemorrhagic stippling is also ob¬
served as a complication in long-standing eczema and
psoriasis of the lower limbs, especially when varicose
veins are present. With regard to vibices, they occur
as streaks. In addition to the cutaneous haemorr¬
hages proper, subcutaneous effusions of blood may
also be present.

The distinctive feature of these lesions is that their
colour does not disappear on pressure, owing to ex-
travasated blood or blood-colouring matter, thus
differing from a simple inflammatory process. The
first thing to do, therefore, in such cases is to pass
the finger firmly over the spots, bearing in mind that
in some patients they may be very tender.

The parts usually affected are the lower limbs.
Next in order of frequency are the forearms and arms,
and more rarely the trunk and face.

It is usual to refer to hsemorrhagic cutaneous mani¬
festations as purpura, but I need scarcely insist on
the fact that this is merely designating a symptom.
The point of course is to form an opinion as to the
cause, in order that treatment may be as rational as
possible. I am well aware that these remarks are
at this time of day commonplaces, and I would not
allude to the matter were it not that diseases of the
skin are sometimes apparently dealt with as if they
were something apart.

In the class of case I am considering, the purpuric
symptom is one that always indicates a marked, not
to say serious, derangement of the organism, and it is
important to be on one’s guard a3 to possible com¬
plications, such as internal haemorrhages. On the
other hand, the skin trouble may accompany or
follow visceral or orificial bleeding, or be premoni¬
tory of some general infection.

The so-called primary purpuras are really signs of
intoxications and infections arising from various
causes, the individual state of the tissues and of the
blood playing their part of course. In approaching a
case of cutaneous haemorrhage, therefore, the impor¬
tance of taking it on its merits and of not being misled
by a label is obvious. It should be dealt with on
general routine lines, with special insistence on occu-
pation, habits, food and drink, a hsemophilic history,
and so forth, and bearing in mind the specific fevers.
The mouth and throat should always be carefully
examined, and in the case of children especially, as
I shall show further on, the lungs should not be over¬
looked. The urine must never be neglected, as it may
reveal the presence of albumin, sugar, indican, etc.,
or indicate renal inadequacy.

The most common condition observed is erythema
p urp uricum, coming into the category of erythema

(a) A Paper read before the West London Medlco-Chlrurirical
Society, 1907.

OCT^ 23, 1907.

multiforme. The patient is often a young woman
whose occupation necessitates a good deal of stand¬
ing. The rash is mainly confined to the legs and
thighs, where numerous spots are found which do not
disappear on pressure. The older ones, for the
lesions come out in crops, are level with the skin, but
recent ones will be found to be elevated when more
carefully examined and the finger lightly passed over
them. • There is frequently a history of previous at¬
tacks, recurrent at certain times of the year, a fact
readily ascertained in some instances by direct
examination on account of the pigmented appearances
left behind. The following cases succinctly stated
may be adduced as showing the diversity of causes.
A domestic servant, aged 23, in whom the purpuric
erythema lesions had been going on for six months,
and which started after “catarrh of the liver,” so she
stated, a good deal of blood being passed at that time
per rectum. In another woman, aged 32, the petechial
and ecchymotic rash one day old came out on the
legs one day after eating some crab. She had had
diarrhoea for three weeks. In the case of a man,
aged 42, a musician playing at times in an orchestra,
the rash appeared four weeks or so after an attack of
influenza. Fresh lesions came out whenever he had
to sit up late. No other cause could be definitely
made out. The upright or sitting posture appears to
be the determining cause in some instances.

A vegetarian diet appeared to be an important
factor in a girl, aged 15, who had a natural distaste
for meat, and could not be persuaded to eat any. As
showing the importance of examining the throat, this
was well brought out in a case which commenced
with reddening of the palms, and was of three days’
duration. The purpuric erythema attacked the legs
mainly, but was also present on the back of the
hands, elbows and arms, accompanied by swelling of
the knees and ankles. On looking at the throat
evidence of acute tonsillitis was discovered. In
another case the only apparent cause was the bad
condition of the buccal cavity and the neglected con¬
dition of the teeth, with pyorrhoea alveolaris. Old
syphilis and diabetes insipidus were found to exist in
a man, aged 28, who had suffered from erythema
purpuricum every winter for five years, with swelling
of the feet and legs. Erythema purpuricum may go
on to necrosis of the haemorrhagic lesions, as
exemplified in a man, aged 40, who had had a previous
similar attack, brought out, he admitted, when he
drank beer, not wisely but too much, no doubt. Here
it may be opportunely insisted on that alcoholism is
an unfavourable factor. The necrotic areas had
given rise to scars, especially about the knees, that
might well have been taken for old syphilitic lesions,
a point of some differential diagnostic interest. A
very unusual erythema purpuricum, which appeared
to be due to the action of strong sunlight, was ob¬
served in a woman, aged 23, in whom the face was
first affected and then the forearms. The aforemen¬
tioned examples will suffice to bring out the point I
desired to insist on, viz., the divers causes leading to
one and the same symptom, a phenomenon of im¬
portance, I may add, in cutaneous pathology. The
reverse of this is the fact that various skin manifes¬
tations or reactions may be due primarily to one and
the same cause.

A more severe and rare condition is the one known
as peliosis or purpura rheumatica (of Schonlein),
which is here in its place after discussing hasraorrhagic
erythema multiforme. In peliosis rheumatica the
pains in the joints are marked, and they may be pre¬
ceded or followed by the cutaneous haemorrhages,
especially about the joints. The patient is ill
generally, and looks it. The temperature may or
may not be raised, although in the latter case the
haemorrhagic manifestations and other symptoms may
be just as severe. The absence of pyrexia must not
mislead the observer, for it is in this morbid con¬
dition that it is of the greatest importance to bear
in mind the possibility of serious internal haemorr¬
hages, which may prove fatal. In one case I ob¬
served death was the result of intestinal haemorrhage.

Whether the qualification rheumatica is a correct
one or not is a point that must be discussed. It is
now so well known that many infections may lead to

ORIGINAL PAPERS.

Oct. 23, 1907.

ORIGINAL PAPERS.

The Medical Press. 44 1

joint symptoms quite apart from rheumatism proper,
as in gonorrhoea, for instance, that it behoves us not
to use the term rheumatica in a loose way. All cases
of so-called peliosis rheumatica are not specifically
rheumatic in origin, but the fact remains, neverthe¬
less, that haemorrnagic rashes may occur in tlie course
of acute rheumatism. Moreover, valvular cardiac
lesions have been noted as a result apparently of
peliosis rheumatica, so it is stated, in the absence of
the general symptoms denoting acute rheumatism.
Again, peliosis rheumatica has been associated with
endocarditis, and although the latter has been shown
to arise from various causes, the rheumatic infection
must be kept in view. In practice too, salicylates have
appeared to do good.

In other cases that come before one, and no doubt
allied to the preceding, the rash may be much milder
in degree, and yet the visceral haemorrhages may be
so severe as to endanger life and even to prove fatal.
Here the gastro-intestinal symptoms dominate the
scene, and are always an indication for caution, as an
opinion must be formed not so much on the appear¬
ances of the skin as on other factors. I need scarcely
emphasise the importance of dealing with cases on
ibeir individual merits, and of avoiding concentration
of the attention on the skin alone.

Closely allied to the purpuric erythema I have
described is the condition known as urticaria haemorr-
hagica or purpura urticans, in which the urticarial
wheals become haemorrhagic. The cutaneous rash
may be asociated with urticarial manifestations in¬
volving mucous membranes, with haemorrhages from
the latter that may be copious. Internal haemorr¬
hages may occur in some cases without haemorrhages
in the urticarial wheals.

I must now consider another clinical condition
which is not uncommon, the so-called purpura sim¬
plex, sometimes alluded to shortly as purpura. Here
the lesions are not raised as in erythema haemorr-
hagicum, but level with the skin. It is often a very
recurrent complaint, going on for years, with intervals
of freedom. The lower limbs are mainly affected,
and the pigmentation left behind may be very great.
In a young woman aged 29, for instance, who had
suffered from the complaint for about twelve years,
the legs were of a dusky sepia brown tint. It is true
that she had had arsenic for some months,' so that
drug may have played a part in the production of the
pigmentation. In this case there was a presystolic
thrill and the catamenia were excessive. When she
took tonics she bled from the nose.

In another case the purpura about the ankles was
accompanied by swelling. The patient had been
subject to epistaxis from childhood. The catamenia
were more or less menorrhagic. On examining the
urine I found albumen but no blood either micro¬
scopically, chemically or spectroscopically. The discs
were normal, but in one fundus there was a white
patch. I could adduce other cases to show that pur¬
puric rashes are not infrequently associated with albu¬
minuria. That is why I have insisted on the im¬
portance of always testing the urine, and I may add
whether the patient be adult or child, for I have seen
the association in the latter. I say association, al¬
though the albuminuria is in some cases, no doubt,
the determining cause of the purpuric rash, other
factors being favourable, the possibility of both
manifestations being the result of an intoxication must
not be overlooked.

The typical petechial rash due to flea-bites must be
mentioned here. In children it may be so generalised
as to be mistaken sometimes for a purpuric eruption
from within.

Purpura haemorrhagica or morbus maculosis Werl-
hofii takes us on a further stage. This is a very
serious condition, in which the cutaneous haemorr¬
hages are extensive and accompanied by marked and
varied internal haemorrhages, so much so that all the
viscera and mucous membranes would require to be
enumerated. Epistaxis may be a prominent feature,
and careful plugging of the nasal passages become im¬
perative. The skin haemorrhages are very recurrent,
so that when cases have gone on for some time, the
integument may present a multicoloured appearance
a- a result of involuting and evoluting lesions. Not¬

withstanding the severity of the symptoms, patients,
generally children, may recover, but owing to the
anaemia and collapsed condition, convalescence is
necessarily protracted. Fortunately the disease is
uncommon. Morbus maculosis has been looked upon
as a diathesis, an easy way of getting out of the diffi¬
culty, but I propose to touch further on this point
when I deal with aetiology, as in my opinion the
condition is not an entity, but the manifestation of a
reaction of the tissues dependent on a variety of
causal factors.

Severe forms of purpura have been variously
described under the names of acute idiopathic pur¬
pura vel angiohaematic typhus, primary hasmorThagic
purpura, and so forth. Mathieu classifies these under
three heads: the typhoid form, the hyper-acute form,
and the pseudo-rheumatic form [1]. But it is difficult
to resist the impression that these attempts at water¬
tight classifications are subjective artificial creations,
useful, no doubt, yet as sign-posts not to be too im¬
plicitly relied upon. Here once more, it is of essential
importance to be guided by what one can observe for
one’s self in the way of facts discoverable by careful
examination. In addition to this, those who have
been much in contact with morbid conditions can
gather a good deal of preliminary knowledge as to a
patient’s state by the impression made on the ob¬
server.

In children, Henoch has described a fulminating
form, purpura fulminans, in which large cutaneous
extravasations occur suddenly and rapidly spread, so
much so that in a few days a whole limb may be in¬
volved, with darker areas interspersed, as of
threatening gangrene. There may be slight fever or
none. The skin hasmorrhages increase, and death
soon closes the scene. In the new-born cutaneous
haemorrhages may occur, purpura neonatorum, as a
result apparently of the sudden changes in the cir¬
culatory apparatus brought about by separate
existence.

Haemorrhages into the skin, mainly affecting the
lower limbs, occur in scurvy, which is sometimes
arbitrarily alluded to either as sporadic, or again as
true scurvy, an artificial distinction. An instructive
case of scurvy which was under the care of Dr.
Seymour Taylor in the West London Hospital,
and described by him at length in the transactions
of the West London Medico-Chirurgical Society,
will, no doubt, be remembered by some of you [2].
In that patient, a woman, aged 51, the cutaneous
haemorrhages involved not only the legs but also the
face, trunk and arms, evidence of the severity of the
disease. At the end of his paper Dr. Taylor remarked
that it was sometimes difficult to decide where pur¬
pura ended and scorbutus began, and notwithstanding
that text-books taught that they were separate and
distinct diseases, he was sometimes led to think that
they were but varieties of the same blood disorder,
and that the symptoms and signs might vary accord¬
ing to the severity of the attack. From my own
observations I agree with most of the views expressed
by him, and I have already called your attention to
my opinion in this respect. But I do not think that
the conditions referred to by him need necessarily be
varieties of one and the same blood disorder. The
cutaneous manifestations, varying in degree, may well
be on the contrary ‘he result of a variety of blood
disorders. I have already mentioned the case cf a
girl with recurrent erythema purpuricum—in whom a
vegetarian diet appeared to be one factor at any rate
in the causation of the cutaneous hzemorrhages and
account for her somewhat cachectic general condition.
The mere I see of these hemorrhagic symptoms the
more I am struck by the complexity of this problem
of causation, a subject I shall have to touch upon
when dealing with etiology. In this place I should
like to insist again on the importance of not taking
diseases considered as entities too literally, especially
from the point of view of treatment. What we have
to deal with in the majority of the cases I am con¬
sidering, is an organism with all its potentialities
labouring under some intoxication or infection, a fact
which will become more and more evident as we
go on.

I may suitably refer here to the cutaneous

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44 2 The Medical Press.

ORIGINAL PAPERS.

Oct. 23, 1907.

hmmorrhages which arise either before, or in the course
of, or after various morbid conditions.

Let us take enteric fever for instance. In the case
of a boy, aged 19, a generalised petechial rash occurred
sparing a triangular “bathing drawers” area, typical
rose spots being present at the time. Widal’s re¬
action was positive. Or, again, one may observe
large areas of ecchymosis.

Purpura may follow diphtheria. In the case of a
girl, aged 11, recorded by Goodall and Basan [3],
there were cutaneous haemorrhages about the limbs
but very little on the trunk. No albuminuria. True
it is that antitoxin had been injected, but Goodall
did not consider that was the cause, as he had seen
the same symptoms in a case before antitoxin was
introduced. I have pointed out that Trousseau noted
these hemorrhages in diphtheria long ago: petechi®,
ecchymoses and epistaxis [4].

As is well known hemorrhagic lesions may occur as

art and parcel of the acute exanthemata, in variola

emorrhagica for instance. Varicella hemorrhagica
is of very rare occurrence. In measles, hemorrhagic
foci may appear about the skin, going on to necrosis,
especially where septic endocarditis is a complica¬
tion. With regard to small-pox, a petechial rash is
sometimes observed at the end of the first stage of
the disease, that is, at the time the true eruption ap¬
pears, or should do so. It is of bad prognosis.
Again, cutaneous haemorrhages may be interspersed
between the papules or vesicles of the efflorescence.
In this connection the finely punctate petechial rash
recorded by Roger under the name of purpura minu-
tissima metamerica [5] must be alluded to as of
differential diagnostic importance. The case was that
of a woman, aged 34, and the rash being accompanied
by symptoms resembling those of variola, the question
of the latter disease arose. The purpuric rash com¬
menced in the groin 3 and axillae, and also about the
joints, ultimately becoming generalised in a way that
strongly suggested a spinal origin, hence the term
metameric or segmental. Further observation
showed the case was not one of variola, although at
first the differential diagnosis from a premonitory
purpuric rash appeared likely. It should be added,
too, that the case had been sent to the isolation fever
hospital under the diagnosis of scarlatina.

A purpura-like eruption in scarlet fever has been
noted by Heubner [6] in a child, aged 14, the whole of
whose body was covered with lentil to thaler sized
patches, not disappearing on pressure. Here and
there the rash was more stippled. The child had not
been isolated as a scarlatina case, as the condition
was thought to be one of “septic” rash. Hubert Biss
has given a good account of a purpura fulminans fol¬
lowing scarlet fever [7] in a boy aged 34, who had
received 24,000 units of antitoxin under the idea the
case was one of diphtheria. But Biss considered it
was highly improbable that this was the cause of the
widespread pin-point h®morrhagic rash which super¬
vened, and which was preceded and accompanied by
other haemorrhages (stomach, rectum). An abun¬
dant growth of streptococci was obtained from the
tonsillar exudation. The child died thirty-six hours
after the appearance of the first h®morrhages. The
kidneys were found to be transformed almost entirely
into fat. I have mentioned this case at some length
on accovnt of the complexity of the factors present:
scarlatina, antitoxin, streptococcal infection and use¬
less kidneys. The condition described appeared to
Biss to come into the category of the purpura ful¬
minans of Henoch I have referred to, and it must be
noted that one of the latter’s two cases occurred after
scarlet fever [8], as did also one of two cases related
by Strom and Alexander [9], but I may point out that
in Henoch’s cases, and in two others he cites
(Michaelis and Charron), there were no hasmorrhages
from mucous membranes and the necropsies were
negative. Rice-Oxley and Cullen have also recorded
similar cases.

Cutaneous hasmorrhages have also been seen as a
complication of vaccination [10].

In erythema nodosum, which appears to be a
disease sui generis, cutaneous haemorrhages may be a
complication.

As to the syphilitic infection, the condition known

as syphilis haemorrhagica neonatorum appears to
have been first established as a fact by Behrend [11].
The clinical picture is made up of cutaneous and in¬
ternal haemorrhages, the latter involving various
ergans. But in adults h®morrhages occurring in the
skin during the early or so-called secondary period
are uncommon. Piccardi has described an instructive
case, with histological details, the subject being a
man aged 38 [12]. Microscopically there were infil¬
trations of extravasated red blood corpuscles. In
another case recorded by Weitz, he could not demon¬
strate haemorrhage into the tissues, but only marked
dilation of the small vessels, which were packed full
of red corpuscles. This explained why the cutaneous
lesions did not disappear on pressure [13].

Cutaneous haemorrhages with haemorrhagic bull*
may occur in the course of enteric fever in syphilitics
under mercurial treatment. In a case of this kind
under Robin, enteric supervened in a woman aged 25,
whilst under energetic mercurial treatment for early
syphilis, death closing the scene soon after the
appearance of skin hemorrhages. Duhot observed a
man in whom enteric developed a month and a half
after a course of mercury. Towards the end of life
petechiae occurred followed by ecchymoses and hemor¬
rhagic bull® [14].

In addition to the infectious morbid conditions I
have enumerated, purpuric rashes have been observed
in connection with many others, such as typhus,
cholera, puerperal fever, malaria, and so forth.
Petechial and purpuric spots are apt to appear in
epidemic cerebrospinal meningitis or spotted fever. In
this disease, as you well know, the diplococcus
meningitidis intracellularis is found in the cerebro¬
spinal fluid, but I desire to allude to it mainly in con¬
nection with the important part supposed to be played
by the spinal apparatus in toxic erythematous and
h®morrhagic rashes, a point I have called attention
to when speaking of Roger’s metameric purpura
minutissima case.

Various micro-organisms have been found in pur¬
puric eruptions. I have dwelt on some already. In
the list are found streptococci and pneumococci, less
frequently, the staphylococcus, bacillus anthracis,
bacillus pyocyaneus and others. With regard to this
point I propose to deal with it further under ®tiology.
I should like to say at once, however, that saprophytic
micro-organisms may find their way into the blood
after death, and also no doubt during life, so that
their presence does not conclusively prove in certain
circumstances that they are the cause of the h®mor-
rhages.

Again, cutaneous h®morrhages occur in cachectic
states, such as those which follow in the train of
cancer, sarcoma, pernicious an®mia, etc. ; also in
various visceral diseases, especially of the liver and
spleen [19]. In this connection may be mentioned the
purpura senilis described by one of the fathers of
English dermatology, Bateman, a condition observed
in the aged.

BIBLIOGRAPHY.

[1] Mathieu. “Diet. F.ncyclop.” S£rie ii., tome 27,
p. 865.

[2] Seymour Taylor. West Land. Med. Journ., vol-
ix., 1904, p. 215.

[3] Goodall and Basan. Lancet, vol. 11., 1901, p. 149 *-

[4] Trousseau. Clinique, tome i., 1865, pp. 363, 364,
365 ; also Pemet, “Drug Rashes,” loc cit infra (15).

[5] Roger. La Presse Midicale, 1902, p. 447.

[6] Heubner. “Lehrbuch der Kinderheilkunde,"

1903, vol. i., p. 342. .. e .

[7] Hubert E. J. Biss. Lancet, vol. 11., 1902, p. 280;
see also Cullen, Brit. Med. Jour., vol. i., 1903, p. 197;
Rice-Oxley, Lancet, 1900.

[8] Henoch. “Vorlesungen fiber Kinderkrankheiten,
1899, p. 848.

[9] Biss. Loc. cit., supra, p. 286, column 1.

[10] Pemet. “Vaccination Rashes and Complica¬
tions,” Lancet, vol. i., 1903; also Poole, “Vaccination
Eruptions," 1893, p. 48.

[u] Behrend. Berliner Med. Gesellsch., 1877 ; Deutscke
Zeitsch. f. Prakt. Med., 1878; cited by Piccardi {vide
infra 9).

Digitized by GoOgle

Oct. 23, 1907. OPERATING

[12] Piccardi. “ Syphiloderma haemorrhagicum
adultorum,” Arch. f. Derm, u Syph., band 1 ., 1899.

[13] VVeitz. Monats. f. praki. Derm ., 1905, p. 544;
cited in Brit. Journ. of Derm., 1906, p. 296.

[14] Robin. Bulletin Gin. de Therapeutique Med.,
etc., vol. cxliii., 1902, p. 610; Duhot’s case (Oral
Communication).

[19] Hadley and Bulloch. Lancet, vol. i., p. 1219.

THE OUT-PATIENTS’ ROOM.

ROYAL FREE HOSPITAL.

A Case of Congenital Syphilitic Osteo-Pcriostitis of the
Femur of an Infant.

By J. B. Legg, M.S., F.R.C.S.

A male infant, 5 weeks old, was brought to the
hospital with a swelling in the lower part of the left
thigh. It had been noticed on the previous day whilst
the child was being washed. The child was said to
be rather more fretful than usual. There was no
history of injury either at his birth—the presentation
was a vertex and the labour was easy—or since. The
mother had had one miscarriage and one child, who
died soon after birth. There was no other definite
syphilitic history. This baby was a rather poorly
nourished child, but appeared otherwise healthy.
There was no rash, no condylomata, and he did not
snuffle. At the lower part of the left thigh, involving
the whole circumference of the shaft of the femur, there
was a uniform, smooth, hard swelling, with shelving
edges, at the upper end. The skin and subcutaneous
tissue were unaffected. The swelling was apparently
tender, and it reached half-way up the shaft a little
further on the inner side, where it was more pro¬
minent. The knee was kept in a flexed position ; the
infant did not move the leg, and attempts to flex or
extend the knee caused the child to cry a good deal.
If he was left alone, he lay quietly and was not fretful.
The knee joint appeared to be unaffected. The tem¬
perature was 99.6°. All the other bones appeared to
be healthy. The diagnosis, Mr. Legg said, lay between
some form of inflammatory swelling and a new growth.
An infant of this age was very unlikely to be the
subject of a new growth : inflammatory swellings were
not uncommon, and therefore until it had been proved
not to be inflammatory, the question of new growth
need not be further discussed. The characters of the
tumour were in favour of it having been present much
longer than the mother had observed. If it was an
acute inflammatory swelling of the bone, and had
reached the size of the present tumour, the tenderness
would have been much greater, there would have been
redness of the skin and oedema of the subcutaneous
tissue, a greater rise in temperature, and the child
would be very ill. All these signs were absent.
Moreover, a leucocyte count showed only 8,200 per
c.mm. For these reasons an acute infective process
could be excluded. A spontaneous subperiosteal
hemorrhage was a possibility, but the child was not
anemic, and its gums were healthy. There remained
practically three things, (a) a fracture, (b) tuberculous
periostitis, (c) osteo-periostitis due to congenital
syphilis. As regards a fracture there was no normal
mobility and no suspicion of crepitus, and no history
of injury at or since birth. A skiagram would be of
value in excluding such injury. The diagnosis really
lay between tuberculous and syphilitic osteo-periostitis.
Tubercle in an infant of this age was rare in the
bones : congenital syphilis was not rare, and affected
the ends of the long bones, specially the humerus and
femur leading to the condition known as “pseudo-
paralysis,” in which the joint is not moved on account
of the pain, but when the pain disappears and the
bone condition recovers, the paralysis also disappears.
This child at present showed no other sign of con¬
genital syphilis. Therefore, one would have to try the
effect of treatment to confirm or disprove the diagnosis.
It was important to remember that congenital syphilis
showed itself in many ways, and there was not always

THEATRES. The Medical Press. 443

present the whole picture of the disease. Unguentum
hydrargyri was ordered to be rubbed in to the
abdominal or chest walls, at first once and then twice
daily. A very important element was that the child
should be kept warm and well fed.

The child was admitted as an in-patient. A skia¬
gram did not show the presence of a fracture. In the
course of the next three weeks, under the above treat¬
ment, the swelling almost completely disappeared, the
general health being much improved at the same time.

OPERATING THEATRES.

KING’S COLLEGE HOSPITAL.

Encefhalocele. —Mr. Peyton Beale operated on a
child, aet. about five months, who had been admitted
under Dr. Still with a large soft tumour, somewhat
larger than the child’s head, projecting from the
occipital region, about two inches below the occipital
protuberance. The tumour was soft in consistency,
and became larger when the child cried. Its point of
attachment to the skull was about two and a half
inches in diameter, and on carefully examining the
occipital bone with the fingers it was clear that the
tumour issued through a foramen of about an inch
and a half in diameter in the occipital bone. The
child was fairly well nourished, but for the last few
days had been taking food badly, so it was determined
to make an attempt to remove the tumour. After the
usual preparation, a vertical incision was made straight
over the mass, which was then seen to be an
enormously distended ventricle covered with cerebral
and cerebellar substance. A strong ligature was
rapidly applied round the pedicle of the tumour, and
the latter cut off. It was then seen that it was an
expansion of both lateral ventricles, but it was not
clear exactly what part was beneath the cerebellar
substance. The stump was then ligatured in three or
four smaller pieces, and the redundant skin having
been removed with scissors the edges were sutured
vertically. The whole operation lasted only a very
few minutes, and the child appeared none the worse
for it, indeed it took nourishment better during the
next week. It then developed some bronchitis, and
died suddenly about a fortnight after the operation.
Mr. Beale remarked that these cases when they were
operated upon usually died very soon from shock ; he
believed, however, that this could be avoided if the
operation were done quickly. In this particular case
there was no reason to suppose that the child died
as the result of the operation, and had the bronchitis
not supervened it would have been very interesting to
observe to what extent the child was deficient as re¬
gards general and special sensation and motion as the
result of the loss of so large an amount of cortical
brain substance. As far as could be determined in
this child there was no impairment whatever with
reference to sensation and motion, at any rate as far
as its age rendered it possible to carry out an examina¬
tion on these points. He said one of the reasons for
operation was the rapid increase in size of the tumour,
which could not be kept in check by tapping.

ROYAL SOUTHERN HOSPITAL, LIVERPOOL.

A Case of Recurrent Intestinal Obstruction.—
Mr. Newbdlt operated upon a woman, aet. 66, who
had previously been subjected to three abdominal
sections for intestinal obstruction. The first operation
was done for a large umbilical hernia fifteen years
previously. The second nine years afterwards for a
recurrence of the hernia with obstruction, and the third
five years ago for obstruction due to matting and
binding down of the intestines in the hernial sac. On
admission she had a feeble pulse counting 96 to the

Digitized by GoOgle

TRANSACTIONS OF SOCIETIES.

Oct. 23,

* 9 ° 7 -

444 The M edical Press.

minute, was vomiting constantly, and complained of
intense colic pain. There was a large umbilical hernia,
and palpitation caused the intestines to contract, giving
rise to an intense colicky. Flatus was passing. From a
previous knowledge of her condition it was probable
that there was again a matting together of coils of in¬
testine, giving rise to a partial but not complete ob¬
struction. A long median incision was made, and the
hernial sac laid open; coils of small intestine were
found adherent to the sac and to one another. They
were carefully separated from the walls of the sac,
but during this process the wall of the gut was de¬
nuded of peritoneum in several places, and bleeding
points had to be secured. When this separation was
complete the gut was returned into the abdomen and
the redundant sac excised. As the patient’s condition
remained good the coils of intestine were withdrawn
loop by loop from the abdomen, and separated from
one another. Each coil was then taken, and the
denuded surface sewn over wherever it was possible to
do so without narrowly constricting the lumen of the
bowel. Saline was poured into the abdomen and the
wound closed in the ordinary way. With the help of
salines and strychnine the patient rallied well, and
her bowels acted freely two days after opera¬
tion. No morphia was given ; her colic disappeared,
and she went home three weeks after this her fourth
operation eating well and feeling quite comfortable.
Mr. Newbolt remarked that the four operations had
all been performed in the Southern Hospital, the first
by Mr. Robert Jones, and the last three by himself.
Of these the second and third had to be performed
hastily as the obstruction was complete and the in¬
testines were distended. At this the last operation
there was not much distension, but the vomiting and
intense colic were the chief symptoms complained of.
Resection of the adherent coils was out of the question,
as too much bowel was involved, and the patient’s
condition did not justify so severe a procedure. En-
tero-anestomosis would have shut off a large portion
of the small intestine. The patient, once a stout
woman, had grown thin from malnutrition, due to her
inability to take solid food. He hoped that the repair
of the denuded intestine would relieve her symptoms
in the future.

TRANSACTIONS OF SOCIETIES.

ROYAL SOCIETY OF MEDICINE.

Obstetrical and Gynaecological Section.

Inacgvral Meeting of this Section, held
October ioth, 1907,

The President, Dr. Herbert Spencer, in the Chair.

Dr. Amand Routh reported a case of Caesarean
Hysterectomy for Atresia vaginae. The patient con¬
sulted him at Charing Cross Hospital in March, 1906,
a fortnight after delivery, for incontinence of urine.
He then found that the anterior portions of the
vaginal and supra-vaginal cervix had been torn away
with the roof of the vagina and base of the bladder.
He successfully repaired the bladder injury, and in
three months’ time the woman became again pregnant.

She again came to the hospital in July this year,
being then actually in labour. Finding that there was
much vaginal atresia, and that if labour proceeded,
further irremediable injury would be caused to the
bladdtr, Dr. Routh removed the child by Caesarean
section, and the uterus by sub-total hysterectomy.
Both mother and child recovered without further in¬
cidents. Dr. Routh advocated Caesarean Hysterectomy
in all such cases, and gave a table of 30 similar cases
in which it had been performed, with a mortality of 20
per cent. In the 11 cases where the stump was

treated by the intra-peritoneal method all the mothers
recovered.

The President said he agreed with the author that
the extensive cicatrization involving the bladder fur-
nished a clear indication for Caesarean section, to be
followed by hysterectomy. He had seen very exten¬
sive vaginal cicatrices yield to the pressure of the head
in natural delivery, but in Dr. Routh’s case this would
have entailed great risk of injury to the bladder. He
would prefer total hysterectomy, if practicable, to
supra-vaginal hysterectomy, on account of the free
drainage which it afforded.

Dr. Tate read a short communication on a case of
CEdematous Fibroma of the Pelvis. The patient was
a married woman, ast. 39, who had had five children.
Since the last confinement, six years ago, she had
noticed enlargement of the abdomen. On admission
into St. Thomas's Hospital the lower part of the
abdomen was found to be occupied by a very ill-
defined swelling. To the left of it the uterus could be
made out the size of a duck’s egg. Abdominal section
was performed, and the tumour was found to consist
of a large flattened aedematous mass, covered with
peritoneum, and embedded in the pelvis. After secur¬
ing many large vessels the tumour was removed by
enucleation. The cavity thus left was packed with
gauze, and the uterus then removed. The ends of the
gauze plugs were brought out through the vagina, and
the peritoneum brought together so as to cover up the
large cavity in the pelvis. The patient had two
attacks of secondary haemorrhage, and subsequently
some sloughing of the walls of the cavity occurred,
but she ultimately made a good recovery. Dr. Tate
found it difficult to say in what structures the tumour
originated, but it certainly had no connection with
the uterus. Mr. Alban Doran asked if the fibroid re¬
moved chiefly occupied the mesosalpinx or meso-
metrium, the portion of the broad ligament below the
level of the ovary. In Mr. Doran’s own case, pub¬
lished in the 41st volume of the “Transactions of the
Obstetrical Society of London,” the bulky tumour lay
between the folds of the mesometrium without opening
up the mesosalpinx, so that the Fallopian tubes and
ovaries lay free on the upper surface of the tumour.
When removing a fibroid by enucleation from the
mesometrium the surgeon must remember that the
ureter may run above it, though as a rule it runs
below the tumour, in which case it may be firmly
adherent to the lower surface of the new growth.

Prof. W. E. Dixon and Dr. Frank E. Taylor gave
an Epidiascopic Demonstration on the Physiological
Action of the Placenta. They set forth the results of
an investigation in which they are engaged into the
physiological effects which result from the intravenous
injection of placental extracts into cats, rabbits, and
dogs. The extracts were made by mincing fresh
normal human placenta, extracting with absolute
alcohol, evaporating to dryness, and taking up the
residue in saline solution. A series of tracings show¬
ing the results they obtained were projected on to the
screen by means of the Epidiascope, and the effects of
intravenous injection of placental extract on the cir¬
culation, the intestinal volume and movement, and on
the uterus were demonstrated. There was a striking
rise of blood pressure, following a preliminary fall, on
injection, which was chiefly due to constriction of the
peripheral arterioles. The general effect on the cir¬
culation was very similar to that proluced by
adrenalin, but differed from this in three ways: (1) A
less rapid rise of blood pressure; (a) a more prolonged
rise, and (3) a less marked cardiac effect. Intestinal
volume was decreased, and its movements were in¬
hibited. In the uterus the results differed in the
pregnant and non-pregnant condition. In the pregnant
uterus there was an increased tonus of the uterine
musculature, together with a well-marked increase in
its rhythmic contractility; They concluded that the
placenta produces a chemical substance, which
develops with the ripening of the placenta, the libera¬
tion of which, by contracting the uterus and the
vessels, may induce the onset of normal labour.

The President thanked the authors for the interest¬
ing and valuable demonstration they had given, and
he hoped that many more papers dealing with experi¬
mental work would be read before the Section. He

Digitized by GoOgle

TRANSACTIONS OF SOCIETIES. The Mkdical Press. 445

Oct. 23, 1907.

asked whether the authors’ results tallied with those
of Acconci, who had written somewhat extensively on
the subject of placental extracts. Acconci’s work,
“Researches on the formation of the placentine from
placental extracts,” published in 1906, had just
come into his hands, so that he had not had time to
master its contents. He thought the authors, in “ sug¬
gesting a tentative hypothesis,” were wisely cautious
in drawing conclusions from their experiments.

Dr. Macnaughton-Jones said that watching the re¬
sults of the experiments on blood pressure, and seeing
that the increase appeared to be greater than that of
adrenalin, placentine would probably prove a valuable
physiological agent for administration previous to
anassthetization in serious abdominal operations, the
more so now that the scopolamine, morphia, and
chloroform method was frequently adopted. Since he
(Dr. Macnaughton-Jones) had seen Prof. Schagers’
paper and Mr. Scharlieb’s experiments conducted in
Edinburgh some few years since, he had always used
strychnine and atropine for the same object. This,
of course, was a collateral iseue arisng out of the
paper.

Dr. Amand Routh alluded to his case of “Parturi¬
tion during Paraplegia” (published in 1897 in the
“Obstetrical Society’s Transactions,” Vol. xxxix.),
where the spinal cord has been destroyed by injury in
the Dorsal Region five months previously. Dr. F. \Y.
Mott and he had suggested that labour was, partly at
all events, induced by the metabolism of the pregnant
uterus. That case clearly proved that lactation, which
was normal, could not have been induced by reflex
nervous action, for the spinal cord was destroyed
between the nerves going to breasts and uterus, and
Dr. Routh then pointed to a bio-chemical cause arising
in the uterus as being the probable exciting cause,
acting through the blood. Had the authors experi¬
mented in this direction by noting the effect of the
injection of placental extract upon mammary gland
activity? He agreed with the authors that perverted
metabolism might produce an autotoxaemia, which
might cause albuminuria, acute yellow atrophy of liver,
insanity and hyperemesis gravidarum.

Dr. W. S. A. Griffith said that the thanks of the
Section were due to the authors for the paper, for the
facts which they had brought forward were the result
of laborious research. He could not however accept
the chief conclusion which they had drawn from these
facts, for which there appeared to be no evidence
whatever, viz., that a substance contained in the
placenta, though ascertained to increase uterine con¬
traction, was the cause of labour either premature or
full time. The question of the nature of the labour
pains, a3 distinguished from the contractions which
are known to occur throughout the active sexual life
of a woman, and are so obvious during the course of
pregnancy, was too large a one to attempt to discuss
on that occasion. It appeared to him that the con¬
tractions of pregnancy are comparable to the colicky
pains of contraction of the bowel unrelieved, and
that the essential difference in each case consists rather
in relaxation of the orifice than of a new form of
contraction. There are many agents which increase
uterine contraction, but which are almost useless for
the indication of labour.

Dr. C. Nf.pean Longridge asked Dr. Taylor if the
induction of labour was a long process in the case ol
induction at thirty-six weeks, in which he found the
placental extract was very active. He mentioned that
he had found a definite and progressive rise of blood
pressure in a moderate number of primigravidae during
the latter months of pregnancy. He also referred to
the theory of Dr. Blair Bell that labour vas brought
about by the accumulation of calcium in the blood.
But since calcium was practically insoluble in alcohol
it could not be a constituent of the extracts which Dr.
Taylor had used in his experiments. One could not
however deny that calcium salts had anything to do
with the matter, because there are so many examples in
which vital activity depends on the interaction of
organic and inorganic substances in the body.

The following specimens were shown: —

(1) Chorion epitheliome of the uterus with meta¬
stasis in the vagina lungs, liver, and brain, by Dr.
T. W. Eden.

(a) An instrument, by Dr. R. Wise.

(3) A pregnant uterus with fibroids, by Mr. J. Bland-
Sutton.

NORTH OF ENGLAND OBSTETRICAL AND
GYNAECOLOGICAL SOCIETY.

Meeting Held at Liverpool, Oct. iSth, 1907.

Dr. E. O. Croft (Leeds), President, in the chair.
intraligamentary bladder.

Dr. W. E. Fothergill (Manchester) mentioned the
case of a single lady, ast. 28, who complained of a
bladder trouble dating from puberty. For about five
years micturition was necessary every hour or so to
relieve intense pain in the left iliac region. None of
the usual causes of bladder irritability could be
found. The uterus could not be retroverted and
appeared to be attached to the back of the bladder,
and to dig into it as soon as two or three ounces of
urine had accumulated. The abdomen was opened,
and it was seen that the utero-vesical pouch was
practically absent, the bladder with the small ante-
flexed uterus lying between the layers of the broad
ligaments. The peritoneum over the fundus of the
bladder was incised and the organ separated from the
uterus. The peritoneum was united from side to side,
so that the line of suture was antero-posterior, a utero-
vesical pouch being thus formed. The fundus uteri
was fastened to the peritoneum in the lower angle of
the abdominal wound, to keep the uterus from press¬
ing on the bladder. The patient a year after the
operation had greatly improved in health, and had lost
tne pain which previously accompanied the distension
of the bladder. The organ, however, was still irritable
at times. Menstruation, which previously was rare
and scanty, was now regular and profuse, and the uterus
had gained in size and tone since it was set free from
the bladder.

POST-CLIMACTERIC H.fcMORRHAGE.

Dr. Archibald Donald (Manchester) communicated
a case of unusual post-climacteric hemorrhage
occurring in a woman aged 66 years, who had one
child 38 years ago. Menstruation, which began at 13
years of age, was normal and regular up to age 39,
i.e.y 27 years ago. For 16 years there was no dis¬
charge of any kind, then irregular haemorrhage began
at variable intervals. The flow would last from two
to ten days, and was not attended by any pain. The
patient was markedly anaemic, and the face presented
a striking appearance, being of a lemon-yellow tinge.
The pulse was 90 per minute, and there was a diffuse
praecordial pulsation. Bi-manually the uterus was
the size of a 3 months’ pregnancy. Vaginal
hysterectomy was performed on May 18th, 1907, and
the recovery was uneventful. On opening the
enlarged uterus, its cavity contained a growth
apparently originating in the endometrium, but in¬
vading the musculature. Microscopically, cylindrical
down-growths of epithelial-like cells ’invaded the
muscular wall. Professor Lorraine Smith pronounced
it to be an endothelioma, probably originating in the
lymph spaces of the endometrium, or body of the
uterus.

A paper on the

PATHOLOGY OF SOLID OVARIAN TUMOfRS
was read by Dr. Briggs and Dr. T. E. Walker. In
the hospital and private practice of the former during
2ofrd years 488 ovarian new growths were removed
by operation. They were arranged in two groups, the
cystic group of 439 including 284 adenocystomata, 44
dermoids, 36 broad ligamentcysts, 24 papillomata, 50
carcinomata, 1 perithelioma (sarcoma),

And the solid group of 49, including 31 ovarian
fibromata, 3 fibromata of the ovarian ligament, 3
adenomata, 1 surface papilloma, 8 solid carcinomata,
1 solid teratoma (myxo-chondro-sarcoma), 1 cellular
spleen-like tumour.

In the cystic group Dr. Walker, during a recent
research, had found 50 ovarian carcinomata and 1
ovarian sarcoma (perithelioma). The rarity of cystic
sarcoma was alluded to, and compared with the

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Oct. 23, 1907.

446 The Medical Press. TRANSACTIONS

statistics of Veit and Martin, and with the general
statements found in text-books. The paper was other¬
wise exclusively confined to the solid tumour group.
Thirty-one fibromata in 488 indicate the occurrence of
these tumours in 6.4 per cent. ; the common text-book
statement is 2 per cent. The wide range of structure
observable amongst these tumours, from the structure¬
less, or almost structureless, calcified fibroma to the
highly cellular new growth was pointed out, and
especially in reference to the latter a brain-like tumour
and a spleen-like tumour, each of large size, were
specially dealt with. The former consisted of round
cells, and looked suspiciously sarcomatous when
removed in March, 1897, from a girl aged isi ; this
patient is now alive and in vigorous health at the
age of 26; the spleen-like tumour as the after-history
of the patient attested, was also innocent. The former
was included in the fibromata, but the latter contained
so little tissue apparently fibromatous that it was
placed in a separate table, under its own briefly
descriptive heading of a cellular, vascular spleen-like
tumour. These features, however, were exceptional
in the structure of ovarian fibromata. The common
fibromatous tumours in the series consisted of spindle
and round cells, embedded in a fully formed fibrous
interlacement in varying proportions.

The position of the ovarian fibroma amongst solid
ovarian tumours was now well estblished, and was no
small tribute to the work of Leopold, published in
1874.

The fibromata included in the paper were arranged
under the accepted forms of ovarian fibromata, is
diffuse, 9 circumscribed, and 7 pedunculated. The
diffuse, the most numerous, was bilateral in 2 cases,
and in 7 instances the patient was beyond the meno¬
pause. Of the total the menstruation was absent in 2
diffuse and in 1 circumscribed; otherwise it was
regular in 4 diffuse, 3 circumscribed, and 4 pedun¬
culated ; irregular in 1 circumscribed, diminished, in
1 diffuse. Pregnancy, in 2 cases, both circumscribed,
was undisturbed by the operation. The pedicles were
twisted in 1 diffuse, 1 circumscribed, and 1 pedun¬
culated. Ascites was recorded as present in 13,
absent in 18. It was least frequent with the circum¬
scribed tumour, being present in 2, absent in 7 ; with
the diffuse form, absent in 8, present in 7 ; with the
pedunculated, present in 3, absent in 4. Its aetiology
was considered. The fibromata of the ovarian liga¬
ment and the valuable work of Doran in this con¬
nection was alluded to.

A solid teratoma, a rare surface papilloma, and a
round-celled sarcoma were each described and illu¬
strated.

The rest of the paper consisted of a report by Dr.
Walker on the solid adenomata, of which there were
3 cases, and on the solid carcinomata, of which there
were 8 cases, 7 bilateral, and 1 unilateral. Of the 7
bilateral, 6 were definitely secondary, 2 to primary
scirrhus of the breast, and 4 to growths in the large
bowel. In the 7th case, in a woman aged 48, the
primary growth was unknown, consequently it was
excluded. Six-sevenths of the evidence was in support
of Bland-Sutton’s conclusions, that solid bilateral
carcinomata are secondary.

The case of unilateral carcinoma was described.

The secondary tumours above referred to, repro¬
duced the structure of the primary growths—scirrhus
carcinoma, colloid carcinoma, and adeno-carcinoma.

OPTHALMOLOGICAL SOCIETY OF THE
UNITED KINGDOM.

First Meeting of the Session, Held on Thursday,
October 17TH, 1907.

The President, Mr. R. Marcus Gunn, F.R.C.S., in
the Chair.

The President’s Introductory Address.

Mr. Gunn first tendered his warm thanks to the
Society for the honour implied in his election to the
presidential chair, and assured the members that he

OF SOCIETIES.

yielded to none in feelings of loyalty to the Society,
whose interests he would do his best to serve. The first
portion of the address was devoted to a review of the
history of the Society, dating from the issue of a
circular letter in February, 1880. He referred to the
most important contributions to the Transactions,
under various headings—physiological, surgical,
clinical, pathological, etc.

Passing on to the future, he said an exact knowledge
of the aetiology of affections of the cornea, iris, and
choroid was much wanted, while they awaited an
explanation of recurrent retinal haemorrhages in eyes
otherwise seemingly sound, in persons whose general
health was not manifestly at fault. If a diminished
coagulability of the blood were found to be present,
and that was kept at bay, it was reasonable to expect
that the recurrence due to that cause would be
checked ; but such treatment had been disappointing.
Opacities in the lens occasionally presented forms
which did not seem inexplicable at all by our know¬
ledge of its anatomy or its nutrition. Could those be
accounted for?

Prognosis was a very important matter to the
patient, yet it was often uncertain, and must continue
so. Yet if the ophthalmic surgeon knew a little more
of the true nature of the different diseases which he
nad to treat, his knowledge of their course and dura¬
tion would be materially increased. In the past few
years a great advance had been made as to the nature
of infective agents, and the ways in which the body
attempted to free itself from invasion. There was the
whole army of bacterial poisons, with their anti-bodies,
and ophthalmic surgeons must know sufficient to be
able to intelligently follow the reason involved in
serum and vaccine therapy. If it was useful in their
specialty, they must inquire when and how far, and
how it should be employed. With regard to medicinal
treatments, he hoped they would keep their armamen¬
tarium as small as possible without the sacrifice of
efficiency. Too many drugs were a weariness of the
flesh, both to him who gave and he who took.

He thought the Society might well revert to more
frequent committees and discussions, as in the earlier
history of the Society. He referred to the large number
of card specimens now shown before the Society,
many of them of great interest and importance, but
members did not seem able to take full advantage of
them, and their very number was the cause of that
inability, for they could not see all, if, indeed, they
could see any, satisfactorily in half an hour in a
crowded room. The institution of clinical evenings
was quite an advance, but much still remained to be
done. It would be well to have standing committees
for men interested in special lines of work, whose
duty it would be to report upon any case when the
member showing it approved. Of such committee the
exhibitor would be a member for the time being.

Mr. J. B. Lawford read a paper entitled

A CASE OF TUMOUR OF THE OPTIC NERVE.

The patient was a female, aet. 38, single, who came
under observation in June, 1906. The eyelids on the
left side were puffy and slightly red ; there was a
moderate degree of proptosis, the displacement being
almost directly forwards. The movements of the eye¬
ball upwards and outwards were restricted, rotation
downwards and inwards full. No oedema, and but
slight vascularity of the conjunctiva. No tenderness
on pressure ; nothing abnormal in the orbit; no pain,
but some discomfort. Vision was reduced to per¬
ception of light. The media were clear, the optic
papillae ill-defined and pale, and the retinal veins
tortuous. No haemorrhage or disease of the choroid.
The family history was good, the patient was a
healthy, robust woman, and tubercular and syphilitic
disease could be reasonably excluded. There was no
history of injury. Something amiss was noticed in
the left eye four years previously, and in April of that
year she consulted Mr. Wherry, of Cambridge, who
recorded the vision on that date as follows: R. 6/6;
L. 6/18, but with correction of hypertrophic
astigmatism, 6/9 partly. The patient was seen by
another ophthalmic surgeon during 1903-4, and was
under treatment by drugs for some months, but there

ized by Google

Oct. 23, 1907.

CORRESPONDENCE.

The Medical Press. 4 l 7 .

was no improvement in the symptoms. The diagnosis
made in 1906 was (?) tumour of optic nerve sheath,
(?) osteoma of orbit.

Treatment by iodide of potassium was advised, and
was carried out for some weeks, but without benefit.
In July, 1907, there was a slight but noticeable altera¬
tion, the proptosis had increased, the movements of
the globe were much restricted in all directions, the
pupil was inactive to light, and there was no per¬
ception of light. The patient could not state how
long the blindness had existed. No haemorrhages
could be distinguished, the retinal veins were tortuous,
there was no tenderness, no tumour could be felt, or
deep pulsation detected by the finger. The proptosis
could not be reduced by pressure. There was no severe
pain. The general health did not appear to be pre¬
judiced by the orbital disease. Operation was
advised.

Three days later the patient was seen by Sir John
Tweedy, who thought it was either osteoma of the
orbital wall cr tumour of the optic nerve, probably
the latter. In June, 1907, the eyeball and tumour
were removed. The tumour extended from the back of
the eyeball to the apex of the orbit, and the nerve
was divided as close to the optic foramen as possible.
There was extensive haemorrhage into the orbital
tissue; the swelling gradually subsided, and she left
the nursing home a fortnight after the operation.
Fifteen similar cases had already been recorded, which
was in contrast to the number of cases of primary
intradural tumour of the optic nerve, which numbered
102 up to 1901. The age of his own patient was
above the average.

The microscopical characters of the growth were
described and demonstrated by Mr. George Coats.

WEST LONDON MEDICO-CHIRURGICAL
SOCIETY.

Meeting held Friday, October 4TH, 1907.

The President, Mr. Richard Lake, F.R.C.S., in the
chair.

Mr. Lake read his Presidential Address on “Some
Reflections on the Relationship of the more important
points of Diseases of the Ear and Nose and General
Medicine.”

He dwelt upon points chosen to illustrate more
particularly the effects of various constitutional com¬
plaints upon the ear and nose; and the effects upon
the general state of the body when the ear and no9e
are affected.

LIVERPOOL MEDICAL INSTITUTION.

First (Inaugural) Meeting ok the Session, Held
Thursday, October ioth.

The President, Mr. F. T. Paul, F.R.C.S., in the Chair.

The President delivered an address on Abdominal
Surgery.

On the proposal of Mr. Edgar A. Browne,
seconded by Mr. Rushton Parker, the President was
accorded a most hearty vote of thanks.

Subsequently the President entertained 150 members
to supper and a smoking concert.

Ur. Hope reported to the Liverpool Health Com¬
mittee on October 9th that the death-rate in the city
for the past week was 18.1, as compared with 22.0 for
the corresponding period last year. There were in the
hospitals 624 cases, including 402 of scarlet fever, 12
of typhus, 51 of typhoid fever, 12 of measles, 53 of
diphtheria, and 12 of phthisis. Mr. Jacob brought
before the committee an offer made by the Hon.
Nathan Strauss of New York, of a pasteuring plant
for the preparation of milk for infants, and Dr. Hope
having reported favourably on the matter, the com¬
mittee, o nthe motion of Mr. Shelmerdine, seconded
^ r - Jacob, resolved to accept the offer, with
thanks.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Paris, Oct. 20th, 1907,

Origin and Treatment of Cancer of the Stomach.

Carcinoma of the stomach sets in, according to
Prof. Robin, in an insidious manner. It begins by
anorexia, with a pronounced dislike for certain kinds
of food, as meat and wine. The patient is seized with
vomiting, which is one of the usual signs of carcinoma,
and is caused by the seat of the neoplasm at the
orifices, trouble in the gastric secretion, and the pre¬
sence of the tumour itself.

The vomiting presents several varieties, the most
characteristic is that observed in the morning fasting,
or during the day, preceded or accompanied by a
nauseous feeling, and constituted by watery liquids
produced without effort as a simple regurgitation; it
is the cancer liquid. At other times food is vomited
several hours after meals, and procures great relief to
the patient. The matter vomited has a sour and putrid
odour. Hydrochloric acid is wanting, but acids in
process of fermentation are abundant, due to the micro-
bian organisms which are in constant development.

At a later stage of the disease black vomiting—
colour of coffee grounds—sets in, and is due to the
blood derived from erosion of the vessels of the morbid
tumour.

Hematemesis, properly called, are rare in gastric
cancer ; they belong rather to ulcer of the stomach.

An important symptom is pain. It is very common,
but has not the acute character of ulcer. The patients
complain rather of a sensation of weight, with a few
lancinating pains over the seat of the tumour, which
is sensitive to pressure. This painful sensation does
not entirely cease in the intervals of meals. It is not,
however, immediately exasperated by the ingestion of
food as in ulcer, but increases slowly during the
digestion, when it is frequently complicated with
pyrosis.

Constipation is the rule ; diarrhoea is only observed
in the advanced period of the disease. Palpation of
the stomach reveals the seat of the neoplasm ; when
the organ is not distended the pylorus may be con¬
sidered intact.

Analysis of the chemical composition of the gastric
secretion can give useful information. Some time ago
the absence of free hydrochloric acid was a patho¬
gnomonic sign of cancer, but this absence was demon¬
strated in a large number of other maladies, while in
carcinoma an excess of this acid was sometimes ob¬
served. However, this absence has a certain import¬
ance in doubtful cases.

Physical signs should not be neglected. It is not
the stomach alone that should be examined, but also
the condition of other organs, as the liver, the
omentum, peritoneum, or the umbilicus. Divers
ganglions should also be sought for, especially above
the left clavicle, which, if present, constitute a
counter-indication to surgical interference.

The legs are frequently the seat of oedema, and some¬
times of phlegmatia alba dolens, localised chiefly in
the veins of the calf of the leg.

Sometimes fever exists to a certain amount, resulting
from gastric fermentation, but usually passes unper¬
ceived. At other times, on the contrary, it reaches 104°,
and is due to absorption of the toxic products.

As to treatment, condurango, chlorate of soda, iodide
of sodium, methylene blue, bichromate of potash,
thuya, etc., enjoyed some favour, and gave temporary
relief, but Prof. Robin recommends bihydrochlorate of
quinine in 10-grain doses twice a day, and cacodylate
of soda, while the cachectic condition mi^ht be treated
with injections of glycero-phosphate of lime, 5 grains
daily for 25 to 30 days.

Chelidonium, or its alkaloid, chelidonin, has been
much recommended by Deiussenko, Ivanov, Kraisky,
Meyer, Robinson and others. In cases of ulcer of the
stomach, carcinoma, cancer of the intestine, the results
obtained would seem to have been favourable and

Digitized by Google

CORRESPONDENCE.

Oct. 23, 1907.

418 The Medical Press.

rapid; under its influence the tumour diminished, and
a general improvement took place. It acts as an
hypnotic, and moderates the development of the neo¬
plasm. Chelodonin is given in pills of 2 milligrammes
in progressive doses (3 to 12 daily), according to
tolerance.

Although there is no curative treatment for cancer
of . the stomach, there is a medical treatment sufficient
to prolong life, relieve suffering, and give hope to the
patients. Gastro-enterostomy should be reserved when
it is impossible to otherwise relieve the pain of
certain cancers.

Treatment of Vomiting.

Hydrochlorate of cocain, \ a a 1 er

Hydrochlorate of morphia ,f 5 K

Lime water, 6 oz.

A tablespoonful every hour.

Or,

Hydrochlorate of cocain, 1 gr.

Antipyrin, 30 gr.

Syrup of oranges, 6 oz.

Or,

Tincture of iodine, 1 dr.

Chloroform, 1 dr.

S drops every half-hour up to 19 drops (pregnancy).

Or,

Tincture of iodine, 30 m.m.

Spirits of chloroform, 2 dr.

Water, 4 oz.

A tablespoonful every hour.

GERMANY.

Berlin. Oct. aotb. 1907.

At the meeting of the Society for Public Health, the
subject of

Epidemic Cerebrospinal Meningitis
came up for discussion. Statistics were brought for¬
ward by Professor Fliigge, who also answered the
question as to how infection took place. There was
no longer any doubt that the disease was caused by
Weichselbaum’s meningococcus. The apparently
healthy were the dangerous ones. The disposition to
contract the disease was mostly amongst children, and
especially those with enlarged tonsils. It was the
coccus carriers, who felt well and not those who were
ill, that were the disseminators of the disease. The
principal danger was for those in the immediate neigh¬
bourhood of the centres of infection.

It was certain that the disease was introduced into
localities previously free by healthy persons coming
from an infected district. Isolation was certainly
necessary but not indispensably so. Disinfection did
but little sendee. All those around a case of the
disease should be looked upon as carriers of it. It
was necessary that instructions should be given that
intercourse with those in the neighbourhood of the
disease should be carried on as cautiously as possible ;
that those who were healthy should receive warning in
regard to those coming from infected houses for at
least three weeks; that children from such houses
should be kept away from school for several weeks,
etc. The carriers of the bacilli should be looked after
daily by the medical officers. The serums prepared by
Merck and also that of Kolle, of Bern, were of value
both for diagnostic and therapeutic purposes.

Hr. Bruhns, Gelsenkirchen, agreed with what had
been said. The society for combating folk-diseases
should erect small sanatoria in many localities, where
the bacillus bearers could be examined at once.

Professor Erismann, Zurich, would isolate all the
bacillus bearers, regardless of all other considerations,
but would compensate them for loss of work. Hr.
Czaplewsky, Coin, drew attention to the special danger
of kissing.

Geh. Obermed.—Rat Kirchner, Berlin, said there was
not money enough to separate all the bacillus bearers,
and there was no possibility of shutting up more than
half the population. Those infected must be isolated
under any circumstances. Wherever the disease ap¬
peared the State should at once send bacteriological
experts, cover the country with a network of bacterio¬
logical institutions, and steadily draw the net closer.
The different parishes must disinfect free of cost.

Hr. Deneke, Hamburgh, thought the time would
come when an outbreak would be foretold, and the
population receive timely warning.

Stabsarzt Dr. Kutscher, Berlin, thought that as the
cocci did not grow outside the body there must be
permanent bacillus bearers. The bacilli frequently
disappeared for a time, to return again later on. In
the Institute for Infective Diseases two kinds of serum
were prepared and distributed gratuitously, one in the
form of snuffing powder for bearers of germs, and the
other for those who were ill of the disease. The serum
was only active during the first three days, and must
be used quite fresh.

Dr. Peerenboom, Wilhelmshafen, proposed that
when an epidemic threatened all the lymphatic
children who were likely to take the disease should be
removed to convalescent homes in time, and detained
there.

The Influence of Mineral Waters on the
Digestive Tract.

The Deutsche Med. Zeitung, No. 76, has a reference
to a paper on this subject by Dr. rewsner. In it the
writer claims that experiments on animals have shown
that the mechanism of gastric secretion is identical in
all particulars in the human subject and in dogs.
Experiments, therefore, that have been carried out
with regard to the action of mineral waters on animals
with gastric fistu’as must have a certain value clini¬
cally. Mineral waters that contain carbonic acid
(Seltzer and Ems) increase the gastric secretion very
much. Simple service drinking water increases it
moderately, Carlsbad water diminishes it, purely
alkaline mineral water (Vichy) and bitter waters (Hun-
yadi-Janos, Friedrichshall) diminish it very much.
The amount of pancreatic secretion does not run
parallel with the quantity of water taken. As regards
the digestive power on albumen and starch, the gastric
juice secreted after taking Vichy water takes the first
place. The juice secreted after taking ordinary drink¬
ing water takes the last place of all. He thinks that
the importance of mineral waters in the treatment of
disorders of the digestive tract should not be over¬
estimated. Where mineral waters are made use of it
is above all important that the diet should be in every
way suitable.

AUSTRIA.

Vienna, Oct. aoth. 1907 .

Tuberculosis.

The conference on tuberculosis has finished its
deliberations for another year, without marking any
epochal event. The disease is still cutting off 2.5 per
thousand, or a i-7th of those who die are tubercular
according to the official reports, which would stand at
a higher figure were it not limited by insurance
pressure.

The Vice-President, Prof. Schrfitter, greeted the
members in the Grand Festesaale of the University.
States, corporations, and private bodies were repre¬
sented by deputies. In his remarks Schrbtter hoped
that this fiend would soon be arrested in its destruc¬
tion, but feared it would not be overcome till the
people practised hygienic principles and drove it from
their midst by their own efforts.

Bienerth, Austrian Minister for the Sanitary Depart¬
ment, described many of the methods and institutions
they had erected in Austria to reduce the number of
victims dying from this disease, and praised Schrfitter
for his rational and scientific assistance he had given
to his own department. He had still hope that these
humane institutions would lead Austria to improve
her hygiene and social politics.

The first paper was read by Prof. Weichselbaum on
the method of infection. He reviewed the earlier
notions, and said our present knowledge was still im¬
perfect, and the method of infection attributed to two
channels, inhalation and alimentation, these being
supported by Calmette and Fliigge.

Calmette holds that tubercle is conveyed to the
system through the alimentary tract, particularly the
bowel, and that dust or moisture had no share in the
communication. On the other hand Fliigge is as
firmly convinced that his “ drop ” theory of the infec¬
tion passing in by the lungs is the correct one.

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Oct. 23, 1907.

CORRESPONDENCE.

The Medicat. PREi>. 449

He believes it is conveyed by the mouth in dust or
moisture, and trickles down the trachea to the lung or
finer bronchi. Calmette founds his opinion on animal
experiments, while Fliigge draws his from cases enter¬
ing his own institution. Between these extremes other
authors form a grand mean of the infection being taken
in by both channels. Weichselbaum recorded many of
his own experiments performed before the discovery of
the tubercular bacillus in feeding dogs with sputum,
which convinced him at the time that tubercle was not
so easily taken in by the animal species by the
alimentary canal as through the lung. Since that time
he has somewhat modified his opinions. In the
pulmonary and bronchial glands the bacilli are fewer
than in the cervical and glands of the mesentery. In
the latter the process is more rapid and intense in
development. The earlier theories were that the pul¬
monary and bronchial glands were physiologically
reduced, and in the older experiment with animals the
anthracosis was attributed to this cause, while in the
later experiments the low development in the
lymphatic tissues was reduced below that of the neck
and mesentery. This explanation accords with the
earlier examination of the lymphocytes, which are
supposed to have played an important part in fighting
the tubercular bacilli; it therefore resolved itself into
an imperfectly developed lymph system as opposed to
the formation of lymphocytes. Notwithstanding the
alimentary theory Weichselbaum is convinced that the
air and the lungs still play an important part in the
connection of the bacilli through the bronchial glands.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

Professor Chiene’s Reminiscences. —Professor
Chiene opened the class of Systematic Surgery rn the
16th by a retrospect of his work as a teacher. “Forty
years ago,” he said, “ John Goodsir sent for me to his
house at Wardie. I found him lying in a narrow,
camp-like bed, in a narrow room, a small table at his
side, and on the table Quain’s ‘ Anatomy ’ and his
B-ible. He asked me how the students were getting on,
and bade me farewell. His last words were, 'Teach
the students, Dr. Chiene,’ and I have taken these words
as my life motto. To-day, when I celebrate my silver
wedding—twenty-five years a professor—I take as my
subject ‘ Looking Backward.’ ’’ Professor Chiene then
gave a sketch of his career since graduating in 1865,
and recalled how, at three o’clock one afternoon, Pro¬
fessor Turner asked him to give the four o’clock
demonstration in anatomy. He felt a little nervous,
and went into the lecture theatre, but forgot to turn
up the gas on the body, and delivered the demon¬
stration. The students were kindly fellows; they never
by word or look pointed out the omission, and he only j
discovered it next day. From the anatomy theatre
Professor Chiene took his audience to the old building ,
on Nicholas Square, where he at one time had his |
systematic class. The turning-point, however, in his i
surgical career came in the spring of 1866, when he 1
was introduced to Joseph Lister. From the day Lister
came to Edinburgh in 1866 until he went to King’s 1
College in 1878, Professor Chiene spent daily two hours
in his wards, and watched Lister at his daily work !
elaborating with zeal, and patience, and doggedness
the imperishable system which he had been privileged
to see an accomplished fact. The comparison of work 1
in the Edinburgh Royal Infirmary in the early’eighties !
and now was of interest, remarked Professor Chiene.

In the first period 752 operations were performed—
io 7-3 per annum; 24 years later 2,803 operations, or
400.5 per annum. Taking the general mortality over
the two periods, the percentage of deaths was 7.2
between 1878 and 1885 ; 6.7 between 1899-1905. In 1882
he started the first teaching bacteriological laboratory
in the United Kingdom, and when the new regulation
became law in 1902 the teaching of bacteriology passed
into the hands of the Professor of Pathology. After
some further reminiscences of the nurses who had
worked under him, and of his early personal friend- \

ships, Professor Chiene went on to say that it was the
kindly, gentle people who were remembered, while the
pushers—rhinocerous-hided or serpentine in their ways
—were soon forgotten. He urged the students to read
their Bible ; he sometimes thought it would be a good
thing if the Bible formed one of the subjects for the
medical preliminary examination. A man who knew
his Bible well was on the way of becoming a good
surgeon.

Larbert Asylum. —In the evolution of asylums into
* hospitals ” for the insane, the female nurse has been
a very important factor, and has done much to revolu¬
tionise the internal economy of such institutions. In
accordance with these facts, a handsome new nurses’
home has just been completed in the Stirling District
Asylum, and will provide accommodation for 85 nurses.
Special features have been made of the library and
lecture-room, so as to enable nurses to study and get
special training in mental nursing. So successful has
the female nurse proved in the management of the
insane, that asylum directors are now anxious to
attract the best class of women. The whole atmosphere
of asylums has been changed in consequence of the
advent of female nurses. Excited male patients, it is
found, who would fight with one of their own sex,
never dream of striking a woman. As an example of
the progress which has been made at the Stirling
Asylum, Dr. Robertson states that for many years not
a patient has been locked up in a single room in the
institution either by day or night. Padded rooms have
become store-rooms, and the strait-waistcoat is obso¬
lete. The new home will shortly be formally opened
by Lord Balfour of Burleigh. It has cost the directors
^10,000.

Fatal Attack on an Asylum Attendant. —Daviot
Asylum, a branch of the Aberdeen Royal Asylum,
where harmless patients who can do agricultural work
are located, was last week the scene of an unfortunate
tragedy. A number of patients were engaged, under
the supervision of attendants, in cutting thistles in a
field. While they were returning from work, one of
them was seized with a sudden impulse, and, without
the slightest warning turned on one of the attendants
and inflicted on him with a scythe a frightful wound
in the throat, which was almost immediately fatal.
The patient who committed the deed had never shown
any sign of homicidal tendencies, and was of a quiet
and inoffensive disposition.

BELFAST.

Derry County Infirmary. —An interesting dis¬
cussion took place at the monthly meeting of the
County Infirmary at Derry last week, when the
resident surgeon, Dr. J. G. Cooke, made an applica¬
tion to be allowed to take consulting practice outside
the county as well as in it. He promised to provide
an efficient substitute during the time he might be
absent from the infirmary. A good deal of objection
was raised to the application on the ground that it
would be in surgical cases that Dr. Cooke would
most likely be consulted and that he would have to
operate, and be absent for rather long times. The
Chairman of the Board wanted to make it a condition
that Dr. Cooke should pay a junior house surgeon £50
a year to spend his whole time in the infirmary, and
be subject to their regulations. It was not clear
whether by an efficient substitute Dr. Cooke meant
some one to keep an eye on the place in his absence,
or some one actually to sleep in the infirmary if he
were absent for a night; some members of the Board
thought that the latter should be the understanding.
Eventually the original proposal was accepted, and
leave granted to Dr. Cooke as asked, without special
restrictions.

Royal Victoria Hospital.— The winter session
opened at the Royal Victoria Hospital on Thursday,
17th, with an address by Dr. R. J. Johnston,
assistant gynaecologist. In the absence of Dr. J.
Walton Browne, the chair was taken by Sir William
Whitla, the senior member of the staff present.
Dr. Johnston gave an interesting and humorous
address on the general education of the medical
student, dwelling specially on the necessity for train-

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450 The Medical Press.

CORRESPONDENCE.

Oct. 23, 1907.

ing the mind in right methods of thinking. On the
motion of Sir John Byers, seconded by Professor
Symington, a hearty vote of thanks was passed and
conveyed to Dr. Johnston.

LETTERS TO THE EDITOR.

THE PROFESSION AND THE PUBLIC.

To the Editor of The Medical Press and Circular.

Sir, —Some of the chief items in the current issue
of your admiiable journal form painful reading for
those who love their profession and appreciate the
fine spirit that pervades the majority of its members.
There is first the quotation from the Socialist
children's catechism. The malignant feeling there dis¬
played is very largely the direct product of the teach¬
ing of rabid anti-vivisectionist and anti-vaccinationist
fanaticism. The former constantly holds up the pro¬
fession to execration, if not as practisers of fiendish
cruelty, as admirers of men who devote their lives to
deliberate infliction of suffering upon helpless brutes,
well knowing that useful results are more than doubt¬
ful. The teaching of Mr. Stephen Coleridge among
laymen, and of Archdeacon Wilberforce, chaplain to
the Speaker, among the clergy, may be cited in this
connection. Your editorial note headed “Vivisection
Horror” exemplifies once more the methods of
fanaticism. Then the anti-vaccinationist's favourite
statement is to the effect that for the sake
of the paltry fees which the duty brings, the whole
profession is engaged in a vile conspiracy—they even
vaccinate their own children to supply colour to their
hypocrisy—to disseminate a loathsome poison through¬
out the population. These teachings prepare a fruitful
soil for the operations of fraudulent quackery, which,
again, is dealt with in another of your pages. The
cynical and cruel rogues who find fortune in one or
other of the lines of quackery gain ready victims
among simple, innocent, and suffering, and therefore
confiding, people, wrought upon by the enemies of
scientific medicine. Every practitioner of experience
must encounter numbers of wretched patients who
have left their diseases to pass into hopeless phases
whilst relying upon the promises of ignorant knavery.
The amount of easily preventible human suffering and
misery which is being indirectly caused in this country
alone by the teachines of “anti” fanatics outweighs
ten thousand times the pain inflicted upon the lower
animals in all the physiological laboratories through¬
out the entire world. In the meantime, the profession
remain passive, if not apathetic, in presence of
systematic libel and vilification, and make no effort
even to demand or force from the State the dues justly
owing to them in return for the obligations they are
obliged to fulfil in obtaining what remains so far a
really worthless status.

I am, Sir, yours truly,

_ . „ Physiologist.

October 18th, 1907.

THE GOVERNMENT’S SCHEME FOR THE
PROMOTION OF UNQUALIFIED MEDICAL
PRACTICE.

To the Editor of The Medical Press and Circular.

Sir,— Dr. Moore, of Huddersfield, claims to be the
true begetter of the “Notification of Births Bill”
(Medical Press, October 10th), and I will not ques¬
tion its genesis; but I will beg of Dr. Moore to remem-
her that we are members of a profession which claims
to be free and enlightened. In our search for truth
we must occasionally criticise the views of each other,
and Dr. Moore must not complain if we exercise our
privilege to comment on the possible effects of his Bill.

I am prepared to believe that Dr. Moore, with the
aid of his two very efficient lady doctors, can have
the Notification of Births Act carried out without
encouraging unqualified practice; but I am firmly con¬
vinced that unqualified practice must result from its
adoption in most big cities.

It is a presumption of law that a man must be held
to intend the natural and proximate effects of his act,

and I insist that the natural and probable effects of
an Act which thrusts an unqualified nurse on a family
the moment a child is born, to direct its rearing, must
result in the establishment and encouragement of these
unqualified persons, to the detriment of the medical
practitioner and the infringement of his rights.

Regarding the discussion of the Bill generally, I
think that I must complain of Dr. Moore. The views
put forward in my paper which appeared in The
Medical Press were given, in effect, in some com¬
ments which I made on the communication of Dr.
Moore to the Douglas Public Health Congress. I may
be right, or I may be wrong, but I claim the right to
discuss such papers freely, for unless both sides of a
question be debated, it is impossible to arrive at the
truth. The Douglas newspapers made a sensational
paragraph out of my observations, which I never saw
or took notice of, but some of my political opponents
in the Dublin Corporation wrote to Dr. Moore in¬
quiring if the paragraph in question represented what
I had said. Obviously, a sentence or two, detached
from its context, is very likely to convey an erroneous
impression ; but, in spite of my denials, and the state¬
ments of the gentleman who presided at the section,
Dr. Moore’s communication to the gentlemen in ques¬
tion seems to have inspired them with the belief that
I advocate the callous neglect of delicate infants, if
not their wholesale murder.

Subject to your ruling, Mr. Editor, I submit that
if a number of doctors are discussing a scientific sub¬
ject in a scientific way, each should be at liberty to
express himself freely; that if a lay paper, for the
sake of making sensational statements, suggests that
one of the speakers advocated something like child
murder, and the doctor in question repudiates the
insinuation, and the president of the section likewise,
his colleagues should not answer his political oppo¬
nents behind his back to the effect that his repudiation
was not to be believed, and so encourage them to have
the repudiated Teport placarded on the walls of the
City Hall of his native town.

This is what has happened to me. The views which
I expressed at Douglas or in your journal I am ready
to defend, as to their truth and their wisdom, in any
medical journal, or before any body of my colleagues.
It does not follow that I should be called on to defend
them in the Dublin Corporation or amongst my
patients. It was not a lay sermon to the laity, but a
scientific discussion before a scientific audience.

There must be an end of free discussion amongst
medical men if one of them is at liberty to convey
to lay outsiders a.garbled account of the statements
of another. Thus, I happen to be a Fellow cf the
Royal Society of Medicine. If I should chance to
take part in a discussion on any subject, if my opinions
are not those usually held, and if some lay paper
makes a paragraph imputing views to me which I
repudiate, is the person whose paper is criticised to
communicate with my adversaries in the Corporation
of which I happen to be a member, and give them
an opportunity of perhaps blasting my career for ever?

I suggest that the unwritten law of the profession
requires that when medical men have a scientific dis¬
cussion, and when views are imputed to one of the
participants which he denies, and which are calcu¬
lated to do him harm, it is the duty of his medical
colleagues to accept the denial, and not to communi¬
cate with outsiders who wish to impeach him on the
question.

I am, Sir, yours truly,

J. C. McWaltsr.

October 10, 1907.

CASE OF THE LATE DR. J. P. MAGUIRE.
To the Editor of The Medical Press and Circular.

Sir, —On behalf of the widow of the late Dr. J. P.
Maguire, I thank you for the assistance you have given
by publishing my appeal in your columns. Appended
hereto is a list of names of those who have generously
subscribed, and who now have the satisfaction of
knowing that their charitable and kindly action has
rescued this deserving case from penury, enabled her
to pay the expenses of training as a midwifery nurse,
and so earn her living in the future.

Oct. 23, 1007.

SPECIAL ARTICLE.

The Medical Press. 45 1

I intend to close the list on the 9th prox., and as
the widow has many expenses to meet I hope to receive
some more subscriptions before the list is closed.

I am, Sir, yours truly,

R. B. Mahon.

Ballinrobe, co. Mayo,

18th October, 1907.

AMOUNT ALREADY ACKNOWLEDGED.£28 9 0

Dr. Hesslon. Tuam ... £1 0 0
Dr. T. McCarthy. Sher¬
borne . 110

Dr. James Little, Dub¬
lin . 110

Dr. G. Goran, Cocker-

mouth. 110

Dr. Lotnbe Atthlll,

Monks town Castle... ? 2 0

“Anon" . 0 10 0

Dr. J. Galway Cooke,
Londonderry ..110

“A. F.”.2 2 a

Dr. J. Medley - Wood,
Bournemouth ... 0 10 6

"C. E.C." 10 0

Dr. J. F. Keenai, Balll-
nalee.Edgworthstown 10 0
Dr. M. McManus, Wal-J

worth Road, London 2 2 0

“H.R.L.” 2 0 0

Dr. Frank Godfrey,
Nettlestone. I. of W. 0 10 0
Dr. E. Murphy, St. Pat¬
rick's Hill, Cork ... 0 10 0

Dr. W. j. O'Sullivan,

Lisdoonrarna ... £110

"D" 078

I)r. J. B. Story, Dublin 1 0 0

Dr. H Allan Bennett,

Saltburn . 110

Mrs. M. H. Bennett,

Saltburn . 110

"M.D.". 0 10 0

••K." . 0 10 0

Dr. J. J. Magrath, St.

Helen's. Co. Donegal 110
Dr. Walter Smith,

Dublin . 10 0

Capt. W. Watson Scar¬
lett, R.A.M.C., Bath .110
Dr. J. F. O'Malley. 16,

WeymouthStreet, W. 110
Dr. O. Baynton Forge,

West Mailing ... 2 2_ 0

£67 15 0
Disbursed to date 6 0 0

Balance in hand £51 IS 0

SPECIAL ARTICLES*

THE DUBLIN HOSPITALS.

As our readers are aware, certain of the Dublin
Hospitals, nine in number, viz., the Westmorland
Lock, Dr. Steevens’, the Meath, Cork Street Fever,
the House of Industry, the Rotunda Lying-In, the
Coombe Lying-In, the Royal Victoria Eye and Ear,
and the Royal Hospital for Incurables, are in receipt
•of direct grants from Parliament. These grants vary
in amount from ^£ioo to the Royal Victoria Eye and
Ear Hospital to .£7,563 to the House of Industry
Hospitals. In order to exert a general supervision
■over the management of these hospitals, a Board of
Superintendence is in existence, which inspects them
and presents an annual report to the Lord Lieutenant.
The signatories to the present Report (a) are twelve in
number, together with the Secretary. The Secretary
and four of the members of the Board are medical
men. The Report, as we have been accustomed to it
for many years, consists of three parts:—(1) General
comments on the hospitals as a group ; (2) brief reports
on the condition of each hospital ; (3) series of tables
giving information regarding each hospital as to
the diseases treated, the sources of income and the
channels of expenditure, the dietaries, the cost of pro¬
visions, and other such matters.

These tables, if trustworthy, are of value to all in¬
terested in hospital management, and the comparison
afforded should, be particularly useful to the authori¬
ties of the hospitals under review. On glancing at
the tables some curious contrasts are noticed. Thus,
comparing the three general hospitals as regards the
average annual cost per bed for maintenance, we find
that in Steevens’ and the Meath the cost is £23 5s. 7d.
and £21 5s. 3jd. respectively, while in the House of
Industry it is only £14 18s. 3id. Again, comparing
the two lying-in hospitals, we find that the Rotunda,
with an average of 88 beds occupied, spends £6 is. 2d.
on stimulants, whereas the Coombe, with less than
half the number of beds (38) spends more than twice
that sum (£15 4s. id.). We have called attention to
this contrast in previous years. Again, the drug bill
at the Coombe is some twenty pounds greater than
that at the larger institution ; while, stranger still, the
drug bill at the Royal Victoria Eye and Ear Hospital
is the largest of any, though it has only an average of
71 beds occupied, against 158 at the House of Industry.

Certain of the tables, however, are hardly intelligible

(a) ‘‘Fortjr-Nloth Annual Report of the Board of Superintendence
of the Dublin Hospitals, with Appendices, for the Year 1906-1907."
Dublin: H.M. Stationery Office. 1907.

I as they stand. Thus, from Table No. 5, p. 29, which
purports to show, among other things, “the present
extent of accommodation for each class of patients,”
it would appear that there are no beds for lying-in
patients, incurable patients, or ophthalmic patients,
although four of the hospitals in the list are devoted
specially to these classes. Presumably, the returns
have not been made, but if so, this should be stated.
It is, however, on comparing the mortality as given
in this table with that as given in Table No. 1,
pp. 10-24, that we find the most astonishing dis¬
crepancies. The figures for the hospitals, regarding
which information is given in both tables, are as fol¬
lows : —

Westmorland Lock.

Table I. Table V.
.. 0 .. 5

Steevens’ .

•• 5 2

52

Meath.

79

... 78

Cork Street.

• x 93

... 200

Hardwicks

• 63

46

Whitworth .

. 64

43

Richmond .

• 3 6

64

Coombe “ Chronic Wards ”

. 0

... 1

Royal Hospital for Incurables

. 40

40

It will be seen that only in two

cases

do the figures

tally.

Turning from the tables to the body of the Report,
we find that the Board saw everything, and, behold, it
was very good. Praise is lavished on everyone con¬
cerned in hospital management, and on every detail
of the hospitals inspected. Nowhere is to be found—
we do not say the slightest censure—but the slightest
suggestion for improvement. We are quite in accord
with the Board in believing that the Dublin hospitals
are, on the whole, well and economically managed,
and in urging that more money is sadly needed, but
we can hardly regard them as perfect. As an example
we may refer to the case of one hospital, on whose
management we have had before now to comment
adversely. The Report says : —

“The Lock Hospital.

“ On inspection we found the wards and other parts
of this institution thoroughly clean, well ventilated,
and in excellent sanitary condition. The bedding and
bed-clothes were in good condition, the floors were
well scrubbed, regularity prevailed in every depart¬
ment, and the whole management impressed us as
highly commendable. Each patient was questioned as
to whether her comfort and well-being were satisfac¬
torily attended to, and the answers without exception
were in the affirmative. In the basement we were
struck by the cleanliness of every corner—a condition
difficult to bring about and maintain in a very old
building. The method of cooking is good, and the
different descriptions of food were all that they should
be.”

In 1903 , we commented (Medical Press and
Circular, July 8th, 1903 ) on the strained relations
which existed at the time between the Lady Superin¬
tendent and the nursing staff, owing to which three of
the four staff nurses resigned. We understand that
these relations have not improved since that time, and
that whereas at the date of the recent inspection by
the Board of Superintendence there were three staff
nurses in the hospital, there is now only one. More¬
over, this remaining nurse is the maternity nurse, who
should not be supposed to concern herself with other
than maternity duties. From the Report it would not
appear as if there were any maternity cases in the
hospital, whereas we understand that there is an
average of some five-and-twenty in the year. We con¬
ceive that it is the duty of the Board of Superinten¬
dence to inquire into and comment on such matters as
these. It is not through ignorance of them, however,
that the Board has kept silence. The affairs of the
hospital were brought before the Board by one of its
members, who expressed strong dissent from the para¬
graph we have quoted. In spite of his dissent, his
signature is attached to the Report, though we under¬
stand he has since sent his resignation to the Lord-
Lieutrnant as a protest against such treatment.

The Board of Superintendence has a serious duty
| to perform to the hospitals of Dublin and the public.

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MEDICAL NEWS IN BRIEF.

Oct. 23 , 1907 .

452 The Medical Press.

It is its duty to bring an intelligent and independent
criticism to bear on the management of these institu¬
tions. Strictures should be made where required, and
suggestions freely offered. There is doubtless much
tc praise, but there is also something to amend. It
was hoped by many that the recent change of secre¬
taryship, consequent on the lamented death of Dr.
Martin, would have resulted in some infusion of
freshness into the Report. This hope has been dis¬
appointed, for the present Report is, as we have said,
pitched in a high strain of eulogium from start to
finish. Moreover, as we have shown, the statistics
are not to be implicitly trusted. The editing is
careless in the extreme, the proofs having apparently
been left uncorrected. Within one table of some
thirty names (p. 21) we find the following misprints:
Hyda-hidiform mole, Lacerated Permaimus, Hyd-
rammos, Galachacele, urticarie, Pyamia.

Medical News in Brief.

The Tuberculosis Exhibition In Dablln.

During the past week the Tuberculosis Exhibition
in Dublin attracted large numbers of visitors of every
class, particularly of members of local sanitary
authorities, who took notice of the means adopted in
various English and ether cities to combat tubercu¬
losis. Each day, either in the afternoon or the
evening, a popular lecture was delivered by a medical
or other expert qualified to speak with authority, her
Excellency the Countess of Aberdeen occupying the
chair at most of the lectures. On Monday evening the
Registrar-General (Mr. Matheson) lectured on “Tuber¬
culosis in Ireland.” He contrasted the statistical
history of tuberculosis in England, Ireland, and Scot¬
land from the years 1864 to 1906. While in 1864
Ireland stood lowest of the three, with a rate of 2.4
per 1,000 living, the rate for England being 3.3, and
that for Scotland 3.6, in 1905 Ireland occupied the
unhappy position of being the highest, with a rate of
2.7, Scotland being next with 2.1, and England lowest
with a rate of 1.6.

The lecturer told hi9 audience that out of a total
of 74> 2 47 deaths registered in Iredand in 1906, no fewer
than 11,756, or 15.8 per cent., were due to the disease.
Amongst the classes which were well housed, clothed,
and fed, the mortality from the disease was -much less
than among those who had not those advantages. He
instanced insanitary houses and surroundings, intem¬
perance, and neglect of precautions against infection
as the main causes favouring the spread of the disease,
and emphasised the necessity of the establishment of
special dispensaries, sanatoria, and hospitals in order
to check its growth.

Dr. Lawson, Medical Superintendent of Nordrach-
on-Dee Sanatorium, chose as the title of his lecture
“ Some Aspects of the Tuberculosis Problem.” It was
illustrated by a number of limelight views. He advo¬
cated, among the measures to be adopted in coping
with the evil, the provision of improved dwellings for
the workers in the towns; the adoption of regulations
which would render it an offence, involving a legal
penalty, to expectorate in public ; the inspection of the
milk supply with a view to securing its purity; the
compulsory notification of pulmonary tuberculosis;
and the erection of two classes of buildings for the
accommodation of consumptive patients—one class
designed for advanced cases, where the patients might
be cared for until they died, and another class to
which others might go with a reasonable prospect of
recovery.

Dr. McSweeney lectured on “The Campaign Against
Tuberculosis in Germany,” giving a resume of the
facts detailed in his well-known Report to the Local
Government Board.

Mr. Lentaigne lectured on “Tuberculosis of Bones
and Joints.” It was most difficult, he said, to get
such cases retained in general hospitals as long as they
should be, and consequently real and permanent cures
were far less frequent than they should be. He thought
it would be well that when sanatoria were being con¬
structed accommodation should be provided for such
cases to complete their cure after a short stay in a

general hospital for special surgical treatment. They
might be accommodated with the pulmonary cases,
but it would be better and safer when cheap wooden
buildings and sheds were being erected for the purpose
to have special buildings of a similar character, but
with special trained nurses and some special surgical
equipment for these cases. Tuberculosis was produced
in three ways—by inhalation with the breath, by swal¬
lowing with food, and by inoculation. Tuberculosis
by inhalation could be prevented from spreading by
segregation and by the education of the public. They
could prevent the infection through the medium of
food by the same means, and by putting an end to the
sale of infected milk. That could be done if it was
made a penal offence for anyone to sell milk from
animals that had not been certified free from tuber¬
culosis. The disease would them be very soon stamped
out in domestic cattle. The campaign should be one
of education and agitation. They had to combat three
enemies—economy, ignorance, and apathy. In order
to overcome the enemy of ignorance he strongly advo¬
cated, among other measures, the imparting to children
a proper health training. They should agitate for
notification for suitable hospital accommodation, and
for the restriction of the sale of poisonous milk.

The attendance at all the lectures was gratifying,
and an interesting discussion followed each lecture.
Prosecution by the Dental Association.

At the Worcester Police Court, on October 14th,
Percy Smith, Beacon View, Woolhope Road, was sum¬
moned by the British Dental Association for unlaw¬
fully using a certain description implying that he was
a person specially qualified to practise dentistry. Mr.
Maund appeared for defendant, who pleaded not
guilty.

Counsel said the case was taken under the Dentists
Act, 1878, which said a person should not be entitled
to take the name of dentist or dental practitioner,
implying that he was specially qualified, unless he
were registered under the Act. Defendant had been
employed by Mr. F. W. Sievers, a Worcester dentist,
first as house-boy and then as mechanic. He had at no
time during that period had experience in dental
operations. He was discharged by Mr. Sievers, and
soon afterwards mentioned that he had started on his
own account, and handed to Mr. Sievers’ cook a card,
which was the cause of the prosecution. The card
was as follows:—“Artificial teeth: high-class work at
moderate charges; painless extractions; advice free.
Mr. Percy Smith Beacon View, Woolhope Road,
Worcester. Seventeen years with Mr. F. W. Sievers,
L.D.S.” The Dental Association maintained the card
was an infringement of the Act the object of which
was to prevent unqualified persons from practising
dentistry. The man implied by the card that he had
had experience. Mr. Sievers said defendant was em¬
ployed by him for seventeen years. He was never
allowed to operate, and witness would not be allowed
to employ an unqualified assistant. Mr. Maund said
defendant was doing nothing that he thought
was legally or morally wrong in adopting the means
of advertisement others used. He had now withdrawn
the card. Mr. Maund argued that the card did not
necessarily imply that defendant was a registered
practitioner.

Defendant was fined £2 and costs.

Royal College of Surgeon* In Ireland.

The Winter Session commenced on Tuesday, October
15th, when the prizes of the previous Session were
distributed by the President of the College as follows:
—Barker Anatomical Prize—£31 10s., G. S. Levis.
Carmichael Scholarship—^15, J. Menton. Gold
Medals in Operative Surgery—P. G. M. Elvery and T.
Sheehy (equal). Stoney Memorial Gold Medal in
Anatomy—Miss I. M. Clarke and G. C. Sneyd (equal).
Descriptive Anatomy—Junior—J. T. Duncan, 1st prize
(£2) and medal; T. Dowzer, 2nd prize (,£1) and
certificate. Senior—H. G. P. Armitage, 1st prize (£2)
and medal; W. Swan, and prize (_£i) and certificate.
Practical Anatomy—First Year—T. M. Thomson, 1st
prize {£2) and medal; F. W. Warren, and prize (/1)
and certificate. Second Year—W. Swan, 1st prize (^z)
and medal; H. G. P. Armitage, and prize (j£i) and
certificate. Practice of Medicine—C. Greer, 1st prize
(£2) and medal; G. S. Levis, and prize (/T) aad

Oct. 23, 1907.

PASS LIS I S.

The Medical Press. 453

certificate. Surgery—G. S. Levis, 1st prize (^2) and
medal; W. R. Burton, 2nd prize (£1) and certificate.
Midwifery—H. W. White, 1st prize (£2) and medal;
G. S. Levis, 2nd prize (£1) and certificate. Physiology
—H. M. E. H. M‘Adoo, 1st prize (£2) and medal;
0 . G. Connell, 2nd prize (^1) and certificate.
Chemistry—P. V. Crowe, 1st prize (£2) and medal;
J. T. Duncan, 2nd prize (£i) and certificate. Pathology
—I. Scher, 1st prize (£2) and medal; C. Greer, 2nd
prize (;£i) and certificate. Physics—J. T. Duncan, 1st
prize (^2) and medal; T. Buckley, 2nd prize (^1) and
certificate. Practical Histology—F. W. Warren, 1st
prize (£2) and medal; J. S. Pegum, 2nd prize (^1) and
certificate. Practical Chemistry—H. C. Gilmore and
J. Kirker (equal), 1st prize (£2) and medal. Public
Health and Forensic Medicine—H. Hunt, 1st prize
{£2) and medal; Miss C. F. Williamson, 2nd prize (^1)
and certificate. Materia Medica—J. Menton, 1st prize
{£2) and medal; Miss C. F. Williamson, 2nd prize (£1)
and certificate. Biology—J. T. Duncan, 1st prize (£2)
and medal; P. V. Crowe, 2nd prize (£1) and
certificate.

The Royal College of Physicians of Ireland.

The annual meeting of this College was held on St.
Luke’s Day. The President, Censors, Examiners, and
other officers for the ensuing year were elected as
follows :—

President—Dr. Joseph M. Redmond. Censors—Drs.
Norman, Murphy, Jellett, and R. Travers Smith.
Vice-President—Dr. Norman.

Additional Examiners to take the place of an absent
Censor :—Medicine—Dr. Matson. Medical Jurispru¬
dence and Hygiene—Dr. Montgomery. Midwifery—
Dr. Glenn. Examiners in Midwifery—Dr. Horne, Dr.
Wilson. Examiners, in addition to Censors, under the
Conjoint Scheme: — Biology — Dr. Kirkpatrick.
Chemistry—Dr. Lapper, Dr. Falkiner. Physics—Dr.
Peacocke, Dr. Winter. Pharmacy, Materia Medica,
and Therapeutics—Dr. Drury, Dr. Dempsey. Physio¬
logy—Dr. Earl. Pathology—Dr. F. C. Purser. Medi¬
cine—Dr. Parsons, Dr. W. J. Thompson. Hygiene
and Forensic Medicine—Dr. Dawson. College Exami¬
ners for the Conjoint Preliminary Examination :—Mr.

E. H. Alton, F.T.C.D., Mr. R. A. P. Rogers,

F. T.C.D., Dr. Connor Maguire. Examiners for the
Conjoint Diploma in Public Health :—Hygiene—Dr.
Bewley. Chemistry—Dr. Lapper. Meteorology—Dr.
Winter. Examiners for the Membership :—Clinical
Medicine—Dr Wallace Beatty, Dr. Murphy. Prac¬
tice of Medicine—Dr. O’Carroll, Dr. R. Travers Smith.
Pathology.—Dr. Earl, Dr. O’Sullivan.

Dr. James Spencer Sheill, M.R.C.P. and L.R.C.S.I.,
was elected a Fellow of the College.

The annual dinner of the College was held on Satur¬
day, the 19th inst., in the College Hall, and was
largely attended. Amongst the guests were Lord Jus¬
tice Holmes, the Master of the Rolls, the Provost of
Trinity College, the President of the Royal College of
Surgeons, the President of the Royal Irish Academy,
the President of the Royal Irish Academy of Medicine,
his Honour Judge Craig, Sir Charles Ball, Mr. Har¬
rington, M.P., Sergeant O’Connor. The toasts con¬
sisted of “The King,” “The Guests,” “The Sister Col¬
lege,” “The President,” “The Registrar.”

Haslar Hospital.

The course of instruction at Haslar Hospital for
the naval surgeons who entered at the spring com¬
petitive examination has just come to an end, and the
usual awards have been made to the three surgeons
who have so far most distinguished themselves. Sur¬
geon R. Connell, M.B. (Trinity College, Dublin), has
gained the gold medal, and Surgeon C. Ross (Glasgow
University) the silver medal, whilst the third award,
in the form of a handsome microscope, has been made
to Surgeon G. Price, a former student of St. Thomas’s
Hospital.

The Medical Exhibition-

In our report and description last week of exhibits
at the Medical Exhibition held in London, we
referred to the recently introduced preparation
“Miol” as an emulsion of cod liver oil and malt.
This was a slight slip of the pen for olive oil and
malt, a decidedly useful therapeutic novelty, one
which doubtless will be duly appreciated by the pro¬
fession when better known. j

PASS LISTS.

Conjoint Examinations la Ireland by tba Royal CoHogo of
Physicians and Surgeons.

The following candidates have passed the first Pro¬
fessional Examination, October, 1907 :—

M. L. Bourke, F. E. Fitzmaurice, J. M. Gilmore,

C. H. Joynt, J. Kirker, C. J. Kelly, A. G. J.
Macllwaine, B. Malaher, B. Murphy, D. McDevit, B.
Neary, A. J. Neilan, M. K. O’Byrne, J. H. Rish-
worth, C. Roche, G. Wilson, and G. Young.

The following candidates have passed the Pre¬
liminary Examination: —

J. T. McConkey (with honours), J. I. Pollock (with
honours), W. I. Adams, A. C. J. Austin, A. J. Bodell,

G. Bailey, A. T. Cannon, G. Campbell, T. F. Collins,

D. Dudley, A. P. Flood, P. A. Gardner, R. M. Gordon,
S. Griffin, D. J. Healy, N. S. Hood, T. Kennedy,
W. J. Marmion, M. Meehan, D. Murphy, J. J. Murphy,

A. J. Patterson, F. P. Shields, M. Scher.

Copies of the Preliminary Regulations for 1908 can
now be obtained on application.

The Royal University of Ireland.—Medical Degrees
Examinations.

The following candidates have passed the under¬
mentioned examinations:—

The M.D. Degree Examination.—Thomas Barry,
M.B., B.Ch., B.A.O. ; Robert Chambers, M.B.,
M.B.B.Ch., B.A.O. ; Foster Coates, B.A., M.B.,

B. Ch., B.A.O. ; William J. Maguire, B.A., M.B.,
B.Ch., B.A.O. ; James B. Slattery, M.B., B.Ch.,
B.A.O. ; Robert Steen, M.B., B.Ch., B.A.O. ; William
J. Wilson, B.A., M.B., B.Ch., B.A.O.

The M.B., B.Ch., B.A.O. Degrees Examination.—
Upper Pass.—Thomas S. S. Holmes, James B.
Lapsley, John E. A. Lynham, B.A., William D.
O’Kelly, Herbert H. Prentiss, James Shaw, James A.
Shorten, B.A., Alexander L. Stevenson.

Pass.—Joseph H. P. Boyd-Barrett, Edwin B. Brooke,
Matthew F. Caldwell, Gault Calwell, William F. A.
Carson, Robert Cox, B.A., James Dewar, Michael F.
Donovan, B.A., James J. Flood, Charles E. L.
Harding, John ]. Hickey, James Horgan, James B.
Horgan, John Hughes, Francis Keane, Joseph P.
Kerlin, Richard R. Kirwan, Thomas J. McAllen,
John S. McCombe, Wiclif McCready, Augustine P.
MacMahon, John J. O’Reilly, Christopher F. X.
O’Sullivan, Daniel T. Sheehan, James Sinclair,
Hans C. Swertz.

The following candidates are exempted from further
examination in the subjects set after their names :—
Robert G. Kevin, the Medicine Group; John F.
Neary, the Medicine and Midwifery Groups.

The following candidates may present themselves
for the further examination for Honours in the groups
mentioned after their names :—James B. Lapsley, the
Medicine Group ; William D. O’Kelly, the Midwifery
Group ; Herbert H. Prentiss, the Medicine, Surgery
and Midwifery Groups ; Daniel T. Sheehan, the Mid¬
wifery Group ; James A. Shorten, B.A., the Medicine
and Surgery Groups; Alexander L. Stevenson, the
Medicine and Surgery Groups.

Reyal College of Surgeons of Edinburgh.

At the annual meeting, held on 16th inst., Mr.
Joseph Montagu Cotterill was unanimously elected
President for the ensuing year. At the same meeting
the following gentlemen, having passed the requisite
examinations, were elected ordinary Fellows of the
College:—

William Rickward Bacot, M.R.C.S.Eng., London,
W. ; Harold Graves Bennetts, M.B., C.M., Sydney,
N.S.W. ; Gerald Hall Lloyd Fitzwilliams, M.B.,
Ch.B., Newcastle Emlyn, S. Wales; James Methuen
Graham, M.B., Ch.B., Edinburgh; William Ezra
Graham, M.D., C.M., Ontario, Canada; Duncan
Lorimer, M.B., Ch.B., Edinburgh; Peter McF.wan,
M.B., Ch.B., Kinfauns, Perthshire; William Latto
Robertson, L.R.C.S.E., M.B., Ch.B., Edinburgh;
William Craig Stewart, M.B., Ch.B., Glasgow, W. ;
and Stanley Martin Wells, M.R.C.S.Eng., Lima,
Peru, South America; and John Pinkerton, M.D., etc.,
Honorary Physician to his Majesty the King, Gwydyr
House, Crieff, Perthshire, was admitted an Ordinary
Fellow without examination.

Digitized by GoOgle

454 The Medical Press.

WEEKLY SUMMARY.

Oct. 23, 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for The Medical Press and Circular.

RECENT GYNAECOLOGICAL AND OBSTETRICAL LITERATURE.

Ruptured Pus Tubes. —Mann ( Amer. Jour. Obst. and
Gyna., October, 1907).—Clinically ruptured pus tubes
may be divided into three classes: (1) Those which
rupture into the peritoneal cavity, but in which the
pus is restrained by adhesions from setting up a
general peritonitis. (2) Those which rupture into
some adherent viscus—as the bladder, rectum, intes¬
tines. (3) Those in which the rupture is into the
peritoneal cavity, the pus not being walled off, and, if
virulent, setting up a general peritonitis which acts
much like an acute ruptured appendicitis, and usually
causes death, unless operative means are employed.
It is, however, more amenable to operative measures
than peritonitis caused by appendicitis. By far the
most common class is the first, the pus escaping form¬
ing an abscess which often reaches above the um¬
bilicus, and contains a quart or more of pus, this
finally rupturing into the bowel, or peritoneal cavity,
or causing death by absorption of toxins. In the
second class the danger of secondary infection through
the sinus is great, and complete cure is obtained only
by removal of the tube and closure of the sinus open¬
ing. Of the third class, when symptoms of peri¬
tonitis begin, to temporise is, in the writer’s opinion,
not giving the patient the best chance, and therefore
that operation and drainage is in order even in the
acute stages. F.

Blood Transfusion In Puerperal Septicaemia. —McKay
(Amer. Jour. Obst., October, 1907). The writer reports
a case in order to show that the rigors of puerperal
septicaemia may be abolished by the transfusion of
blood, and to point out the negative effect of enormous
infections of antitoxin in this case. The case was
admitted to hospital on the fifth day after premature
labour; examination of uterine discharge showed a
streptococcic infection. Antistreptococcic serum was
injected with no result. Having found in previous
experience that the antidiphtheritic serum seemed to
act well when the antistreptococcic serum failed, he
gave her 2,000 units of these sera alternately every four
hours. The patient grew steadily worse, and the anti¬
toxin was increased. Rigors began on the fourth day
after admission, and continued daily till the joint
transfusion of blood and saline. After this trans¬
fusion—in which not more than a few ounces of blood
was employed—the rigors disappeared for six days,
then began again. Thinking that perhaps the c alt
solution had brought about the happy result, a vein
was opened, and thirty ounces of normal saline, to
which one ounce of peroxide of hydrogen had been
added, was introduced. The patient had a most severe
rigor forty-eight hours later, the temperature rising
to 106 deg. On the following day ten ounces of blood
and twenty ounces of normal saline were transfused,
and the patient had no more rigors for twelve days,
during which time the pulse and temperature improved,
and the patient progressed so rapidly that she was
allowed to sit up in bed. Whilst in this posture she
fainted, and died in a few minutes. F.

Retention in Utero of Separated After-coming Head.—

McKerron (Jour. Obst. and Gyn., October, 1907).
Separation of the after-coming head, with retention in
utero, is probably a not uncommon accident, while it
usually occurs in the case of long dead decomposing
children, in whom the tissues are very friable. When
the complication occurs the delivery of the head is
often a matter of considerable difficulty, and more
especially when its extraction has not been undertaken
at once, and the os uteri has had time to retract. In
view of the comparative frequency of this accident,
and of the difficulties that may attend extraction, it is
surprising that few writers and no text book refer to
it. There are several ways in which extraction of the

retained head may be effected. Sometimes expulsion
is completed spontaneously, but this is exceptional.
The selection of a method of extraction will depend on
the extent of dilatation, and on the dilatability of the
cervix uteri. When the case is seen at once, before
the cervix has retracted, firm downward press ire on
the fundus may be sufficient, either alone or combined
with moderate traction on the head by the hand or
volsella. It is seldom separation takes place at the
immediate base of the skull; a part of the cervical
column is usually left, and affords a good hold for the
hand. Where the cervical vertebrae are torn off, trac¬
tion may be made in the lower jaw, but this even may
tear off. Then delivery must be effected by getting the
tip of index finger through the foramen magnum, or
by making traction by means of forceps or volsella.
When the cervix is imperfectly dilated, or is rigid and
unyielding, great difficulty may be experienced in
effecting extraction. The cervix must first be dilated,
then if a good grasp of the head cannot be obtained
with the hand, the volsella, with pressure from above,
may be tried ; but if much force is required, it is not
likely to be successful, owing to the friability of the
tissues. Should they fail the forceps may be tried,
and its application assisted by steadying the head from
above. In the event of failure with the forceps, the
cephalotribe or cranioclast, both of which have been
successfully used, may be tried. Bcrgufes, in a recent
paper on the subject, recommends when the cervix has
become retracted, that the head should be fixed by
means of a volsella, to which a weighted cord is
attached, and allowed to hang over the end of the bed.
The continuous traction induces contractions of the
uterus, dilatation is thus secured, after which the head
can be delivered by traction on the volsella. F.

Ventral Hysteropexy. —Olshausen (Zentralbl. fur
Gynak., 1907, No. 41) describes his method modified
by his former assistant, Professor Koblanck, which
has been employed in his klinik during the last ten
years. After opening the abdomen, the skin and
adipose tissue are separated from the rectal fascia by
a few strokes of the knife at each side of the ab¬
dominal incision. A needle with a thick silkworm gut
suture is then passed from the superior surface of the
bared fascia through the remainder of the abdominal
wall into the abdominal cavity. The needle point is
inserted about 2 cm. external to the incision, and
before passing the needle through, it is important to
see that the peritoneum and fascia are pulled well
into the incision on each side, so that they may come
together easily during the closure of the abdomen
When the needle has been passed into the abdomen it
is picked up and guided through the origin of the
round ligament, taking up underneath the latter a little
of the muscle of the uterine cornu. It is ihen passed
back from within outwards through the abdominal
wall, the point being inserted a few centimetres distant
from the former point of ^ntry. The suture is then
tied. The knot is thus on the superior surface of the
fascia. Before the knot is tied one must be certain
that the cornu of the uterus lies closely against the
abdominal wall. The same proceeding is to be fol¬
lowed on the other side. The operation has been per¬
formed hundreds of times in Olshausen's klinik, with
excellent results. When it is properly performed it is
practically impossible to get a recurrence. The only
time a possibility of a recurrence arises is when the
silkworm gut suture is tied so very tightly that it cuts
through the fascia. The silkworm gut does not alter,
therefore it is the best suture material. Olshausen has
never seen any hindrance to the development of the
uterus during pregnancy after this operation. Neither
has he ever seen the operation followed by an abor¬
tion. It has been reported that he had a case of in-

Digitized by GoOgle

WEEKLY SUMMARY.

Oct. 23, 1907.

testinal obstruction following this operation, but this
is not true. As regards ventral fixation in cases of
prolapse of the uterus, he very seldom performs this
operation, and then only in combination with col-
poTrhaphy, etc. In such cases, in addition to the silk¬
worm gut suture on each side, he puts in a catgut
suture in order to get a broader attachment between
the uterus and the abdominal wall. G.

Epilepsy and Pregnancy. —Neu ( Monatssch. fur Geb.
und Gytt., Bd. XXVI., Hft. I.) describes a case as
follows:—A primipara, aet. 24, developed epilepsy in
the sixth month of her pregnancy. She had 26 fits in
23 hours. As a result she became comatose, and died
without regaining consciousness, but with all the
symptoms of oedema of the lungs. The patient had
suffered before her pregnancy from epilepsy. The
author then discusses very thoroughly the relationship
between epilepsy and pregnancy. It is his opinion that
pregnancy is not the primary cause of the epilepsy,
but that epilepsy can be influenced by pregnancy.
Whether in cases of pregnancy complicated by epilepsy
labour should be induced or not, must be decided by
observation of the cases individually. Induction will
very often be indicated when the convulsions are very
numerous, and always in every case of status epilep-
ticus. G.

Suprapubic Delivery and its Relationship to Other
Operations in Cases of Contracted Pelvis. —In a paper
on this subject, Frank {Archiv. fur Gynak., Bd.
LXXXI., Hft. I.) agrees with the views of Kehrer on
the superiority of the low incision in Caesarean sec¬
tions. The greatest danger still consists in the in¬
fection of the peritoneum from the uterine cavity.
If this could be prevented the Caesarean section be¬
comes an operation free from danger which would
certainly reduce the number of operations which are
performed for artificially enlarging the pelvis, and
also there would be a greater freedom of choice as
regards the time at which the Caesarean section could
be performed. The author considers that all this may
be obtained by his suprapubic method of delivery by
which the abdominal cavity' is definitely shut off before
the incision into the uterus is made. A transverse
incision is made two fingers breath above the sym¬
physis, and directly above the bladder. After the
abdomen is opened, the loose fold of peritoneum on
the uterus is picked up, cut across transversely, and its
upper border is sutured to the parietal peritoneum of
the upper edge of the wound. When this has been
carefully completed a transverse incision is made in
the region of the lower uterine segment. The head is
usually spontaneously delivered—one may even wait
for spontaneous deliverance by the pains. The author
can report from a series of thirteen cases, which were
all of a very doubtful nature as regards asepsis, in
which the results for the mothers were excellent. It
is also his opinion that when suprapubic delivery has
been fully developed, it will cause a disappearance in
cases of contracted pelvis, of induction of abortion,
induction of premature labour, the perforation of the
living child, and the sterilisation of women. For
infected parturient women whose natural powers have
worked in vain, and for whom also the operations for
enlarging the pelvis are not without danger, and are
also not permissible for every degree of pelvic con¬
traction, this method of delivery is one which may be
employed without danger to save the mother and
child. G.

Cesarean Section when the Uterus is Infected —

Relying upon the statement of Frank, the Caesarean
section was performed by Veit (Monatssch. fur Geb.
und Gyn., Bd. XXVI., Hft. 1) for two women whose
liquor amnii was infected. In order to prevent in¬
fection of the peritoneal cavity by the liquor amnii,
he sutured the peritoneum of the uterus to the parietal
peritoneum after dividing the abdominal wall trans¬
versely. Having opened the lower uterine segment, he
removed the contents of the uterus and sutured the
incisions. He is quite content with the result of the
operation in both cases, but advises that the operation
shall not be done too early, as good dilatation of the
lower uterine segment is desirable. He regards this

The Medi cal Press 455

method of Caesarean section as most important in
cases of decomposition of the uterine contents, as it
prevents the entrance of the infection into the ab¬
dominal cavity. G.

Complications of Retroflexio Uteri, and their Influence
on the Operative Treatment. —In a paper on this sub¬
ject, Guggisberg (Zentralbl. fur Gynak., 1907, Nr. 41)
discusses the aetiology and the symptoms of retroflexio
uteri. He then speaks of the complications which
may affect the myometrium, the endometrium, the peri¬
metrium, and, further, the adnexa, whose diseases he
attributes to the congested condition of ihe genitals.
Among 176 patients who were operated on in the Bern
klinik, 60 had complications. The majority of the
women dated their sufferings from an afebrile puer-
perium. The principal symptoms are sacral pain and
haemorrhage. The complications : endometritis, metri¬
tis, perimetritis, and, finally, diseases of the adnexa
either inflammatory or degenerative. The latter were
frequently not diagnosed. As regards the indications
for treatment, one must first exclude hysteria, and
it must then be determined whether the symptoms are
due to the displacement or to the complications.
Operative treatment is indicated when the pessary does
not work, or causes pain, or when its insertion is not
desirable. When operation is decided on, the endo¬
metrium must especially be subjected to energetic
treatment. Then, having opened the abdomen by the
transverse incision, after inspection, and, if necessary,
treatment of the adnexa, the round ligaments are fixed
to the anterior abdominal wall by one or two silkworm
gut sutures which go through the peritoneum, the recti,
and the fascia. G.

Alcohol in Midwifery and Gynaecology. —Theilhaber
(Miinchcner Med. W ochensch., 1907. Nr. 4).—In
pregnancy, during labour, during puerperal fever, and
during lactation, alcohol enjoys the reputation of being
a therapeutic agent of value. In all those conditions
the author declares that this reputation is unjust, since
the action of the alcohol is more injurious than bene¬
ficial. It is just as injurious in gynaecology. It causes
hyperaemia of the female genitals, it increases the
sexual desire, it increases the secretions from the
genital system, and also the amount of menstrual
haemorrhage. lie forbids, therefore, that it should be
given to young girls, to those with diseases producing
haemoirhage and secretions, for all pelvic neuroses,
and for the symptoms associated with the menopause.
In cases of chlorosis and anaemia there is nothing to
be gained by the administration of red wine.
Physicians should join in the crusade against alcohol.
They can do much by limiting the prescribing of
alcoholic drinks. G.

The Chelsea Hospital for Women has received from
Earl Cadogan a donation of ^500, and the Council
have resolved to name a ward of the hospital in
memory of its late benefactress, the Countess Cadogan.

Dr. Thomas, the Medical Officer of Health for the
Borough of Stepney, reported recently that in the
parish of St. George’s-in-the-East, the centre of the
alien immigration in the East End, the birth-rate for
the past fortnight was as high as 52 pci 1,000, prac¬
tically double that for the whole of London.

The annual surgical report of the Xetley Hospital
shows that 1,282 we e treated in twelve months. The
number returned to duty was 791, whilst 357 were
invalided. The number of deaths was 14, and the
balance of admissions remained under treatment. Out
of 220 surgical operations no fewer than 190 were com¬
pletely successful, whilst 17 were partially successful,
and 13 were failures, chiefly owing to the weakness of
the patient.

A sub-committee decided on Monday afternoon to
recommend the Public Health Committee of Dundee
Town Council to adopt the Notification of Births Act.
The Act provides that notification shall be given to
the Medical Officer of Health, and failure to comply
with the Act is punishable by a penalty of 20s. The
principal idea of notification is that ihe Medical
Officer may send health visitors to any house after the
birth of a child, and in this way assist the mother to
build up a healthy child at the very outset.

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Oct. 33, 1907.

456 t„. Medical P.ess. NOTICES TO CORRESPONDENTS.

NOTICES TO
CORRESPONDENTS,

tfe.

m&- Correspondents requiring a reply in tide oolumn »re p«r-
tioularly requested to make use oi l Dut\nct%v* Sjgnatu r» or
Initial, end to avoid the praotioe of signing themselres
" Reader," “ Subscriber,” " Old Subscriber, eto. Much con¬
fusion will be spared by attention to this rule.

SUBSCRIPTION 4.

Subscriptions may commence at any date, t™t th ® t ’T°
eaoh year begin on January 1st and July W rei^tiMl^. Tennj
per annum, 21s.; post free at home or abroad. Foreign sub¬
scriptions must be paid in adranoe For India, Meeara
Spink and Co., of Calcutta, are our officially-appointed agents.
Indian subscriptions are Its. 15.12. . ...

Contributors are kindly requested to send their
tions if resident in England or the Colonies, to the Editor at
ihe London office; if resident in Ireland to the Dublin office, ta
order to saye time in reforwardine from offloe to office^ When
sending subscriptions the same rule applies as to office, tnese

, b0 uld b. ■"".'-'“'ffAMB,

The limits of the ominous in the physician’s name are ' » ttr *}y
reached in the case reported from Sheffield in the following
note—It may interest you to know that we have here a Dr.
Kilham. Also there is a Dr. Reckless, of long-standing con¬
nection here. The initial letter of his Christian name being A.
for Arthur, his name-plate used to read, A. Reckless, Sur
K eon." But he had it altered to his full name.

After this the ’’Coffins" and the Philgraves cease to
move our admiration. The Kilham who enters the medical pro¬
fession demonstrates the invincibility of the human will as few
men have done it.— Daily Nexei. , ,, .

Anxious (Exeter).—It is always best, under the circum¬
stances, to submit the case to a consultant. The question of
fee oould no doubt be arranged to meet the position of the

pa,lent ' 08LERISMS.

" Examinations are merely the meeting of certain tests. They
make a man a mere talking machine or a human monotype
“ Take no thought for the morrow. Let the interest of the
day’s work absorb all your energies."

Be sceptical to the Pharmacopeia as a whole. He is the
best doctor who knows the worthlessness of most medicine.

" Study your fellow-man-and fellow-woman; and learn to man-

a? “ Onoe get down to the purely business level and your influence
is gone, and the light of your life goes out.

Du 8 C Y.—An X-Ray examination of the limb should un¬
doubtedly be made. Without it there can be no certainty as

to the real condition of affairs. ... __,

8 rBB (Birkenhead).—There is nothing in the course pursued
by our correspondent which we regard as being derogatory in a
profeeeional respect.

Jffttiings of the goddito, ICtctorts, Ac.

Wednesday, OcroBia 23 bd.

Rotal Societt or Medicine (Suboical Section in conjunc¬
tion with the Clinical Labtnoolooical, Medical, and^Ob-
8 TETBICAL Sections).— 5.30 p.m.: Speoial Meeting. Demon¬

stration (by means of the epidiascope and microscopes):—Prof.
Goldman' (Freiburg): (1) The Growth of Malimant Disease in

Man and the Lower Animals, with x'rrts

Vasoular System; (2) The Diagnosis by the help of the X-Rays,
of Abdominal Malignant Disease. 8ubphrenio Abscess, Appen-

d MedicIl 0 'Gbaduates’ Collxoe and Polyclinic
Street VC).—* p.m.: Mr. J. Pardoe: Clinique. (Suitfical.)
5.15 p!m.: Lecture: Dr. D. Drummond (Newcastle-on-Tyne):: The
Mental Origin of Neurasthenia and its bearing on Troatment.

Nobth-Eint London Post-Oraduatb College (P*™ 0 ® °"
Wales’s General Hospital, Tottenham, N.).—Oliniques: 2.30 p.m.:
Medical Out-patient (Dr. Whipham); Deraatologioal (Dr. G. N-
Meachen); Ophthalraological (Mr. R. P. Brooks).

Thursday, Octobeb 24th. . „.

Child Studi Society (Parkes Museum. Margaret Street, W )

8 p.m.: Lecture:-Dr. C. A. Mercier: Principles of Ednostmi.

Medical Graduates’ College and Policlinic (22 Chenies
Street W.C.).—4 p.m.: Mr. Hutohinson: Clinique. (Surgical)
5.15 p.m.: lecture:—Dr. D. Drummond (Newcastle-on-Tyne):

The Diagnosis of Thoracic Aneurysm. _ .

North-East London Post-Graduate Co 0 , L £?°* rn (Pri ( ?°® (p< °5
Wales’s General Hospital, Tottenham. N.).—i2-30 p.m.: Qjnteco-
logical Operations (Dr. Giles). Climques :—Medioal Out-patient
(Dr Whiting), Surgical Out-patient (Mr. Carson). X-Ray (Dr.
Pirie) 3 pm.: Medical In-patient (Dr. G P. Chappel.
4.30 p.m.: Lecture Deraonstralion:—Dr. T. R. Whipham: Chil¬
e's?.* John’s^Hosmtal tob Diseases or the 8bin (L^Mster
Square, W.C.) —6 p.m.: Chesterfield Lecture:—Dr. M. Dockrell.
The Treatment of Eczema in all its Forms.

Fbidat, Octobeb 25th.

Rotal Societt or Medicine (Epidemiological Section) (20
Hanover Square. W.).—7.45 p.m.: Council Meeting. 8.30 p.m.:
Presidential Address :-Dr Newsholrae : Poverty and fasease as
illustrated by the Course of Typhus Fever and Phthisis in Ire-

la RoTAt. Societt or Medicine (Electro-Therapeutical Section)
(20 Hanover Square. W.).-8.30 p.m.: President s Address.

Medical Obaduates’ Colleoe and Poltclinic (22 Chenies
Street WC)—4 p.m.: Dr. D. Grant: Clinique. (Far-)
North-Eant London Post-Graduate College (Pnnce of
Wales’s General Hospital, Tottenham, N3-—10 a.m.: Clinique: —
Surgical Out-patient (Mr. H. Evans). 2.30 p.m.: Surgical Opera¬

tions (Mr. Edmunds). Oliniques: —Medical Out-patient (Dr.

Auld), Eye (Mr. Brooks). 3 p.m.: Medical In-patient (Dr. M.

Leslie).

Appohtttnrmc.

Bell, W. W., L.S.A., Clinical Assistant to 8 t. John’s Hospital
for Diseases of the Skin, London. ,

Brat, P. D., M.R.C. 8 ., L.S.A., Clinical Assistant to the Chelsea
Hospital for Women. _ ., .

Brown, A. Carnarvon. M.R.C. 8 ., L.R.C.P.Lond., Resident
Medical Officer at the Farringdon General Dispensary and
Lving-in Charity, Holborn Circus, London.

Cowan, J., M.B., M.S.Edin., Certifying 8 urgeon under the

Factory and Workshop Act for the New Galloway District
of the county of Kirkcudbright.

Davidson, James A., M.B., Ch.B.Aberd., Junior House Surgeon
at the Croydon General Hospital. _ ___ .

Jones, Ernest, M.D., B.S.Lond., M R.C.S.Lond., D.P.H.Oantab.,
Registrar and Pathologist to the West-End Hospital for
Diseases of the Nervous System.

Laverick, F. R. H., M.D., B.S.Durh., House Surgeon to the
Torbav Hospital, Torquay.

Pobteb, W., M.B.. B. 8 .R.U.I., Certifying Surgeon under the
Factory and Workshop Act for the Portrush District of the
county of Antrim. „ ,

Rice, D.. M.D.Brux., M.R.C.S., L.R.C.P.Lond., Resident Medical
Superintendent at the Norwich City Asylum.

Thomas, W., M.R.C.S., L.R.C.P., Medical Officer and Public Vac-
oinator for the Third Distriot by the Liskeard (.Cornwall)
Board of Guardians. _ _ , _ _ _ .

Tubton, Edward, M.D., Ch.B., B.Sc.Vict., M.D.Leeds, M.R.C.P.
Lond., Honorary Physician to (he Hull Royal Infirmary.

Warren, A. 0., M.R.O. 8 ., L.R.C.P.Lond., Clinical Assistant to
the Chelsea Hospital for Women.

UaranarB.

Bristol Royal Infirmary.—House Surgeon. 8 alary, £100 per
annum, with apartments, board, and laundry. Applications
to W. E. Budgett, Secretary and House Governor.

Bristol Royal Infirmary.—House Physician Salary, £100 per
annum, with apartments, board, and laundry. Applications
to W. E. Budgett, Secretary and House Governor.

Rochester St. Bartholomew’s Hospital—House Physioian.

Salarv, £110 per annum, with board and residence at the
Hospital. Applications to Thos. Orockford, Clerk to the
House Committee.

Lancaster County Lunatio Asylum.—Assistant Medical Officer.
Salary, £150 per annum, with board, lodging, and washing.
Applications to Medioal Superintendent.

Birmingham General Dispensary.—Resident Surgeons. Salary.
£150 per annum, with furnished rooms, fire, lights, and
attendance. Applications to Ernest W. Forrest, Secretary.

Holborn Union.—Assistant Medioal Officer. 8 alarv, £100 per
annum. Applications to J. Allan Battersbv, Clerk to the
Board, Guardians’ Offices, 53, Clerkenwell Road, E.C.

The Children’s Hospital, Dublin.—Aisiatant 8 urgeon. Imme¬
diate applications to Hon. 8 eo., Temple Street.

jBirths.

Richmond.—O n Oct. 20, at 67, Drayton Gardens, London, the wife of
W. Stephenson Richmond. M.R.C. 8 .Eng..of a son.

Jeans.—O n Oct. 13th, at 43 Canning Street, Liverpool, the wife
of Frank A. G. Jeans. M.B., F.R.OJ3., of a son.

Wolfe.—O n Oct. 16th, at Hanwell, London, the wife of John
Hennr Wolfe, M.R.C.S.Eng., L.R.C.P.Lond., of a son.

Wood.—O n Oot. 16th, at Emotts, Penshurst, Kent, the wife of
W. Charrington Wood, M.D.Lond., F.R.C.S.Eng., of a
daughter.

JBarriages.

Collins — Brandt.— On Oct. 16th, in All 8 aints’ Church, Chelten¬
ham, J. Rupert Collins, M.D., to Agnes Mary, younger
daughter of Mr. Francis Brandt, J.P., (I.C.S., retired),

of Cheltenham.

Evans — Davis. —On Sept. 21st, at Bombay Cathedral, Major
Usher W. Evans, R.E., second son of Usher W. Evans, M.D.,
Dy. Inspect.-Genrl., of Clifton, to Gertrude Julia, younger
daughter of the Rev. W. 8 m!fh Davis, late Rector of 8 teeple
Gidding, Huntingdonshire.

Flood—Pitkin.—O n Oct. 17th, at St. Mary's, 8 hapwlok, Somerset
Frederick Grey Flood, M.&.C.S., L.R.C.P.. of Wymeswnld,
Leicestershire, only son of the late Alfred John Flood, banker,
of Witney, Oxon., to Roth, youngest daughter of Rev. J. Pitkin.

Harries—Lion. —On Thursday, Oct. 17th, Arthur J. Harriee,
M.D., of 30 St. James's Square, Pall Mall, London, S.W.,
to Clara, widow of the late Reuben Lyon, formerly of
Johannesburg, South Africa. No oards.

Kinobburt—Holland. —On Oct. 17th, at St. James’s Church,
Paddington, William Neave Kingsbury, M.R.C.S., L.R.C.P.,
eldest son of W. O. Kingsbnry, of Ealing, to Marion,
younger daughter of the late George Holland, of Sandbach,
Cheshire.

Scathe.

Hoile —On Oct. 18fh, at 112, Oakwood Court. Kensington, Lieut.-
Col. Edmond Hoile, M.D., late of the 17th Lancers.

Simon.— On Oct. 16th, at the resldenoe of his daughter, White¬
hall, Pembroke, George Simon, M.D., Lt.-Col. A.M.S., Hon.
Brig.-Surg., aged 70 years.

Stephens. —On Oct. 17th, at Preston, Brighton, Helen Words¬
worth, wife of J. Stephens, L.R.C.P., lata of Old Sterne,
Brighton.

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The Medical Press and Circular.

-SALUS POPULI SUPREMA LEX.**

Vol. CXXXV. WEDNESDAY, OCT. 30, 1907. No. 18

Notes and Comments.

How fast may a medical man drive
The his motor? This question is one
Speed which is likely to be more apd more

Limit. debated in the course of the next

few years. The bulk of the pro¬
fession has little enough sympathy with the road-
hog, be he medical or lay, but just as the King is
above the law, so the diotaites of humanity are
higher than police regulations, and in certain cases
constitute a legitimate excuse for exceeding the
speed limit. In the South-Western police-court re¬
cently the chauffeur of a medical man was sum¬
moned for driving a motor containing his master at
an excessive speed on the road beside Wimbledon
Common, the police estimate placing the pace at
28 miles an hour. The owner did not deny the soft
impeachment, but boldly claimed his right to travel
as fast as he could along an open road when called
to an urgent case of illness. Mr. de Grey, the
magistrate, with good sense, recognised the force
of the argument and dismissed the summons. We
beg to congratulate him on nis discrimination.
Medical men have several times been summoned
under similar circumstances in different parts of
the country, but we do not remember e\er to have
heard it admitted by the Bench that the excuse of
humanity was reasonable. This case, then, should
prove a valuable precedent to country Shallows.

But if this privilege is claimed by
Justifiable c ^ e profession, and is granted to
Excess. them by the sense of the com¬
munity, it is most important that it
Should never be abused. A form of
travelling which at the present calculated rate, kills
a thousand persons and maims over fifty thousand
a year in this country, adds a very real danger and
terror to the lives erf the mass of the people, and
improper and reckless driving certainly deserves
the most heinous penalties. If then a medical man
claims exemption in case of emergency, it might not
be a bad plan if he were summoned whenever the
legal speed was exceeded, and if excused by the
magistrate on the ground of an urgent call to a
patient, the latter were made to pay all the expenses
of the prosecution, together with an adequate fee to
the doctor for the loss of time involved in attending
the Court. By some such means as this it might
be possible to regulate the number of “ urgent ”
summonses to patients, and thus relieve the general
practitioner’s life of its heaviest load.

It has been thought a matter of
From Christian such moment to the world that a
Science to Christian Scientist in America should
Medidae. call in a doctor, that a Marconi wire¬
less message was employed to flash
the fact to this country. The doubting sister in
question, Mrs. Augusta Stetson, is, it happens, a

candidate for the leadership of the faithful in the
presumably impossible event of Mrs. Eddy being
called “ up higher ” ; at any rate, she is regarded as
a kind of second string, and her bad example is
likely therefore to have a powerful influence on
the shaky members of the flock, though doubtless
amongst the real believers it will be regarded
merely as an act of magnaminity such as one prac¬
titioner might show to another. The Christian
Scientists in America have gradually been adding
to the occasions on which a doctor may be called
in ever since the day when Mrs. Eddy had tooth¬
ache, and was found Nicodemus-like repairing to
the dentist. Some three years or so ago medical
aid was permitted in the case of infectious diseases,
and lately we understand doctors were officially
permitted when Christian Science had failed. Per¬
haps we shall soon find these enthusiastic idealists
ranging themselves under the orthodox banner, and
being sent by medical men to persuade their
troublesome patients that there is nothing wrong
with them except febris imaginata.

We find that in these notes the
Vivisection other day we did something of an
Commission’s injustice to the Morning Leader
Difficulties, when we chaffed it about the

“ Vivisection Horror ” that it had
dug out of the report of the Royal Commission
on Vivisection. We stated then that that ablv-
edited journal had adopted the short and pic¬
turesque way of supporting its views on experimen¬
tation by pasting large upon its sheet the Incident
of the four puppies. Our attention has been called
to the fact that two articles in which Mr. Cole¬
ridge’s evidence was dealt with had also appeared.
We have read these articles with interest, and can
certainly say that the best is made of the extra¬
ordinarily puzzling statements of that doughty
protagonist. But we cannot say that we think the
Commissioners have been greatly helped along
their way. It is the duty of Royal Commissioners
eventually to make a report, and we do not
envy the present ones their task. There are
only two suggestions that appear to us possible,
namely, an increase of the inspectorate, and
some alteration in or addition to the body that
advises the Home Office as to candidates’ claims
for licenses. No doubt it is humanly impossible
for the present inspector, Professor Thane, to be
present at a tithe of the experiments performed;
indeed, to compass that end a small army of
officials who understand the points involved
in anaesthesia, physiology, pharmacology, and
pathology, would be needed. At any such proposal
we fancy the economists would cry out.

gitized by CjOO^Ic

458 The Medical Press.

LEADING ARTICLES.

Experimenters themselves having
Usque nothing to fear from increased pub-
ad licity would have no objection, qud
Aras. experimenters, to the presence of
anv number of inspectors, though as
taxpayers they might be inclined to grumble Then
too, they could have no cause to complain of
any impartial body, which understood the issues
at stake, giving advice to the Home Office on the
capabilities of would-be experimenters to ascertain
truth from experiments and to carry them out with
humanity and skill. But what better body could be
chosen than the present one? It would hardly be
contended that a committee composed of Mr.
Coleridge, Miss Lind-af-Hageby, Miss Beatrice
Kidd, and Dr. Hadwen, would be competent for
the task. Besides, after the committee had been
sitting a month, we fear that as in the tragedy of
the Kilkenny cats nothing but tails would be left.

There is a sad time in store for the
The M.A.B. Metropolitan Asylums Board. That
and body, it appears, proposes that the
its Matrons, matrons of its hospitals shall no
longer be first-class officers, but shall
serve their common task in the less Olympian
sphere of the second class. The full heinousness
of this proposal will not be apparent to outsiders
till it is realised that this revolutionary proposal
actually means- that the matron is to rank no
longer with the medical superintendent, but with
the assistant medical officers, and that the nursing
administration of the hospials will be pulled down
to the level of the mere medical treatment of
patients. No wonder that an emergency meeting
of the Matrons’ Council for Great Britain and
Ireland was called at forty-eight hours’ notice and
that the room was crammed to suffocation. No
wonder that the fair president proposed a resolu¬
tion calling the attention of the public, the Local
Government Board, and the nursing profession to
this attempted degradation. No wonder that the
motion was carried with the utmost enthusiasm.
But the matrons are not going to stand any non¬
sense. They threaten the unlucky Board with a
boycott, also agreed to unanimously, and they
have represented to the President of the Local
Government Board the advisability of receiving a
“ small deputation,” lest he should not understand
the “ widespread and prejudicial effects ” that the
change will cause.

Indeed, the matrons are so excited
A Plea that they say they feel themselves
for incompetent to show clearly in a
Justice. letter all that they feel, and it really
seems that if Mr. Burns declines to
override the Metropolitan Asylums Board we shall
have to be on the look out for relays of mounted
police to protect him from the suffragette-like im¬
portunity of these indignant ladies. At any rate,
let us hope that in this crisis in the affairs of the
nation Mr. Burns may keep a cool head, and that
he may be led to perceive the anomaly of allowing
the matrons to fall so low as the rank of mere
doctors. But we would implore the Metropolitan
Asylums Board, if it consents to this “degradation,”
that it will at least grant the matrons the privilege,
now so sumptuously enjoyed by the assistant
medical officers, of being “ rationed as a principal
officers." Dreadful things may happen if the
matrons are let down in rank, but who can con¬
ceive the result if they were contemporaneously
docked of their tea and sugar?

A death from cholera has taken place at Lemberg,
and has caused great alarm among the authorities,
who have promptly formed a cholera commission.
Four deaths have already occurred at Kieff.

Oct. -,o, 1907-

LEADING ARTICLE.

THE TUBERCULOSIS PROBLEM IN
IRELAND.

It is a serious matter to the health of Ireland
that sanitary affairs in that country are taken so
lightly. In nearly every point as regards sanitary
administration she is far behind the sister countries,
though, indeed, in one particular she shows an
example which England might well follow. We
refer to protection against small-pox. Ireland
has a thoroughly vaccinated population, and it is
gratifying that the fads and superstitions which in
England have led to such disastrous outbreaks of
small-pox, are in Ireland without any upholders.
In other particulars Ireland is not merely behind
the rest of the Kingdom, but behind the civilised
world. Her capital, with the sinister boast of
being the most unhealthy in Europe except
St. Petersburg, does not possess a whole-time
medical officer of health! This seeming incapacity
to deal with sanitary problems is nowhere better
exemplified than in regard to tuberculosis. The
death-rate from tuberculosis has in Ireland shown
a slight increase during the past forty years,
whereas the death-rate from the disease in Eng¬
land, Scotland, and Germany, has diminished by
nearly a half. The number of deaths in Ireland
each vear from tubercular diseases is nearer twelve
than eleven thousand, and up to the last year or
two it is the bare fact that nothing was done
to face the problem. There is no need to attempt
to fix the responsibility for this scandal, since
everyone concerned is responsible in some degree.
The medical officers of health are more to be
pitied than blamed, on account of the conditions
of their service. Their sanitary work is secondary
only to their work as dispensary medical officers,
and they are in all cases dependent for their
living on the good-will of the people among
whom they live. Many of them have done in this,
as in other directions, noble work, but power to
deal with the problem as a whole has been lacking.
Of the sanitary work in the large towns such as
Dublin and Belfast it is sufficient to say that
satisfactory results have been absent. The local
sanitary authorities have, in fact, up to within the
last year or two, ignored the whole question. No
attempt has been made to erect sanatoria or to
disinfect houses where tubercle has occurred, and
nothing has been done to educate the people. The
Local Government Board, which exercises a general
supervision over the local sanitary authorities, has
occasionally issued a circular on the subject of
tuberculosis, but has never seriously attempted to
make its advice effective. It would seem, however,
as if a general awakening might be at hand-
Within the past two years the public has taken
some interest in the matter, and schemes are on
foot in many counties for the erection of sanatoria.
The local bodies are beginning to discuss practical
measures, and discussion is a means of educa-
cation. Popular lectures have been delivered in
many centres, and instruction in hygiene is given
to teachers. Since her arrival in Ireland, Her
Excellency the Countess of Aberdeen has shown a
marked interest in the subject, and, as our readers
are aware, her interest has borne fruit in the
Tuberculosis Exhibition at present open in Dublin.
Moreover, the Local Government Board has de¬
clared that it is alive to the importance of the

Digitized by Google

Oct. 30, 1907.

CURRENT TOPICS.

The Medical Press. 459

subject, and has devoted two pages to the question
in its Annual Report. At the present moment Che
Tuberculosis Exhibition has aroused much interest,
and the series of lectures organised in connection
therewith have been the means of interesting and
educating large numbers of the general public.
What is requisite is to make use of this general
interest before it wanes. It is necessary to have a
definite programme ready, and, fortunately, there
need not be much dispute about the terms of it. The
first thing necessary is to educate the people in the
means to be adopted in every home to prevent the
spread of the disease. The value of fresh air and
cleanliness, and the need for proper precautions
where the disease is present, must be impressed on
every man, woman, and child in the country. In
this work of education the chief, but by no means
the entire, responsibility must rest with the mem¬
bers of the medical, clerical, and teaching profes¬
sions. Along with this, steps must be taken to
provide for those who are already diseased.
Sanatoria, isolation hospitals, and dispensaries
must be established where required, and it must
not be forgotten that money spent in this direction
is soundly invested, for the capital of a nation is
its healthy sons and daughters. Finally, the
housing problem must be settled. We believe that,
given determination to deal with it on such lines,
the tuberculosis problem in Ireland is capable of
arrangement, and the next generation should be in
a fair way for settlement.

THE BRISTOL INFIRMARY DEADLOCK.

The deadlock at the Bristol Royal Infirmary,
much as it is to be regretted from many points of
view, nevertheless brings to the front various
points of vital importance to the future welfare of
medical charities in the United Kingdom. It is
too much the fashion of the governing boards of
such institutions to override the deliberate and
expressed wishes of their medical staffs. After all,
the services of the latter are purely honorary, and
they are plainly entitled to some say in matters
which intimately concern the ordering of their
private lives. In the present controversy the
governors of the Royal Infirmary were requested
to attend the half-yearly meeting of the Board to
vote on the proposed alteration to Rule 36, which
laid down that no member of the staff should hold
anv further appointment other than in the local
University or Medical School, or engage in other
than consultant or special practice. We are in¬
formed on good authority that when this proposal
was discussed in committee it was thought that the
Faculty had given their approval; and so they had,
with the following addendum “ This rule, as it
stands, seems unfeasable; we assume that certain
exceptions are contemplated.” As a matter of fact,
that opinion was not before the Committee, and
the exceptions have never been formulated or
discussed. The reason for this latter curious fact
is, we learn, that the President would not permit
discussion. Accordingly, the bald rule was passed,
although in obvious opposition to the medical staff.
The forts et origo of the whole affair appears to
lie in the determined resolution of a strong Pre¬
sident to carry the rules. That gentleman, Sir
George White, has already done a great deal for
the Infirmary, and in the event of his present
wishes being carried into effect, we understand will
do a great deal more. It is clear, however, that

the rule cannot be passed without the resignation
of the medical staff. If Sir George White is pre¬
pared to face that contingency he is assuming a
position of very grave responsibility. Approaching
this matter from a professional point of view, we
own that our sympathies lie wholly with the staff.
We feel that they are asserting the ordinary rights
of medical men who hold these honorary posts,
and we may congratulate ourselves that the safe¬
guarding of important ethical principles is for¬
tunately upon this occasion vested in strong and
able hands. If once it be conceded that the bene¬
factor of a medical charity is entitled to play fast
and loose with the private lives of the honorary
medical staff then the prestige of such institutions
will indeed receive a deadly blow. The medical
profession is long-suffering and anxious to work
in harmony with all philanthropic schemes. It is
too much, however, to ask them to sacrifice their
independence of thought and action at the bidding
of autocratic presidents and boards. The ultimate
decision lies in the hands of the governors, and we
shall be disappointed if the latter do not prefer to
uphold the legitimate and strictly reasonable wishes
of the medical staff, even should there be a prospect
of some temporary loss of material prosperity to
an ancient institution.

CURRENT TOPICS.

The Irish Local Government Board and
Consultants' Fees.

The Irish Local Government Board is a body
which, as a rule, endeavours to do its best under
difficult circumstances, and which undoubtedly
gets numerous opportunities of showing its
powers. Indeed, so numerous are these oppor¬
tunities that we should have thought it un¬
necessary for the Board to go out of its way
to create difficulties. Yet, apparently, such is its
desire. The latest task which this voluntary
Sisyphus has set itself is that of regulating the
fees charged by consultants over whose actions they
have no more control than have we over the
salaries of the eminent gentlemen who comprise
the Board. On a recent occasion, a well-known
Dublin Hospital surgeon was called into consulta-
tion by the medical officer of a country workhouse
hospital to see a patient who had received q
compound fracture of the skull and severe injury
to the spine, the result of a fall off a bicycle. In
order to give the patient the benefit of his advice
the consultant had to travel some twenty miles,
and was away from his practice for four hours.
As a result of the united efforts of the two medical
men the life of the patient was saved. The con¬
sultant named five guineas as his fee, and the
amount was ordered for payment by the local
Board of Guardians. Such Boards, even in Ireland,
contain cranks among their number, and the par¬
ticular crank in this case was a gentleman whose
views expressed themselves in the dicta that five
guineas were too much to pay any doctor, and that
their medical officer had no right to summon a
consultant from Dublin when he could have called
in one of his local colleagues. With this gentle¬
man’s views it is unnecessary to deal. It is
probable that if he required medical advice himself
he would seek what he considered was the best
advice available, and it is obvious that he is
determined that the poor under his charge

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CURRENT TOPICS.

Oct. 30, 1907

shall not similarly benefit, since it is im¬
possible for any medical man to be a good
general practitioner and at the same time to
have the intimate special knowledge which is
possessed by a consultant, if he is one in more than
name. The crank accordingly wrote to the Local
Government Board to protest against the payment
of the consultant’s fees. The Local Government
Board in turn wrote to the local Board, and in the
letter, in which it asked for information regarding
the case—a very proper request—it stated “ that
five guineas certainly appeared to be an unusually
high sum to pay a doctor for consultation fee.”
Sisyphus must roll his stone up the hill; it is for
that he is paid, but why, for the sake of the
plaudits of the onlookers, should he increase his
difficulties by occasionally pushing it in the oppo¬
site direction? The Local Government Board has
no power whatsoever over the fee charged by a
consultant, brought in as was the consultant in the
present case, and why it should go so far out of
its way as to make an incorrect and unjustifiable
statement about a matter over which it has no
control is one of those often-occurring puzzles with
which “ Boards ” like to perplex the public. Much
as we should like to support the Irish Local
Government Board in a good cause, when by its
actions it departs so far from its proper sphere as
to try to lay down the fees to be charged by
medical men over whom it has no control, especi¬
ally when those fees are below rather than above
the average, and when it indirectly endeavours to
inculcate into the minds of local guardians that
expert advice is a luxury for the rich, and is not a
necessity for the poor, we cannot but feel that
“ quern Deus vult perdere, prius . . .”

School Board Medical Certificates.

The question of payment for School Board certi¬
ficates deserves the deep and earnest attention
of all bodies concerned in protecting the interests
of medical men. At present medical practitioners
for the most part sign these documents free of
charge, either in hospital or private practice, and
thus add to the already swollen volume of gratui¬
tous service conferred upon the community. As
usual, the organisation that demands the certifi¬
cates makes no provision for remuneration of the
responsible professional man who grants the docu¬
ment. Obviously, the majority of parents are
unable to pay fees for certificates. Why should
not the State pay for documents which it finds to
be vital to the safe and proper conduct of its
schools? What possible excuse can there be for
declining to pay? While i{ is hard to find an
answer to that question, it is easy enough, on the
other hand, to imagine that the unbusinesslike
medical profession has never asked collectively to
be paid for its services. If the medical staff of one
dictrict or of one hospital decline to issue unpaid
certificates, they are at once stale-mated by neigh¬
bours who are ready to continue the gratuitous
service. It seems more than likely that if the
medical profession united and took a firm ground
upon the matter, that the School Board authorities
throughout the kingdom would be reduced to
reason within a short period of time. The Colches¬
ter medical men intend to try, for they have
notified the Education Committee of the town that
they will in future refuse to sign School Board
certificates except at a fee of half-a-crown apiece.

The Committee some time ago offered eighteen-
pence. This result shows what may be done with
a little courage and enterprise.

The Administration of Anaesthetics for
Unqualified “Dentists.”

We have received a letter from the secretary of
the Irish Branch of the British Dental Association
calling our attention to the efforts of the Associa¬
tion to stop the administration of anaesthetics for
bogus “dentists” by medical men. We are aware
that such a practice exists, but we venture to
think that it is not of such important dimensions
as the Association seems to imagine. Still, even
if only isolated cases occur, the fact remains that
it is not only forbidden by the General Medical
Council, and grossly unfair to the dental profes¬
sion, but that it is also a short-sighted policy from
the point of view of the medical profession itself.
How can the latter profession hope to obtain the
support of the public in its struggle against
quackery and unlicensed competition, if it directly
or indirectly supports similar competition in
another and allied profession? The excuse which
we have heard offered, that the “ dentist ” for
whom the anaesthetic has been administered is
capable of doing his work, or is a highly respect¬
able individual, has nothing to do with the case.
If such is a true description of him, then it is a
great loss to himself and to the public that he has
never become a registered dentist. Medical men
cannot take these points into consideration, but,
rather, are bound by every consideration of honour
and of professional interest to refuse to have any
professional dealings with unregistered dental
practitioners. We are glad to see that the Irish
Branch has brought the matter before the General
Medical Council, and that the latter body has com¬
municated with alleged offenders. We trust that
the warning thus given by the Medical Council
will be sufficient, as it would be a most unpleasant
occurrence if more serious action had to be taken.
En passant we take the opportunity of again
pointing out to correspondents that if they wish
their communications attended to, they must send
them, in the case of Great Britain, to the London
office, or in the case of Ireland, to the Dublin
office.

Medical Examination of Engine-Drivers.

Of all callings in the world, that of an
engine-driver demands the most perfect alertness,
both of mind and body. A moment’s delay in per¬
ception, a moment’s indecision or inattention, and a
hundred lives may be hurled into eternity. Under
such circumstances it is a standing monument to
the listless apathy of the British public that they
do not insist upon a reasonable limit for the hours
of duty of railwaymen. Hardly less amazing is the
fact that they have not long ago made it com¬
pulsory for the railway companies to maintain a
constant medical supervision of enginemen and
guards. Only last week an inquest held at Pad¬
dington revealed the fact that an engine-driver
was affected with locomotor-ataxy, and that he
had returned to work shortly after an attack of
broncho-pneumonia. Medically speaking, to place
a man suffering from locomotor-ataxy in charge of
a train would be little short of criminal reckless¬
ness. On general grounds, we maintain that even-
driver, stoker, guard, and signalman should be

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Oct. 30, 1907.

PERSONAL.

The Medical Press. 46 1

examined medically, say, once every three months.
Nor should he be permitted under any circum¬
stances to resume his duties after an attack of
illness without a special medical certificate of his
fitness. In the face of many serious railway acci¬
dents of late it is to be hoped that the House of
Commons will enquire into the simple but highly
important matter of the periodical medical inspec¬
tion of railwaymen.

Medical Heroism.

The institution of a special decoration for
heroism amongst medical men might be worth some
little attention of the powers that govern such
matters. Certainly there would be no difficulty in
finding worthy recipients of any such distinction
from time to time amongst members of our pro¬
fession. The latest reported instance of self-
devotion of this kind comes from Glossop, where
a well-known Belfast physician, Dr. Thomas
Waddell, has once more performed the now
familiar feat of sucking a tracheotomy tube free of
diphtheritic membrane. The details have a familiar
ring. The patient was the only child of a poor
woman, and the instant clearing of the tube was a
matter of life or death. The child got well, and
his rescuer contracted the disease, from which we
are glad to say he has since recovered. From a
philosophical point of view it may be argued that
Dr. Waddell was not justified in risking his own
valuable life for the sake of that of an infant in
■which the value was merely potential. Apart from
intellectual analysis, however, we are proud to
claim him as a fellow member of the profession
in which unswerving self-sacrifice and obedience
to the call of duty constitute the supreme law.

Norman Kerr Memorial Lecture.

The problem of inebriety was dealt with by Dr.
Welsh Branthwaite in his second Norman Kerr
Memorial Lecture in an extremely interesting and
useful fashion, and it would be good if this
puzzling question were always handled in the same
detached and unbiassed fashion. Dr. Branthwaite
shows that the inebriate, properly so called, is a
person who cannot live soberly; that, indeed,
is his definition of an inebriate, and that in
a large proportion of cases he is suffering from
obvious mental defect. Of persons confined in
Inebriate institutions he finds no fewer than 62 per
cent, are actually mentally defective, and he adds
that if he had his own way he would class prac¬
tically the whole number as lacking mental com¬
petence, but he fears to do so lest he should be
taken for a special pleader. A fair proportion of
persons committed to retreats by magistrates are
actually certifiably insane, 15 per cent, indeed, and
the majority of these have become alcoholic because
of their tendency to insanity, and not insane as the
result of alcoholism. In the more or less defective
group—constituting 46 per cent, of the whole—
nearly all the patients show definite stigmata of
degeneration, in cranial conformation, general
physique, or conduct. The mental symptoms ex¬
hibited by such include impaired development of
the moral sense, imperfect control over impulse,
and defective judgment. From a practical point
of view all these inebriates are hopeless as
regards cure. Of the 37 per cent, of “average
mental capacity ” Dr. Branthwaite says that by
no means arc all these improvable, for though not

actually and demonstrably defective, they are all
of persons of impulse and dwarfed moral respon¬
sibility, although they have some qualities which
may be appealed to. In the redeemable class Dr.
Branthwaite has found that moral influences, such
as religious emotion, the impress of a strong
character, and even faith cures, are at times suc¬
cessful, whilst he speaks hopefully of the reinforc¬
ing value of medicinal treatment, and, naturally,
of hygienic measures, for the reformed drunkard
good social environment and total abstinence are
imperative.

Quarterly Journal of Medicine.

We have a new medical contemporary to wel¬
come, namely, the “ Quarterly Journal of Medicine,”
and we can honestly say that if it keeps up to the
standard of its first number, even if it does not have
a large circulation, it will have a decided influence
for good in stimulating authors to produce papers
of equal merit. Although not specificially stated, we
gather that the new “ Quarterly ” is practically the
journal of the new Association of Physicians of
Great Britain and Ireland, which held its first
meeting last May; at all events, the papers in the
number before us are those communicated to that
meeting. The editors are six in number : Professor
Osier, Dr. Rose Bradford, Dr. Garrod, Dr. Hale
White, Dr. Hutchinson, and Dr. Rolleston, and as
they have the assistance of twenty-five assistant
editors, we judge there will not be much fear of
failure. The Quarterly is beautifully printed on
really good paper, with plates and diagrams of
great excellence, but considering the cost of each
number is 8s. 6d., that is not to be wondered at.
Naturally, in a journal of this type the contributions
are mostly records of purely scientific work or of
rare individual cases, but they are all very interest¬
ing, and of a high level of merit. We have been
much interested ourselves in a paper of Professor
Osier’s “ On Multiple Hereditary Telangiectases,
with Recurring Haemorrhages.” which describes a
condition not infrequently met with, and up to
the present very inadequately described, but perhaps
the most important contribution is that, by Dr.
E. I. Spriggs “On the Excretion of Creatinin and
Uric Acid in some Diseases involving the Muscles.”
We wish our contemporary all the success it so well
deserves.

PERSONAL.

Mr. C. T. Street has been elected President of the
Wigan Medical Society for the coming year.

Dr. R. J. Probyn-Williams, President of the Society
of Anaesthetics, took the chair at the annual dinner of
that body on October 18th.

Dr. S. J. Gee presided on October 22nd over the
first meeting of the Medical Section of the Royal
Society of Medicine.

Professor Howard Marsh has been elected Master
of Downing College, Cambridge, in succession to Dr.
Alexander Hill, resigned.

Mr. J. Howard Mummery gave the inaugural address
at the meeting of the Odontological Section of the
Royal Society of Medicine on Monday last.

Dr. J. Ritchie has been appointed an examiner in
Pathology at Cambridge University, and Professor R.
Stockman an examiner in Pharmacology.

Mr. A. J. Balfour, M.P., performed the inaugura¬
tion ceremony of the new building in connection with
the Royal Victoria Hospital for Consumption, Edin¬
burgh, on Friday last. The hospital was founded in
1887 as a memorial of Queen Victoria’s Jubilee.

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462 The Medical Press.

CLINICAL LECTURE.

Oct. 30, 1907.

A Clinical Lecture

ON

THE PREVENTION OF FEVER IN THE PUERPERIUM. (a)

By H. OLIPHANT NICHOLSON, M.D H FJLGPJL,

Assistant Physician to the Royal Maternity Hospital; Late Obstetric Physician to the New Town

Dispensary, Edinburgh.

Gentlemen, —In the near future it will fall to the
lot of most of you to engage in general practice, and
in this sphere of work midwifery will claim a large
share of your attention. Midwifery work not only
taxes the bodily strength severely, but to men of high-
strung sensibility the anxiety associated with it is very
great. When you have to undertake the entire respon¬
sibility of your midwifery cases you will worry espe¬
cially over two things—haemorrhage during the third
stage of labour, and fever in the puerperium.

It is difficult for you to realise at present, working
as you are in hospital practice and under supervision,
the kind of anxiety that is occasioned from these two
causes in the attendance upon labour cases. The con¬
stant fear of post-partum haemorrhage makes mid¬
wifery work impossible for some men, and drives them
into other branches of the profession. I am not going
to speak about haemorrhage to-day, but only wish to
say tha-t although serious flooding after labour is a
terribly trying ordeal for the practitioner to pass
through, and severely tests the strongest nerves, still
it is not the right attitude to take up to admit that one
is afraid to face it and deal with it. I do not think
that any form of anxiety can be so intense as that
experienced by the physician during the management
of a dangerous post-partum haemorrhage. It is then,
gentlemen, that you will realise the heavy load of
responsibility which you bear, when you see the woman
who relied upon you to conduct her safely through her
confinement lying exsanguine and possibly all but
moribund. The terrible anxiety associated with such
haemorrhage is, however, of comparatively short dura¬
tion, and I wish you particularly to remember that a
fatal result is quite exceptional. In almost every case
a competent, cool-headed man can control the bleeding.

The other source of worry in midwifery work is the
occurrence of fever in the puerperium. You notice
that I say fever in the puerperium, and not puerperal
fever, and for this reason—that any rise of temperature
in the early days of the pueiperium will cause you
anxiety. You cannot say precisely what is the signi¬
ficance of the raised temperature, and you will gene¬
rally find yourself taking the worst possible view of
the abnormal symptom. Fever in the puerperium,
whatever its origin, if it is moderately high and lasting,
will greatly disturb your peace of mind, and the
anxiety occasioned by it will continue so long as the
temperature is elevated.

When you realise how important it is, both as regards
success in your practice and pleasure in your work,
that you should have a practically afebrile puerperium
after each labour, you will understand why I wish to
take the earliest opportunity of discussing some of the
measures whereby such results can be secured. My
remarks relate to the safeguarding of your patient from
fever in the puerperium which is due to septic in¬
fection. You cannot, of course, always control the
other conditions which cause a rise of temperature at
this period, but these are generally unimportant and
harmless compared to true septicaemia.

While it is a well-established principle that anti¬
septic measures are absolutely essential in the practice
of obstetrics as a means of preventing septicaemia, still,
as regards details, the technique varies considerably in
the hands of different practitioners. First let me im-
press this fact upon you, for it is an important one—
namely, that the antiseptic treatment of a midwifery
case is one thing, and that of a surgical case something

(a) A Lecture dellrered at the Royal Maternity and Rimpson
Memorial Hospital, Edinburgh. F

I quite different. Do you imagine that it is possible in
routine practice, or even in a maternity hospital, to
sterilise the external genital organs and vulvar skin
! of your patient as completely as you can the skin of
the abdomen previous to an operation? It is quite
impracticable, and even assuming that you can get
these parts relatively aseptic, there is also this differ-
, ence from a mere surgical procedure—that you have to
keep everything in an aseptic condition for a week or
1 ten days at the least, in order to avoid the introduction
of infective material from without. You must remem-
; ber also that your own responsibility for the antiseptic
1 treatment of the patient terminates at the end of the
1 labour; the nurse or the next-door neighbour under-
I takes to carry out similar precautions during the puer¬
perium. And yet, gentlemen, it is the rule for things
to go well. I am putting the matter before you in this
way because I am bound to confess to you that the
safety of the lying-in woman does not depend upon
real suTgical cleanliness on your part; if it did, the
mortality from sepsis would be too appalling to think
about. Practically speaking, something far short of
this seems to be sufficient to enable one to obtain a
normal puerperium even after the most complicated
labour. Now, although you know that you cannot
render your hands and the vulvar orifice of your
patient surgically aseptic, please do not conclude that
you can afford to neglect one little detail in the attempt
to do so. You simply must not, or, sooner or later,
disaster will certainly follow. No precautions which
both you and the nurse take to prevent infection can
be too elaborate, and the more systematic they are the
better. In the present state of our knowledge it is
criminal to conduct even a perfectly normal labour
without the most careful preparation of the hands,
and the proper disinfection of the vulva and vaginal
entrance is of quite equal importance. Neglect to
cleanse the vulva is unpardonable, and yet I do not
advise you to shave it and scrub it, as the gynaecologist
would do before performing vaginal hysterectomy.
That is quite unnecessary, and if you attempt to carry
out such thorough disinfection your midwifery list will
never be a large one. Simply remember that the
cleansing of the skin around the vulva by means of a
strong antiseptic solution is absolutely essential if you
hope to keep your patient free from septic infection.

At the best, as I have told you, neither your hands
nor the vulvar parts will be surgically aseptic, but,
with reasonable precautions, they are sufficiently clean
to make it very unlikely that infective material will be
introduced into the vagina and uterus during an ordi¬
nary examination, or in the course of any operative
interference.

I do not wish you to run away with the idea that
you can in this way keep the vagina free from micro¬
organisms, because you can never do so. You can keep
it free from dangerous pus-producing organisms—
streptococci and staphylococci—and that is all you
need care about. Bacteria are always present upon the
vulva and in the lower third of the vagina, and some
of these organisms, if implanted in the uterus by the
examining finger, are doubtless able to set up putre¬
factive changes if there is any material present suitable
for bacterial growth. Fortunately, in the majority of
cases, there is no suitable culture medium, and I want
to particularly impress upon you that it is for this
reason, and also because the normal vaginal secretions
possess strong protective powers against bacteria, that
the puerperal woman comparatively seldom goes septic.
You must never flatter yourselves that the antiseptic
precautions you have adopted—absolutely necessary as.

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Oct. 30, 1907.

CLINICAL LECTURE.

The Medical Press. 463

they are—deserve all the credit in the successful
recovery of your patient; the normal protective
mechanism against infection is an enormously im¬
portant factor to take into account. A knowledge of
this carries with it a warning against the use of the
antiseptic vaginal douche. Before labour, such a pro¬
ceeding is, in my opinion, almost always more likely
to be a source of danger than a safeguard ; and routine
douching after labour, I sincerely trust, will soon be
entirely abolished. It is positively dangerous, and is
often the surest way to court disaster in the way of
sepsis.

Safeguarding Against Septic Infection.

I shall describe to you what I regard as the best and
simplest means of safeguarding the parturient woman
from septic infection. The methods are simple in the
extreme, and can be carried out in the poorest cottage
in town or country.

All the methods commonly adopted for the pro¬
tection of the lying-in woman from infection have one
aim—they are all concerned with keeping bacteria out
of the genital canal. Rigid precautions are therefore
taken to prevent the introduction of infective material
during vaginal examination and during operative inter¬
ference. This is all very well, and is, of course, very
important; but in my opinion too little attention has
been given to the equally important matter of making
sure that the involution of the uterus goes on normally
in the puerperium. It is admitted by everybody that
there is a very close connection between a relaxed en¬
larged uterus and the occurrence of septic trouble, and
the very best safeguard against this is that the uterus
should remain well contracted during the whole course
of the puerperium. I invariably adopt measures to
secure efficient uterine involution, and, in the pro¬
phylaxis of puerperal morbidity, I have no doubt in
my own mind how important this part of the treat¬
ment is.

To come to practical details, gentlemen, let me first
tell you how to avoid introducing infective material
into your patient’s genital tract.

You can do this, as I have already told you, by the
proper disinfection of your hands and of the skin
around the vulvar orifice, and you require nothing
more than a good nail brush, soap, and some reliable
antiseptic. In the poorest house you can always
obtain soap and a couple of basins of hot water. Take
off your coat, turn up the sleeves of your shirt, and,
if possible, put on a long sterilisable overall. Then
scrub your hands, arms, and nails very thoroughly in
soap and hot water. This means that the washing
process lasts for nearly five minutes, and if you can
get two changes of water, so much the better. When
the nails are softened, trim them and clean them, if
necessary, before soaking the hands in the antiseptic
solution. Next comes the question of what antiseptic
you are going to employ, and let me advise you very
strongly to stick always to corrosive sublimate. You
may use either the perchloride or the biniodide of mer¬
cury, and, in the form of compressed tablets, one can
readily make a solution of the necessary strength. Per¬
sonally I always use perchloride tablets, one of which,
dissolved in an imperial pint of hot water, makes a
solution of 1 in 1,000 strength. Here let me ask you
to remember two things: first, that perchloride of
mercury is far and away the best and most reliable
antiseptic to use for the hands and for the patient’s
vulva; and, secondly, that 1 in 1,000 is the weakest
solution you can trust for such disinfection. Do not
believe anyone who tells you that some other anti¬
septic is equally safe for the protection of your patient,
or that a 1 in 1,000 strength is unnecessarily strong.
After a preliminary use of the perchloride solution for
your hands and for the patient’s external parts, you
may conduct the labour, if you wish, with a solution
of lysol (1 in 150 of water); but if you take my advice
you will never omit to use perchloride in the first
instance.

After the hands have been thoroughly washed, the
soap is removed by rinsing in clean water; a towel
should not be used. Then you proceed immediately
to disinfect your hands in a basin of hot perchloride
solution of 1 in 1,000 strength. Put a pledget of ab¬
sorbent wool into the solution, and bathe the arms

thoroughly, and again use a brush for the nails. Make
this disinfection process last about three minutes.

The hands are now ready to make the vaginal exam¬
ination, and they must not come in contact with any¬
thing until that time arrives; the next thing is to be
equally careful about the disinfection of the vulvar
skin and vaginal entrance.

In dispensary practice, where no nurse is present at
the time of labour, I teach my students to carry out
the following method, which, imperfect as it may
appear to you, is, nevertheless, to be relied on, when
carried out in conjunction with the after-treatment I
recommend, to give you a complete immunity from
septic infection. First, it is important to get the patient
into the proper position in bed, so that the vulva may
be efficiently cleansed, and the vaginal examination
easily carried out. The left lateral position is the
best, and the patient is placed well across the mattress,
so that her back is nearly parallel with the top of the
bed. You then carry the basin containing the per¬
chloride solution over to the bedside, and, with a
pledget of wool soaked in the antiseptic, swab the skin
around the vulva. Then separate the labia and gently
scrub the external organs as well. This being done,
the patient may be safely examined, and, in my
opinion, examined as often as you wish, if you con¬
tinue to swab the parts from time to time, and keep
your hands soaked in perchloride or lysol solution. I
am not one of those who advocate one or two vaginal
examinations only during the course of labour. I
believe no increased risk is incurred from frequent
and, if necessary, prolonged examinations, if due care
is exercised in maintaining the antisepsis of the hands
and external parts. You may use a lubricant if you
wish, and it is pleasanter for the patient if you do so.
If you use vaseline it is a good plan, after smearing it
on the fingers, to immerse the hand in the perchloride
solution before you examine.

So much, then, gentlemen, for the first part of your
preventive treatment of puerperal infection—namely,
keeping the genital tract free from pathogenic bacteria.
But that is by no means all. You have next to take
care that trouble does not arise from pieces of blood-
clot, placenta, or membranes, which may be left in
the uterus and vagina, and which, for some reason,
do not remain aseptic until they are got rid of in the
lochial discharge. Otherwise the temperature will rise
in the puerperium.

This is why the second part of the treatment, namely,

Assisting and Maintaining the Involution of the
Uterus,

is so important. Many practitioners, however, who are
sufficiently careful of their hands and of the patient’s
vulva neglect this side of the question, and, by quite
unnecessary interference, set things wrong when they
would otherwise go right. I refer to the common prac¬
tice of douching, not only immediately after labour,
but also during the puerperium. Personally, gentle¬
men, during the last ten years of my practice, at any
rate, no patibnt for whom I have been responsible has
had her uterus washed out, no matter how complicated
the labour may have been. The whole principle of
the thing is wrong, and while a single washing out
of the uterus, after having had one’s hands or instru¬
ments inside, may do no actual harm, it cannot pos¬
sibly do good m the way of killing organisms. Routine
douching of the vagina, especially in the early days
of the puerperium, may be a source of much harm,
and it is only when the lochia become highly offensive
that I sometimes advise it.

I wish now to tell you how you can best carry out
the second part of the prophylactic treatment against
sepsis ; how you can guard against the infection of
retained clot and membranes, and assist the uterus to
expel these safely.

When the placenta leaves the uterus and is expelled
out of the vagina, it sweeps the whole genital tract
clean. It may be assumed that any pieces of clot and
membrane left behind are aseptic, and that they will be
safely got rid of if the uterine action is efficient.
Hence, from this moment, it is most important to keep
the tract closed, and thus avoid the infection of any¬
thing left inside. That is why I caution you so strongly
against reopening the vagina with the nozzle of your

464 The Medical Press.

ORIGINAL PAPERS.

Oct. 30, 1907.

douching apparatus. If you can assist the uterus to
involute rapidly and well, and expel anything retained
in its cavity, it must be admitted that there is greater
safety for the lying-in woman. I have now ample
evidence that this can be accomplished in a precise and
definite manner.

The uterus can quite properly be compared to the
heart; both are hollow muscular organs, and both are
endowed with the power of contracting rhythmically.
The uterus, like the heart, goes into a systole, and this
is followed by a diastolic period. During its systole
the uterus contracts; during diastole it is retracted. I
want to remind you that the uterus begins to contract
and relax from an early period of pregnancy—painless
contractions; that it does so more actively during the
period of labour, when the contractions become pain¬
ful, and that it continues to contract during the puer-
rium. The systoles of the uterus are few and far
tween, but it is a perfectly well-established fact that
certain drugs can definitely increase and prolong the
contractions, and, just as in the case of the heart,
improve the general tone of the organ. Digitalis is
the principal remedy one uses for the heart, and it
acts beautifully on the uterus during the puerperium,
keeps it firmly contracted, and helps it to get rid of
anything retained in its cavity.

Acting on this principle, gentlemen, I order a “ post¬
partum ” pill for every patient who comes under my
care. The pill I usually prescribe contains pulv.
digitalis, 4 gr. jergotin and quin, sulph., of each a i£ gr. ;
and ext. nucis vom., J gr.; and, in most cases, it is
given thrice daily for the first ten days of the puer¬
perium. Sometimes it is given every four hours at
first, if the uterus is larger than it should be, while
in other cases one pill night and morning is sufficient.
This pill was given from the first day of the puerperium,
to nearly every one of the thousand patients who were
attended from the New Town Dispensary during the
five years that I acted as obstetric physician, and with
most gratifying results as regards the puerperal mor¬
bidity. There was no maternal death from any cause,
and no case developed septic complications which
caused us more than quite temporary anxiety. When
one has no death in over 1,000 cases of labour in this
class of practice, there is, of course, some element of
luck, because eclampsia and haemorrhages may, at any
time, claim a victim. And in this series of cases there
was more than the average proportion of difficult and
dangerous labours. But when one can keep such a
large number of cases, treated under far from favour¬
able conditions, practically free from septic infection,
some credit must be given to the preventive measures
adopted. None of the cases treated by this pill had
secondary haemorrhage, though frequently large pieces
of membrane and bits of placenta were expelled from
the uterus during the puerperium.

Should the temperature rise to 102 0 or more, and the
pulse rate simultaneously quicken, as sometimes
happens about the third or fourth day or later, I order,
in addition to the pill, powders containing 5 grains
of quinine with 10 grains of salicylate of soda. Such a
powder is given every six hours for three or four doses,
and this often leads to the temperature falling, and
the puerperium goes on normally again. Certain ob¬
jections have been raised to the use of this “post¬
partum ” pill, but they are mainly theoretical, not
practical. It has been said that when the temperature
is raised in the puerperium, digitalis, by slowing the
pulse, will mislead one into thinking that there is not
much wrong. This is quite a mistaken idea, because,
if fever is present, digitalis will have practically no
effect in slowing the heart’s action. It has also been
said that the quinine and nux vomica are excreted by
the mammary gland, and that the baby will refuse
the breast because the milk tastes bitter. This is like¬
wise a purely theoretical objection.

You may take it from me, gentlemen, that by the
routine use of this pill in the puerperium you will
greatly lessen your anxiety over the recovery of your
cases. If you have been, in the first place, thoroaghly
careful in the details of your disinfection, you will
be agreeably surprised to find even your most unlikely
cases go through the puerperium without the develop¬
ment of any untoward symptom.

Note. —A Clinical Lecture by a well-known teacher
appear 1 »» each number of tkie journal. The lecture for
next week will be by Thomas Sinclair, M.D, F.R.C.8.
1Eng., Professor of Surgery in Queen's College, and
Surgeon to the Royal Victoria Hospital, Belfast. Subject:
“ A Case of Traumatic Epilepsy Treated by Operation .”

ORIGINAL PAPERS.

A PLEA FOR THE WIDER RECOGNITION OF
BUDIN’S METHOD OF

FEEDING INFANTS ON STERILISED
WHOLE MILK.

By M. P. KERRAWALLA, M.D. (Baux.), L.R.C.P.
and S.E., L.M.R.C.P.I.

Resident Medical Officer to the Brighton and Hove Hospital (or
Women and hying-In Institution.

At the present time, when so much is written and
said about the prevalent high rate of infant mortality,
want of efficiency and safety of milk supply, I
beg to urge a wider adoption of the plan of bringing
up infants on sterilised whole milk as a contributing
factor towards the amelioration of the above con¬
ditions. Apart from the deplorable tendency among
the present-day mothers of trusting more and more to
artificial feeding, under certain conditions breast feed¬
ing is impracticable, and in such cases the above
method would go far towards lessening the disadvan¬
tages and evils of artificial feeding.

According to Dr. G. F. Still (a), 96 percent, of the
cases of infantile diarrhoea investigated by him at the
Children’s Hospital were hand-fed. He also points
out that condensed milk is particularly dangerous,
and the child who is taking it runs a special risk of
summer diarrhoea. He found that of the fatal cases
of diarrhoea, 25.8 per cent, had been fed upon con¬
densed milk.

In the unfortunate absence of any proper State
supervision of milk supply, the milk has to be ren¬
dered innocuous, but in a manner that does not pre¬
judice its nutritive value.

Boiling, though it kills germs, alte-rs the nutritive
value of milk, and is therefore unsuitable for very
young infants.

Pasteurisation requires a rather complicated appara¬
tus, and if rapidly done, though it retards the growth
of germs, it does not destroy them.

Sterilisation of milk is attained by surrounding the
vessel containing milk with water which is raised to
boiling point and kept so for 40 minutes. It is ad¬
mirably achieved by means of any of the sterilisers
on the market, notably that of Soxhlet, in which the
quantity required for each feed is separately dealt
with. But the method is capable of being carried out
even without the aid of any special apparatus. The
plan, as successfully tried by me in the case of my
poorer patients, was to instruct the mother as to the
great importance of cleanliness and procuring milk
from a reliable source, and then advise her to put the
milk required for each feed in a separate small glass
bottle (or, if that was too troublesome, the quantity
for 24 hours or part of it), and put this bottle
immersed three-quarters in a saucepan of water, the
water being subsequently raised to boiling point and
kept so for 40 minutes.

The milk is slightly warmed before giving it to the
infant, and no addition of sugar or cream is required.

The plan, as originally suggested by Professor
Budin, of Paris, has been carried out by him and
other Continental authorities for many years with
gratifying results. In this country there exists a great
prejudice against sterilisation, as it is thought to lead
to scurvy ; but Budin and other authorities who have
reared a very large number of infants, have failed to
record even a single case of scurvy resulting from the
use of sterilised milk.

Professor Kenwood, in a paper (b) read before the

(«) Medical Press ai»d Circular, August 28tb, 1907.
i (b) Medical Press add Circular, August 21st, 1907.

ized by CjOO^Ic

Oct. 30 , 1907. _ ORIGIN AL

Section of State Medicine at the last annual meeting
of the British Medical Association, makes the follow¬
ing remarks:—“In America, Denmark, and France,
each with an extensive experience covering many years,
the verdict is favourable to sterilised milk. Dr. Variot,
whose experience is unique, since his feeding experi¬
ments at the “Goutte de Lait ” at Belleville relate to
over 3,000 healthy as well as unhealthy children who
were closely observed by him for many months, has
seen nothing of infantile scurvy resulting from the use
of sterilised milk. The facts collected from the experi¬
ence of other such institutions abroad, and from the
Consultations des Nourrissons in France, are further
testimony to the almost absolute harmlcssness of steri¬
lised milk. On all sides the general experience is that
extremely little scurvy results from the use of sterilised
milk, and the late Professor Budin, whose consulta¬
tions are now established all over France, and were
first started in 1892, wrote to me under date April 6th,
1906, that as the outcome of his wide experience he
had not seen a single case of scurvy resulting from
the use of sterilised milk. ”

By using the milk previously sterilised, Budin and
other authorities claim that they never saw in their
patients, rickets, eczema, abdominal distension,
dyspepsia, tuberculosis, scurvy or diarrhoea. By steri¬
lisation the milk itself is submitted to a temperature of
about 180 0 F., which, though enough to destroy germs,
does not lead to any detriment in its nutritive value.

As regards the use of cow’s milk undiluted from
birth, I cannot do better than quote the following from
Dr. Maloni's translation of Budin’s work, of which I
have availed myself freely. Should cow’s milk be
given undiluted?

It is generally supposed to be harmful to infants,
owing to the excess of casein it contains, compared
with human milk. To counteract this defect, great
quantities of water are usually added to the milk, the
dilution varying with the age. But casein is not the sole
constituent of milk. It also contains sugar, butter,
and salts, all of which materially contribute to the
value of milk as a food. Diluted cow’s milk is gene¬
rally deficient in these substances, and therefore forms
but a poor substitute for a mother’s milk. To obtain
sufficient nourishment on this attenuated diet, infants
are obliged to absorb great quantities of fluid, which
causes them to pass a large amount of urine. They
are almost always crying from hunger, whereas infants
on undiluted milk wait contentedly for their next meal.

It is alleged that casein of cow’s milk forms large
clots in the stomach, and gives rise to digestive
troubles. This is obviated if the milk is heated in a
steriliser at a temperature of about ioo° C.

“According to my experiments in vitro,” says
C'havane, “the clot of milk thus sterilised offers no
resistance or sense of elasticity to the finger on pres¬
sure. It yields like a thick fluid, such as cream, and
on microscopical examination, although the fat
globules are not appreciably altered, the particles of
casein are found to be smaller and more homogeneous.

It differs from the fine clot of human milk. It is
distinct from that obtained from asses’ milk, but it is
quite comparable with the latter as regards the size
of the casein particles. Obviously this sterilisation
below boiling point— i.e., heating to 100 0 C.—modifies
the casein so as to effect the state of sub-division of
the clot, and also the molecular structure of the par¬
ticles. This probably explains why milk thus sterilised
is more easy to digest than either fresh or boiled milk.

Sterilisation is greatly simplified by the use of un¬
diluted milk. It is a complicated process when dilu¬
tion has first to be performed according to the infant’s
age. When the same milk is dispensed to infants of
all ages, the mother’s duties are made easy, and the
work greatly facilitated.”

Lazard says:—“Infants, who are, after all, the best
test of the quality of the milk, support sterilised milk
admirably. I recommend it undiluted. Experience
has taught its great value, for not only is it easily
tolerated by healthy infants, but it is also the best
remedy for diarrhoea in certain cases, and has saved
marasmic cases veritably from the jaws of death.”

Just as all infants do not thrive even on breast
feeding, so some infants during the first month or so
will not thrive on whole milk. In such cases, and in

PAPERS. _ The Medical Pkess. 4& 5

the case of weaklings and premature babies, Budin
gives the milk, not diluted, but peptonised. He recom¬
mends pepsin in the form of small scales, a small
amount of which (a pinch to a salt-spoonful) is given
in water before meals. In some cases the addition of
water, one-fourth the bulk of milk, added before steri¬
lisation will be found efficacious.

The number of feeds in 24 hours is the same as in
the case of undiluted milk, although a slightly less
amount is required. In every case it is best to be
guided by the condition and progress of the infant.
By this method the infant takes less fluid, which in
itself is an advantage, puts on weight more rapidly,
and by reason of its leaving a greater residue in the
alimentary tract, ensures regular action of the bowels.
I can bear out these facts by personal experience. The
obvious advantages of a method which brings about
freedom of milk from germs, and obviates the neces¬
sity of handling it for the purpose of dilution and
addition of cream and sugar, will not fail to appeal
to those who are conversant with the drawbacks as
regards these points in the poorer classes of community
where the nature of these articles hardly inspires con¬
fidence as to their quality or purity.

The plan has been successfully employed at the
Rotunda Hospital, Dublin, by its present Master, Dr.
Tweedy, who in a letter on the subject to me states
that during the interval of feeds the infant should be
given as much water as it can take.

Personally, I have found the administration of a
teaspoon ful of olive oil night and morning a great
help. According to Holt, one gets scurvy in every
form of feeding. It is obviously the poor quality of
milk which gives rise to the disease, and therefore the
risk of it is greater in diluted than in undiluted milk.

During my connection with the Brighton Lying-In
Institution, I tried the method in several cases, and in
every case it gave me entire satisfaction. Even the
nurses and mothers who at first regarded the plan in
the light of a novel experiment did not fail to be im¬
pressed with the progress and well-being of the infant.

I have selected the following two cases to illustrate
some of the remarks I have made above:—

(a) Baby D .—Weight at birth, 7 lbs. It was fed
from birth on sterilised whole cow’s milk, with dr. 1 of
olive oil night and morning :—

lit week fed on m. 1 2 hourly weight at the eud of week 71 lbs.

2nd ox.il 2 7 lb*.

3rd „ „ ox. ill 2 8 Ibe.

4th „ „ ox. It 2 ,, .. „ ,. 8 Ibe.

8th ,, ox.il 3 ,, ,, „ „ 9 Ibe.

12th .. ox. xil 3 . „ 14 Ibe.

The child never suffered from sickness, diarrhoea, or
any other trouble.

(£) Baby P .—Premature 7$ months baby. Weight at
birth, 6 lbs. It was brought for advice when six weeks
old, being very restless and irritable; weighed 6 lbs.,
and was suffering from abdominal distention and sick¬
ness. On inquiry it was found that the mother was
feeding it on condensed milk, because she said she
could not afford cream to dilute cow’s milk. She,
however, consented to try feeding it on sterilised cow’s
milk (undiluted), as it needed no outlay for purchasing
cream. At the end of a week’s trial, the baby looked
better in every way, slept well, and had gained a little
in weight. For twelve subsequent weeks it gained
weight at the rate of half a pound a week.

The ease with which the method can be carried out,
coupled with the immediate and remote advantages it
holds out over other methods, will not, I feel sure,
fail to impress anyone cn a trial of it.

HEMORRHAGIC RASHES, (a)

By GEORGE PERNET.

Asa it taut to Skin Department, University College Hospital, London.

(Concluded -from our last issue.)

An important group of toxic purpuric rashes due
to drugs must now be touched upon [15]. A number
of drugs have been from time to time accused in this
way, the chief culprits being iodide of potassium,
quinine, antipyrin, chloral, copaiba and mercury. In

(a) A Paper read before the West London Medico-Chirur 1

Society, 1907.

, y Google

466 The Medical Press.

ORIGINAL PAPERS.

Oct. 30, 1907.

such instances the general condition of the patients has
usually left something to be desired, either in the way
of faulty renal elimination or cardiac disease, or the
existence of other toxic conditions of organism at the
time. Iodide of potassium as a toxic agent of this
kind appears to head the list. Thus in a man with a
purpuric eruption, it was found he had been taking
iodide of potassium. He had a diastolic murmur and
a cloud of albumin in the urine; moreover, there was
some evidence of alcoholism. In a case of advanced
nodular leprosy I had had under observation, and
notwithstanding my warning that iodide of potassium
should not be administered, the drug was ordered
under the quite erroneous idea the case was one of
syphilis after all; the result was a purpuric eruption
about the legs. Lepers are specially susceptible to
ordinary doses of potassium iodide, and this fact was
made use of by Danielssen, of Bergen, as a test. In
connection with this drug it should be borne in mind
that it is the basis of advertised blood mixtures.
Shepherd has recorded a case of purpuric eruption
ending in gangrene, which was apparently caused by
sodium salicylate [16]. Sandal-wood oil, administered
under various names for gonorrhoea, has led to
nephritis and cutaneous haemorrhages, but it must be
pointed out that the latter have occurred in the course
of gonorrhoea apart from drugs, although doubts have
been thrown on the gonococcus as the forts et origo

[171-

In another group of cases, the acute pemphigus I
have described as occurring in butchers, and arising
from the infection of a wound, haemorrhagic lesions
and bullae were noted in three of the eight cases I
observed and collected [18]. In my case, Bulloch
isolated a diplococcus corresponding to the micro¬
organism described by Demme, a fact he has confirmed
in another case very much like my own [19]. The
complaint, a severe infection, is frequently fatal (seven
out of nine in butchers).

The following haemorrhagic vesicular eruption in an
infant, one month old, was instructive. The skin con¬
dition commenced four days after birth, and when
first seen the lesions, varying in size from a pin-head
to a pea, were scattered about the body and limbs,
including the soles and palms, but the child was well
nourished and there was no evidence of syphilis. The
eruption was totally different to that observed in
congenital syphilis. At the post mortem a few days
after, the right pleural cavity was found to be full of
pus, demonstrating the toxic origin of the rash.

In herpes zoster some of the vesicles may be haemor¬
rhagic, evidence of the severity of the attack, and
mixed up with the vesicular rash haemorrhagic
punctate groups without vesiculation may be present.
In haemophilics, cutaneous hemorrhages may occur
either spontaneously or after slight injuries. As you
know, bleeders are generally of the male sex, though
the “ diathesis ” is handed down mainly in the female
line. Were it otherwise the females would run great
risks at the establishment of the menses and also at
parturition, but here again haemophilia appears to be
less severe in women when they are affected. Such
haemophilic haemorrhages may be of medico-legal
interest. In a case mentioned by Poore, the body of
a boy, who had died after a flogging, was exhumed
and numerous subcutaneous haemorrhages were found.
This was in 1856, when flogging and violent repressive
measures were in fashion, the schoolmaster getting a
long term of penal servitude. The case was probably
an instance of haemophilia fao].

In this connection I would call your attention to
the importance of ecchymoses about the genitalia,
breasts, face, lips, arms and legs of women and girls
in cases of rape or attempted rape. Hoffman has
pointed out that in some women there are pigmented
areas at the upper inner parts of the thighs, that look
very like ecchymoses or bruises eight or ten days
old [21]. In investigating such cases, the characteristic
signs of cutaneous and subcutaneous haemorrhages
must be borne in mind. It is also essential not to lose
sight of the possibility of simulation. Fallot records
the case of a girl who pretended she had been violated
m a wood by some unknown man; in proof she
showed some bluish spots on the internal surface of
the thighs and posterior part of the back. The spots

were round with a broken border and more discoloured
at the edges than in the centre, two points suggestive
of simulation, I may say. It was found the girl had
been supplied with some thick blackish liquid which
she had applied [22]. In the old days simulation of
ecchymoses appears to have been frequent in the ser¬
vices. When produced by dry cupping or suction,
the shape must be taken into account.

Again, spontaneous ecchymoses and skin haemor¬
rhages are stated to occur in the hysterical, and indeed
to have been produced by suggestion. But although
cases of this kind have been recorded by sceptical
observers, it is well to keep an open mind on the
subject. Such manifestations as bloody sweat and
bleeding stigmata were at one time held to be a proof
of possession by incubi, or as in the well-known
Louise Lateau to be miraculous (23]. As to haemor¬
rhages under the nails apart from injuries, I may
merely mention that they may accompany cutaneous
haemorrhages, or occur alone, as in hemiplegia, for
instance [24].

I must now deal rapidly with the histology and
mechanism of cutaneous haemorrhages, together with
their pathogenesis and aetiology [25]. On d priori
grounds, diapedesis appeared at first to explain every¬
thing, but microscopical investigation showed this
view applied to a few cases only, in the majority
rupture of the vessels being present. On the other
hand, Darier points out that almost all the vessels in
purpura offer a remarkable integrity of aspect [26].
I would remind you of the two vascular networks of
the skin, one superficial just below the papillae of
the skin and supplying the papillae with capillaries
(cutis vasculosa), the other subcutaneous, connected
up with the former by vessels passing through the
thickness of the cutis. According to Unna it is in
connection with the deeper network that haemorrhages
most usually take place apparently, more rarely extend¬
ing to the papillary network; more rarely still is
haemorrhage limited to the latter and the epidermis.
The weak spot appears to be the point of entry of the
hypodermic vessels in the cutis proper. In the micro¬
scopical investigation of haemorrhages it is necessary
to cut horizontal sections of the skin to get a clearer'
idea of the state of affairs, a method which enabled
Unna to demonstrate more readily the seat of rupture
in the vessels.

In the first place haemorrhages may occur as a result
of negative pressure, as in cupping. Here I should
like to mention that, according to Leduc, the osmotic
pressure of the blood is enormous, seven and a half
atmospheres [27]. Another explanation was throm¬
bosis, but the fact is that venous thrombosis may be
present, with paresis of the arteries, as in erysipelas,
without haemorrhage necessarily occurring.

Again, bacterial emboli may be present in the
capillaries without consecutive thrombosis, although
the latter may occur. But it is beyond doubt that in
purpuric eruptions bacillary emboli have been found.

In venous stagnation of the legs, ecchymoses and
subsequent pigmentation may occur. I have seen
ulcerations in varicose legs become distinctly haemor¬
rhagic, with a tendency to sloughing. But neither
stagnation nor hypostatic hyperaemia in the veins of
the leg leads necessarily to haemorrhages in the skin.

I need scarcely insist on the post mortem hypostatic
discolouration and lividities sometimes taken for
bruises by juries; they are not extravasations.

Naturally a point of importance in the subject we
are considering is the condition of the vessel walls. A
variety of changes have been put forward to explain
haemorrhages, such as molecular destruction, hyaline
degeneration and so forth, to say nothing of defective
formation. Again, it was natural to think of the toxic
effects of poisons, bacterial and otherwise, on the
walls of the cutaneous vessels. And here I should
like to call your attention to the experiments which
have been made with snake venom. Snake-bites are
well known to produce haemorrhages very rapidly.
Snake-venom is a complex body, and its haemolytic
properties need not be insisted on here. But in
addition to this property, Flexner and Noguchi have
apparently shown that these haemorrhages are due to
the presence in venom of a cytotoxin, which has the
power of dissolving endothelial cells, in other words

jOOQle

o

Oct. 30, 1907.

ORIGINAL PAPERS.

The Medical Press. 4^7

an endotheliolysin [28]. This appears to me all the
more important when taken in connection with the
fact that the osmotic pressure of the blood is equi¬
valent to seven and a half atmospheres, according to
Leduc, a pressure which does not assert itself by
morbid changes in ordinary circumstances. But
when the vascular walls are damaged, the blood itself
altered in various ways, and the vascular innervation
interfered with, it is no wonder that rhexis should
occur. I put this forward merely as a hypothesis, for
I know but too well how many of our explanations
need explaining. Things are not so simple as they
seem, for in addition to the factors I have just alluded
to, the cells of the organism are extremely sensitive
to changes in osmotic pressure; thus in concentrated
chloride of sodium solutions, the blood corpuscles lose
their water and shrivel; in water and very dilute salt
solutions they swell up and burst. It has been shown
that all bodies are more or less radio-active, and
moreover, it would appear that haemoglobin acts like
a catalytic ferment [29]. Haemoglobin contains iron,
which varies in quantity in different species. And
here I would suggest that inorganic iron, which
empirically sometimes gives good results in haemor¬
rhagic rashes, may act in a catalytic way, for accord¬
ing to Bunge, inorganic preparations of iron do not
appear to be assimilated by the organism [30]. May
not arsenic act in a similar manner, for arsenic un¬
doubtedly does appear to act beneficially, in some
purpuric conditions at any rate.

As far as the blood is concerned, the coagulability
and the freezing-point (cryoscopy) are also elements
in the problem, a very complex one indeed, as you
will perceive, which will require much labour to
elucidate, or even to approach elucidation.

Haemolysis in vitro , at any rate, occurs as you know
in a variety of circumstances, apart from snake-
venom, as, for instance, by the addition of water,
glucosides, foreign serum, and so forth [31]. On the
other hand, Carnot and Desflandres have shown that
if a rabbit be bled the blood is rapidly regenerated,
but if during this regenerative process the serum be
injected into a normal rabbit, a considerable increase
of red corpuscles takes place in the latter, the number
rising from about five millions, to eight, nine, and
twelve millions on the three following days respectively.
This regeneration appears to be due to a chemical
substance which is destroyed at 55° and exists in small
■quantities under normal conditions, but in larger
quantities after bleeding. This substance is present
not only in the serum but also in the bone marrow [32].
Whether anything can be made out of this in the
treatment of haemorrhagic rashes the future will show.

As regards haemolysis, may it not be that owing to
the disintegration of the complex molecule of the
haemoglobin, a liberation of energy takes place with a
bombardment of the walls of the blood-vessels by
ions, electrons and other radiations? Leduc found
that the experimental introduction of ions of calcic
alkaline earths into the skin of animals produced
blackish and ecchymotic lesions the next day,
ultimately leading to ulceration with indurated base
133 l

As an illustration of the severe attack on the blood
in purpuric eruptions, I may mention a case of
streptococcal morbus maculosus recorded by Heubner,
a girl aged 9£, in whom the number of erythrocytes
sank in a few days from 4,400,000 to 1,200,000, the
white corpuscles numbering 9-10,000. Microscopically,
there was neither poikilocytosis nor megaloblasts, but
numerous normoblasts with pyknotic nuclei were
present. The lymphocytes compared with the poly-
nuclears were as 90 to 10. At the necropsy the bone-
marrow was found to be raspberry-coloured and jelly-
like, and almost entirely made up of mononuclear
cells, with homogeneous protoplasm. Short strepto¬
coccal chains were also present between the cells. A
pure streptococcal culture was obtained from the
spleen [34]. The state of the bone-marrow and spleen
have not, as far as I know, been systematically
investigated in fatal cases of purpuric eruptions.

I have already referred to various micro-organisms
found in cases of cutaneous haemorrhages. But Kolb
f 35 ] Finkelstein [36] have described what they

consider to be the specific bacillus of idiopathic pur¬

pura, a bacillus which proved pathogenic when inocu¬
lated in animals. With regard to the pneumococcus,
Klein has described the instructive case of a nurse
who developed a purpuric rash over the lower part
of the abdomen and inner part of the thighs. This
rash was diagnosed clinically as haemorrhagic variola,
for the patient had had some intercourse with nurses
who had been to the small-pox ships. The patient
died. Sections of skin revealed numerous pneumococci
and haemorrhages in the cutis, but there was a
subepidermal zone free from both, the epidermis being
normal [37]. The “bathing-drawers” rash was
certainly in favour of variola, but how account for
the pneumococci? In a section of true haemorrhagic
small-pox figured by Klein the haemorrhages were just
below the epidermis, the latter showing cleavage on
the way to vesiculation. To complicate matters
further, Klein found in the nurse case micro-organisms
that stained in a bi-polar manner, not dissimilar to
those of Bacillus pestis , in addition to the diplococcus
pneumoniae.

I need not remind you of the fact that in plague
cutaneous haemorrhages may occur, especially in some
epidemics.

I have referred to the influence of the nervous
system, which is well exemplified in herpes zoster with
haemorrhages, depending as that eruptive condition
does on a lesion of the posterior ganglion. When the
toxic effects on the nervous system are intense, as is
the case in severe variolous infection, a purpuric rash
with a rapidly fatal denouement may sometimes lead
to variola being overlooked. Experimentally the
destruction of the abdominal sympathetic ganglion in
the frog has been followed by haemorrhages in the
lower limbs. At the necropsy in a case of purpura
haemorrhagica, Hale White [38] found acute inflam¬
mation of the semi-lunar and cervical ganglia, but
whether there was here a relation of cause and effect
or whether both morbid conditions in the skin and
nerves arose from the same cause is a point that
necessarily suggests itself. Schwimmer was strongly
of opinion that purpura was trophoneurotic in origin.
But the facts I have brought forward will not allow
of our agreeing with such a dogmatic attitude,
especially as physiologists tell us that no certain proof
of the existence of specific trophic nerves has been
given [39]. In neuralgia, haemorrhages have been
observed at the point of greatest pain, and this
repeatedly in successive attacks. Similarly injuries to
nerves and nerve involvement in malaria, etc., have
led to haemorrhages. When the innervation of a limb
is below par, as in old hemiplegia, a rash may be
more marked in it than in the sound one. Thus in a
man with an eruption on the legs, the old hemiplegic
limb presented many bullous lesions, whereas in the
sound one the lesions were papulo-vesicular and not
numerous. This was not a purpuric case, it is true,
but I mention it as an illustration merely. I have
already alluded to subungual haemorrhages in hemi¬
plegia. This consideration of the nervous system
leads me now to refer to the suprarenal glands, and
also adrenalin, the haemostatic properties of which I
need not insist on, for according to Balfour, the
suprarenals have in the foetus a twofold origin, the
cortex being derived from the mesoblastic tissue,
while the medulla is formed by a direct outgrowth
from the sympathetic system, consisting at first of an
aggregation of neuroblasts. In some animals, e.g.,
teleostean fishes, the two parts of the gland remain
separate throughout life, but in the higher vertebrates
the sympathetic outgrowth becomes surrounded by
the cortex, and the cells rapidly lose all traces of
resemblance to a nerve cell. But the medullary
portion is genetically part of the sympathetic system,
and its specific secretion, adrenalin, has an action
which is apparently confined to that system [40]. The
excision of the suprarenal bodies causes a profound
fall of blood-pressure; whereas injection of adrenalin
increases blood-pressure [41]. It has been suggested,
on insufficient grounds it appears to me, that because
haemorrhages into the suprarenal glands were found
in some cases of purpura evidently streptococcal in
origin, that the suprarenal condition had led to the
haemorrhages in the skin. The explanation appears
to me pretty obvious, viz., that both the visceral and

ized by G00gle

46$ The Medical Press.

ORIGINAL PAPERS.

Oct. 30, 1907.

cutaneous haemorrhages depended on the streptococcal
infection. Suprarenal haemorrhages have been found
where there was no involvement of the skin in the way
of purpuric manifestations. Moreover, in Addison’s
disease I do not remember ever having seen cutaneous
haemorrhages, nor have I heard or read of such
occurring in that disease, nor would one expect any¬
thing of the kind on the d priori ground that lowering
of the blood-pressure is the result of excision of the
glands. But in dealing with a subject that requires
so much elucidation, it is advisable to keep one’s mind
open on these points. The changes in the circulation
which occur at the menstrual period have been con¬
sidered to play a part in ecchymotic and purpuric
conditions. Danlos [42] and others have published
cases of cutaneous hmmorrhages apparently connected
with the catemenia. I would here point out that,
according to the recent researches of Marshall and
Jolly, the changes in the uterus which determine
menstruation are due not to ovulation but to an internal
secretion from the ovary [43], so that the question
arises as to whether the rashes I have referred to,
which appear to be connected with menstruation, may
not be connected in some way or other with this
internal secretion. Howbeit, the extract from another
gland, the thyroid, has apparently given rise to rashes
with haemorrhagic tendency. When purpuric rashes
occur in pregnancy, the idea of a toxaemia of course
suggests itself.

Reviewing what has been stated as to causation and
pathogenesis, it is unnecessary for me to call attention
once more to the complexity of the problem, so that
when one is face to face with a haemorrhagic rash,
treatment must be to a great extent empirical. The
first indication, especially where there is any severity
of the onslaught, or the condition is complicated by
other haemorrhages, is posture, that is, the horizontal
position. Bed alone will do a great deal. As I have
already told you it is important to be on one’s guard,
and the general impression made by the patient must
be borne in mind. Cutaneous haemorrhages may
commence in, a mild way, but ultimately, perhaps
suddenly, more serious symptoms may develop.

The prima via are frequently at fault in the erythema
purpuricum conditions. Intestinal auto-intoxications
must be dealt with by means of saline aperients, etc.,
but I need scarcely insist, after what I have said, on
the need for caution in this direction.

The buccal cavity, especially the teeth, should
always receive attention, even when the haemorrhagic
rash does not appear to be directly traceable to the bad
condition of the mouth.

In the ordinary run of cases, arsenic and perchloride
of iron sometimes answer well. In more severe cases
turpentine may prove very useful, but it requires to be
administered with caution: nix. to nixxx. of the oil
of turpentine (commencing with the smaller dose and
gradually increasing) suspended in mucilage in mixture
three times a day immediately after meals, the last
dose being taken not later than 6 p.m. Plenty of
barley water should be drunk during the treatment.
These precautions are necessary to prevent kidney
trouble. The urine, it goes without saying, should be
examined regularly.

Since Wright’s work on the coagulability of the
blood and the administration of calcium chloride, this
drug has been used, as also lactate of calcium. In
some cases I have found calcium chloride of use, but
it requires to be pushed before any effect is obtained.
When testing a drug, too, with a patient in bed, it is
important not to commence its administration at once,
but only after some days, to avoid giving credit to
the drug really due to the horizonal position of rest.
Various other drugs have been extolled, but here the
post hoc, propter hoc fallacy needs to be warily
watched. Perchloride of mercury and gelatine injec¬
tions have been recommended, but with regard to the
latter subsequent experience has shown that complica¬
tions might arise. In cutaneous haemorrhages depend¬
ing on general conditions, such as albuminuria, liver
disease, enteric, etc., treatment must be directed to
them. The care of such patients may become a
difficult matter.

In streptococcal infections antistreptococcic serum
would certainly be indicated. And in this connection

I would mention rectal injections of polyvalent serum,
which answered so well in two cases of severe pur-

? uric rash complicated by other haemorrhages under
enwick and Parkinson. In one of these patients the
injection synchronised with rapid cessation of the
haemorrhage at a time when death seemed to be only
a question of a few hours, so there seems no reason
to doubt its efficacy in that case [44].

In a general way, attempts should be made to keep
up the patient’s strength by the administration of real
foods; this is important in bad cases. By real foods
I mean raw white of egg, for instance, and not meat
extracts. The latter, as foods, whatever they may be
as stimulants, always remind me of the man who got
a stone when he asked for bread. There is not much
to expect from alcoholic stimulants, which are likely
to do more harm than good in hemorrhagic conditions,
and are pretty certain to hurry a patient down hill
when they arise in the course of infections.

As to adrenalin, its value or otherwise is a point
which does not appear to have been decided. But
some observers have spoken well of it as well as of
ergot. Bandaging the legs carefully may be of use,
especially in out-patient cases of hospital practice.

Altogether treatment must depend on the individual
case to be dealt with, its merits, surroundings and
circumstances. There is no royal road and no specific.

BIBLIOGRAPHY.

[15] Pernet. “Drug Eruptions,” Brit. Med. Journ.,
vol. i., 1903.

[16] Shepherd. Journ. of Cut. and Genito-Urin.
Diseases, 1896.

[17] Souplet. “La Blenorrhagie, Maladie generate,”
1893, p. 118.

[18] Pernet. Brit. Med. Ass. Meeting, London,
1895; also Pernet and Bulloch, Brit. Journ. of
Derm., vol. viii., 1896.

[19] Hadley and Bulloch. Lancet, vol. i., p. 1219.

[20] G. Vivian Poore. “Medical Jurisprudence,” p.
357. 1st Ed.

[21] Brouardel. Gauette des HSpitaux, February 20,
1906.

[22] Fallot. Cited by Hector Gavin, “Feigned and
Factitious Diseases,” 1843, p. 358.

[23] Bartltelemy’s “Le Dermographisme,” 1893, p.
117; also O’Malley and Walsh’s, “Essays in Pastoral
Medicine” (New York), 1906. As to incubi, see a
curious work by Sinistrari, “De Demonialitate, et
Incubis et succubis.”

[24] Pernet. “Diseases of the Nails,” “Encyc.
Medica,” vol. viii.; Heller, “Die Krankheiten der
Nagel,” 1900; Purves Stewart, “The Diagnosis of
Nervous Diseases,” 1907, plate i., fig. 128.

[25] For an exhaustive account see Unna’s “Histo¬
pathologic”; (also Walker’s Translation, 1896, p. 44),
with bibliography.

[26] Brocq. “Trait6 ^tementaire de Dermatologie,”
vol. i., p. 66.

[27] Leduc. “Les Ions et les medications ioniques,”
1907, p. 3.

[28] William H. Welch. “ Recent Studies of Im¬
munity” (Huxley Lecture, 1902), Brit. Med. Journ.,
vol. ii., 1902, p. 1 1 1 1 ; see also Kobert, “ Lehrbucb
der Intoxicationen.”

[29] Gustave le Bon. “L’Evolution de la Matifere,
12th Ed., 1906, p. 275.

[30! Bunge. “Physiologie des Menschen,” vol. u.»
p. 488.

[31] Buckmaster. “Morphology of Normal and
Pathological Blood,” 1906; one of the latest con¬
tributions for reference.

[32] Carnot and Desflanders. “ L’Activity cyto-
poietique du sang,” Soc. de Biologie, Nov. 24, 1906;
cited by Bohn in Mercure de France, April 1, 1907,
p. 516.

(331 Leduc. Op. cit., supra., p. 27.

(■34I Heubner. Op. cit., supra., vol. ii., p. 38.

[35] Kolb. “ Zur ifetiologie der idiopath, Blutflecken-
krankheit,” Arbeiten aus dem Kaiserlichen Gesund-
heitsamt, vii., 1891.

[36] Finkelstein. Berliner Klin. Wochensch., 1895,
No. 23.

[37] Klein. “Report of the Medical Officer, 1901-

Oct. 30, 1907.

ORIGINAL PAPERS.

The Medical Press. 469

1902” (L.G.B.), Appendix B, No. 8; “The Micro¬
pathology of Haemorrhagic Small-pox” (with plates),

>903-

[38] Hale White. Mcd.-Chir. Trans., lxviii., 1885.

[39] G. N. Stewart. “Manual of Physiology,” 1899,

P- 5 » 7 -

[40] Starling. “The Chemical Correlation of the
Functions of the Body,” Croonian Lectures, July, ;
1905 ; a most instructive set of lectures.

[41] Kobert. “Lehrbuch der Intoxicationen,” 1904- j
06, vol. ii., p. 1238.

[42] D&nlos. “Etude sur la menstruation au point
de vue de son influence sur les maladies cutanees,”
1874; for many details of cases and bibliography see
Bulkley, “Menstruation and Skin Diseases,” 1906.

[43] Starling. Loc. cit., supra. Reprint, p. 27 ; see
also Blair Bell, “Calcium Salts and Uterus,” Brit.
Med. Jour., vol. i., 1907, p. 920.

[44] Soltau Fenwick and Porter Parkinson. Med.-
Chir. Soc., April 24, 1906.

THE

PREVENTION OF TUBERCULOSIS,

WITH SPECIAL REFERENCE TO

TUBERCULOSIS IN IRELAND* (a) I

By ROBERT E. MATHESON, LL.D., j

R«glitrmr-General for Ireland.

The question of the prevention and cure of tuber¬
culosis has for some years occupied grave attention
in all civilised States in the world.

An International Congress on the subject was held
in London in 1901, and a further Congress in Paris
in 1905, both of which I attended in my official capa¬
city as a delegate from the Irish Government. The
Paris Congress was particularly interesting and help¬
ful, and the French Government spared no pains or
expense to make it a really useful conference. It was
held in the Palais des Beaux Arts in the Champs
Elys^es, a magnificent building, eminently suited to
the purpose. The Congress was opened by the late
President of the French Republic, Monsieur Loubet,
and in the opening ceremony delegates from many
countries took part. The Museum was a source of
practical instruction. On entering was a Bureau cf
the Prefect of the Seine, where many excellent notices
were exhibited warning the public as to the deadly
nature of the disease, and the means of preventing
infection. Further on was shown a bedroom in an
hotel, ill lit and ill ventilated, and side by side with
it was presented a model of an hotel bedroom, well
lit and well ventilated, arranged by the Touring Club j
of France. Then a model of a domestic servant’s room 1
in a Paris house was contrasted with the model of a
cell in the French Prison at Fresnes. Further on there I
was an ideal sanatorium—a model room in the Lari- |
boisiere Hospital. The Museum contained also many
beautiful pathological specimens, and portions of the 1
human body and the bodies of animals affected by |
the disease in its various forms. There were also many 1
statistical charts, exhibiting the status of the disease ■
in the various countries, and models and designs of |
sanatoria and of sanitary appliances having special
bearing on the subject. j

These Congresses have undoubtedly done great ser¬
vice in bringing together those interested in combating j
the ravages of the disease in the various countries, .
enabling them to compare notes and discuss together
the many practical problems which arise in dealing
with the disease. !

I cannot, perhaps, open my address this evening in '
a better way than by showing my audience a copy of
the badge issued to delegates and members of the |
Paris International Congress, 1905. The figure on the
badge represents a poor victim of tuberculous disease j
stretching out her hand and imploring help in her
desperate condition. The author of this beautiful
design touched a chord of pity in every heart, and
lent a pathos to all the deliberations of die Congress.
Substituting a fair Irish colleen for her unhappy

(a) Beings Lecture dellrered st the Tuberculosis Exhibition held !
In Dublin in October, 1907. ,

French sister, we have a picture of what might be
represented in many an Irish home, where the flower
of youth and beauty are year by year being carried
off by this awful scourge.

The august lady, our gracious Vice-Reine, who has
organised this Tuberculosis Exhibition, and to whom
Ireland is under so deep an obligation for her un¬
ceasing activity in promoting every good work tending
to the improvement of the country and the ameliora¬
tion of the condition of its inhabitants, has had the
same humanitarian object before her as was before
the Paris Congress—viz., how this dreadful disease,
which is so fatal in Ireland, can be successfully com¬
bated.

In furtherance of this object the first step is, I think,
to ascertain clearly how we stand with regard to it,
and the information collected and tabulated by my
department affords a solid basis on which all adminis¬
trative action must rest.

Though the registration of deaths only came into
operation in 1864, we have statistics of the deaths from
pulmonary tuberculosis back as far as 1831. In the
Report of the Census Commissioners for 1841 it appears
that the number of deaths from consumption, or pul¬
monary tuberculosis, from June, 1831, to June, 1841,
was 135,590. The Commissioners remark that this
malady is “by far the most fatal affection to which
the inhabitants of this country are subject.” Accord¬
ing to the Census Commissioners of 1851, the number
of deaths from consumption between June, 1841, and
March, 1851, was 153,098. The census reports of 1861
record 130,739 deaths from pulmonary tuberculosis
between March, 1851, and April, 1861. In the period
between April, 1861, and January, 1864, when the regis¬
tration of deaths commenced, it appears from the
report of the Census Commissioners of 1871 that 26,267
deaths occurred from consumption. These figures
make the appalling total of 445,694 deaths from pul¬
monary consumption from June, 1831, to January,
1864, and, having regard to the manner in which the
information was obtained, there is no doubt that this
total is considerably under the truth.

On January 1st, 1864, the Act for the Registration
of Deaths in Ireland came into operation, that for
England having been in operation since 1837, and that
for Scotland since 1855.

Tuberculosis in England, Scotland, and Ireland,
1864—1906.

In my annual report for 1906 is a chart showing the
statistical history of tuberculosis in the three countries
from 1864 to 1906. From this it appears that while
in 1864 Ireland stood lowest of the three, with a rate
of 2.4 per 1,000 living, the rate for England being 3.3,
and that for Scotland 3.6, in 1905 Ireland occupied
the unhappy position of being the highest with a rate
of 2.7, Scotland being next with 2.1, and England
lowest with a rate of 1.6. The attention which has
been paid to sanitation in the sister countries has
doubtless largely conduced to this result, and the
chart, an enlarged copy of which is included in my
exhibit, loudly calls for a sanitary campaign in this
country with a view of reducing our death-rate from
this dreadful disease.

But it is not only with respect to the other divisions
of the United Kingdom that we are in so disadvan¬
tageous a position, but Ireland occupies a lamentably
high position as regards death-rate from this malady
when compared with other countries. The last annual
report of my colleague the Registrar-General for Eng¬
land gives an interesting table showing the death-rates
from consumption in various British possessions and
foreign states. This table, an enlargement of which
is in the Exhibition, deals with pulmonary consump¬
tion only, and discloses the sad fact that in the world’s
records our country stands fourth highest, being only
exceeded by Hungary, Austria, and Servia.

Having thus reviewed our position as compared
with other States, I now come to consider in detail
the status of the disease in this country. In my last
annual report I presented a diagram showing the mor¬
tality from 22 of the principal causes of death in Ire¬
land in the year 1906. From this diagram (an enlarged
copy of which will be found in the Exhibition) it
appears that the mortality from tuberculous disease

Digitized by GoOgle

47 ° The Medical Press.

ORIGINAL PAPERS.

Oct. 30, 1907.

far exceeds that from any other causes of death. Out
of a total of 74,427 deaths registered in Ireland in
1906, no fewer than 11,756, or 15.8 per cent., were due
to this disease, which is in a great degree preventable.
But it is not only that so large a number of our fellow-
countrymen and women have been carried off by this
scourge but that the mortality is greatest in those ages
which ought to form the backbone of our population.

My exhibit includes a table showing by sexes and
age periods the number of deaths from tuberculosis
registered in Ireland in 1906, with the rate per 1,000
living at each age period. This table shows the
highest number of victims, and the highest rate per
1,000 living at each age period appear in the period of
life from 15 to 45 ; the age period 15-20 claimed 1,355
victims, or 2.91 ; the age period 20-25, 1,660, or 3.80;
the age group 25-35, 2,821, or 4.37; and that of 35 and
under 45, 1,717 persons, or 3.61 per 1,000 living at
those ages.

In my annual report for 1905, I gave a diagram
showing the proportion of deaths at each age period
in England, Scotland, and Ireland in the year 1903.
An enlargement of this diagram will be found in my
exhibit. A comparison of the ages of the persons who
died from tuberculosis in England and Scotland with
those who were carried off by that scourge in Ireland,
as shown in the diagram, reveals the further fact that
the mortality rate from tuberculosis to the number per
1,000 living at those ages in Ireland at the ages 10-15,
15-20, 20-25, 25-35, and 35-45, is enormously higher
than it is in England or Scotland.

The explanation of this may, I think, be looked for
under two causes:—(1) The emigration from the
country for so many years, which has removed the
able and healthy, and thus left amongst the residue
an increased percentage of the enfeebled and persons
less able to withstand the attacks of disease.

(2) The deaths of emigrants who have contracted
the disease in other countries, chiefly in America, and
have returned to die here. These persons, some of
whom were not enumerated in the population, but
whose deaths are included in the death-rates shown
in the diagram, abnormally swell the death-roll.

(In support of this view Dr. Matheson quoted the
reports from several Registrars of Deaths, showing
that the death returns were largely increased by
returned Irish-Americans, who had been sent back
from America by their medical advisers suffering from
phthisis. This practice, of course, assists in the
spreading of the disease among the poor people at
home.)

Though infant mortality in Ireland, as a whole, is
much lower than in England and Scotland, the ques¬
tion of tuberculosis amongst infants is an important
one, specially in our urban districts. In my annual
report for 1906 I presented a diagram showing the
infant mortality from 14 principal causes during that
year, from which it appears that the infantile victims
of tuberculous disease numbered about 400, being
equal to a rate of 3.85 per 1,000 births registered. A
similar diagram (enlarged) for the year 1905 will be
found in my exhibit.

The next point with which I propose to deal is the
relative percentage of mortality from the principal
forms of tuberculous disease, and their distribution
under each sex. This is shown in a diagram contained
in my annual report for 1904, an enlargement of
which, for the year 1906, is included in the Exhibition.
It appears that in 1906 the deaths from phthisis, or
pulmonary consumption, were 76.0 per cent, of the
total deaths from tuberculosis. The deaths from
tuberculous meningitis were 6.8 per cent. ; from tuber¬
culous peritonitis and tabes mesenterica 3.9 per cent. ;
from general tuberculosis 7.3 per cent., and from
other forms of the disease 6.0 per cent.

The deaths among males from phthisis were slightly
less than those among females, the former being 75.8,
and the latter 76.2. The percentage of deaths from
tuberculous meningitis was the same for both sexes,
viz., 6.8 per cent. The percentage of female deaths
from tuberculous peritonitis and tabes mesenterica was
in excess of the male percentage, the rate for females
being 4.2, and for males 3.7 of the total.

The seasonal mortality from tuberculosis in Ireland
is shown in a diagram contained in my annual report

for the year 1904. From that diagram it appears that
of the total deaths from tuberculosis, 29.1 per cent,
were registered in the June quarter, 27.3 per cent, were
registered in the March quarter, 22.3 per cent, were
registered in September quarter, and 21.3 per cent,
in the December quarter of the year.

In my annual report for 1905 is a map showing the
death-rate from all forms of tuberculous disease in
1905 for each Poor Law Union (of which there are
159)—the deaths in lunatic asylums and certain insti¬
tutions being assigned to the Union to which the
deceased belonged. An enlarged copy of this map is
suspended in the exhibition. From it it appears that
in two unions—viz., Lisnaskea, in the County Fer¬
managh, and Tulla, in the County of Clare—the rate
did not exceed 1.0 per 1,000; that in 59 unions the
death-rate from tuberculous disease ranged from 1.0
to 2.0 per 1,000 of the respective populations; that in
68 unions the mortality exceeded 2.0 per 1,000, and
was under 2.7 per 1,000, which was the average death-
rate for all forms of tuberculous disease for Ireland
in 1905. That in n unions—viz., Antrim, Dingle,
Dundalk, Enniscorthy, Lame, Limerick, Listowel,
Lurgan, Middleton. Naai, and Rathdrum, the rate
exceeded 2.7, but was under 3.0 per 1,000 of the re¬
spective populations.

That in 16 of the Poor* Law Unions of Ireland—
viz., in Banbridge, Bandon, Belfast, Carxick-on-Suir,
Castlederg, Clonakilty, Downpatrick, Kinsale, Lis¬
burn, Londonderry, Mallow, Newtownards, Skull,
Strabane, Tullamore, and Waterford the rate ranged
between 3.0 and 4.0 per 1,000. Finally, that in three
Unions the rate exceeded 4.0 per 1,000. In North
Dublin Union the highest death-rate from all forms of
tuberculous disease was recorded, being 4.76 per 1,000;
in Cork Union the rate for the year was 4.53 per 1,000,
and in Dublin South Union it was 4.38.

There are not materials for preparing statistics of
the mortality from tuberculosis for the whole country
by occupations or social positions, but a table will be
found in the annual summary of my weekly returns
for last year showing the occupations or social posi¬
tion of the persons whose deaths were registered in
the Dublin registration area as having died from tuber¬
culous disease during the year 1906. A large table
dealing with this subject is included in my exhibit.
From this table it appears that of the total deaths,
1,694, representing a rate of 4.5 per 1,000, 6 only
belong to the clerical, medical, legal, and other pro¬
fessions, naval and military officers and heads of
public departments ; that amongst the merchants and
manufacturers of the higher class there was only one
death; that amongst persons of rank and property
(not otherwise described) there were only 4 deaths.
In all, amongst the professional and independent
classes there were only 11 deaths out of the total
of 1,694.

From the middle classes 243 deaths were registered
as follows:—11 from the general body of officials,
Civil Service, banking, etc. ; 49 from traders (except¬
ing petty shopkeepers), business managers, etc. ; 120
deaths of clerks and commercial assistants, and 63
deaths of householders in second-class localities, not
included in above.

The deaths from tuberculosis among the artisan class
and petty shopkeepers numbered 391, and comprise the
deaths of 26 working engineers, engravers, printers,
watchmakers or jewellers ; 115 persons engaged in the
building and furnishing trades; 84 in the clothing
trades; 127 in other callings ranking with trades, and
20 petty shopkeepers.

In the general service class, of a total of 635 deaths,
27 were employed in the army, police, postal delivery,
or prison services; 66 were those of domestic servants;
58 of coach and car-drivers, and vanmen, and 484
were described as hawkers, porters, or labourers. In
addition to this, the deaths of 414 persons who were
inmates of the workhouses occurred from tuberculous
disease. Comparing the mortality in the first four
classes, excluding Class V., workhouse inmates, we
find that in the professional or independent class the
rate was .63, in the middle class it was 2.79, amongst
the artisan and petty shopkeepers it was 3.54, and in
the general service class it was 4.12. These figures

Oct. 30, 1907.

OPERATING THEATRES.

The Medical Press. 471

show that amongst the classes which are better housed,
clothed, and fed, the mortality from this disease is
much less than amongst those who have not the same
advantages as regards housing, clothing, and diet, and
whose callings expose them more to the severity of the
weather than those more affluent in their circum¬
stances.

Causes Favouring the Spread of the Disease.

I now come to consider the causes favouring tuber¬
culosis, and I may mention three principal factors con¬
tributing to the spread of the disease: —

1. Insanitary Houses and Surroundings. —This is
undoubtedly a very prominent cause in disseminating
the germs of the malady. The notes on the sanitary
condition of their districts, which are supplied to me
each quarter by the Registrars, contain many refer¬
ences to this. The Registrar for Cloyne District
'Middleton Union) remarks:—“I attribute 40 per cent,
of the cases of illness amongst my dispensary patients
to overcrowding and the filthy condition of the dwell¬
ings, the breathing and re-breathing of vitiated air
causing a form of anaemia, accompanied with great
debility, low'ering the germicidal powers of their
tissues, making them easy victims to tuberculous
disease.” The Registrar for Waterford No. 1 Urban
District reports:—“The sanitary conditions in many
parts of the district are bad—there are many houses
having objectionable surroundings. The housing is in
places deficient in air space, light, and ventilation.
Tuberculosis is prevalent—it accounts for about 28
per cent, of the deaths.” The Registrar for Holywell
No. 2 District (Enniskillen Union) states:—“Tuber¬
culosis is on the increase, and, I fear, will continue
to be so until more stringent measures are taken to
compel the people to pay more attention to the cleanli¬
ness of their houses and their surroundings, and
particularly to the principle of ventilation and sun¬
light.”

In connection with the influence exercised by in¬
sanitary surroundings in promoting tuberculosis, it is
interesting to note the low death-rate from tuberculosis
which prevails in our Irish prisons, which is doubtless
due, in a large measure, to the care exercised by the
Prisons Board in regulating the sanitary condition of
the cells in which the prisoners are confined, and
controlling their dietary. Her Excellency has been
presented by Mr. James S. Gibbons, C.B., Chairman
of the Prisons Board, with a series of photographs,
showing the various descriptions of cells in the Irish
prisons, which will be found in the Tuberculosis
Exhibition.

2. Intemperance. —A further cause which operates
more especially in urban districts is intemperance. In
addition to the enfeebling of the constitution from
over-indulgence in strong drink, the money spent
thereon is frequently taken from that required to
provide food and clothing for the children, who are
thus rendered less able to withstand the attacks of
disease.

3. Neglect of Precautions against Infection. —A third
powerful agent is the practice which largely prevails
in this country of living with consumptive patients
without any precautions against infection—the result
being that one sufferer is liable to infect the whole
family. Nothing is more commonly met with than
to find a poor consumptive living in a cabin with
brothers and sisters, sharing their meals, and frequently
sleeping with other members of the family, without the
slightest regard to disinfection, and when remonstrated
with the answer is, “Sure, it is only a decline.”
Several other causes might be mentioned, but these will
suffice for my purpose this evening.

Remedial Measures.

We now pass to the remedial measures which come
within our power to adopt, and these also may be
considered under three heads.

1. The Improvement in the Dwellings of the Working
Classes. —I am glad to say that much has been done in
this direction. Those who remember the dreadful
cellar dwellings which were to be found in Dublin
thirty years ago will feel grateful to our distinguished
Medical Officer of Health, Sir Charles Cameron, C.B.,

for his unceasing exertions to better the housing of
the working classes. It is hardly necessary to refer
to the deep obligation which the inhabitants of Dublin
owe to Viscount Iveagh, K.P., through whose princely
munificence large unhealthy areas have been cleared
and sanitary dwellings erected. Much, however, still
remains to be done, not only in Dublin, but throughout
the country generally, if we are to have the terrible
tuberculosis death-rate reduced.

2. Dispensaries , Sanatoria, and Hospitals. —The
second way which is open to us to limit the ravages
of the white scourge which paces out land is by the
establishment of special dispensaries, sanatoria, and
hospitals for the treatment of the disease. As this
particular province of the subject will be dealt with by
some of my co-lecturers who are professional experts,
I need only allude to it here. In addition to the value
of sanatoria and special hospitals for the cure of the
disease, there can be no doubt that these institutions
effect three other great objects:—(1) The alleviation
of the symptoms of the poor sufferers, and (2) the
withdrawal of the patients, at least temporarily, from
their surroundings, in which in all probability they
have been infecting others, and (3) the education of
the patients and their friends as to the necessary pre¬
cautions.

3. Administrative and Educational Measures. —A
third preventive lies in administrative and educational
measures. Pulmonary tuberculosis should be made by
statute a compulsorily notifiable disease. A resolution
to this effect was passed at the special meeting of the
Consultative Committee of the Exhibition held on the
12th October. Children at school should be made
liable to periodical inspection, so as to have the
disease detected in its earlier stages, and hygiene should
be taught everywhere in our schools. It is pleasing
to note that the Board of National Education have
taken this matter in hand, and that in their Pro¬
gramme of Instruction for National Schools, which
came into operation on 1st July, 1906, they have
directed that simple lessons on health and habits
should be given to the scholars.

In bringing this lecture to a close, I desire most
earnestly to impress on my hearers the responsibility
which rests on the members of the community
individually to do their utmost to aid in the efforts
which are being made by Her Excellency the Countess
of Aberdeen and the Women’s National Health
Association, as well as by other societies, to awaken
the people generally to a sense of their danger. It is
my firm belief that if our countrymen and country¬
women were really aroused to the gravity of the situa¬
tion, their common sense, and intelligence would make
them able allies in this great conflict, and that we
should soon have to congratulate ourselves on the fact
that the excessive mortality from tuberculosis, which is
a present disgrace to Ireland, was a thing of the past.

OPERATING THEATRES.

ROYAL FREE HOSPITAL.

Malignant Disease of the CEsophagus.—
Gastrostomy.—Mr. T. P. Legg operated on a man,
ast. 61, who had suffered from increasing difficulty in
swallowing since the beginning of this year. During
the last two or three months he had been able to take
nothing but soft solids, and had developed a cough
and hoarseness. He had become steadily weaker and
emaciated rapidly. A bougie was arrested just below
the cricoid, and the smallest size could not be passed
through the stricture. There was some thickening in
the lower part of the neck, behind, and on each side of
the trachea. Laryngoscopic examination showed that
the left vocal cord was quite paralysed, and some
cedematous swelling over the arytenoid cartilages. With
such signs, it was obvious that the part was affected
with malignant disease in the upper third of the
oesophagus, and it was equally clear that he would
succumb to starvation unless something was done to
enable him to take more nourishment. In these cases.

Digitized by GoO^Ic

472 The Medical Press.

OPERATING THEATRES.

Oct. 30, 1907.

Mr. Legg pointed out, there are two alternative methods
of treatment: either to perform gastrostomy or to pass 1
a tube through the stricture and leave it in situ. This l
latter method was, in his opinion, inferior to gas¬
trostomy. Moreover, it was not always possible to use
it. In this patient, a tube could not have been got
through the stricture, as the narrowing of the lumen
was so great, and the site of the disease being in the
upper part of the oesophagus, and close to the opening
of the larynx, the part would probably not have re¬
tained the tubs on account of the cough and irritation
set up by its presence. Gastrostomy was, he thought,
a very satisfactory operation from the point of view of
the patient always being able to take enough nourish¬
ment, and it had few drawbacks. As it is performed
nowadays, there is very little leaking of the stomach
contents, and the skin around the opening rarely be¬
comes excoriated. It frequently is never reddened for
more than half an inch, so the discomfort to the patient
is exceedingly slight. The operation has a low
mortality, if it is done before the patient is extremely
exhausted and in the last stages of his illness. The
operation is indicated (1) when there is absolute in¬
ability to take liquids or solids, provided the general
condition is fairly good ; (2) when there is great diffi¬
culty in swallowing liquid or solids, or there is regur¬
gitation of the nourishment; (3) when coughing is pro¬
duced every time the attempt is made to take food.
One sometimes sees a patient with carcinona of the
oesophagus, who is able to take sufficient nourishment
without much difficulty, and whose general condition
is fairly good. In such a case, gastrostomy is not
necessary. One must remember that the operation is
a palliative and not a curative one, and therefore is
not tc be done unless there is a definite indication for
it After the operation the patient always improves
for a time ; he puts on flesh, is very often able to
swallow again by the natural passage, and is benefited
in every way. But it is impossible to say how long
such improvement will last. Some of the most hope¬
ful cases die suddenly from perforation into the
trachea causing septic pneumonia, or from haemorrhage.
Other cases will live a few weeks to three or four
months, and occasionally one finds the patient living
for twelve or eighteen months. Unfortunately one can
never tell beforehand how long the life is likely to be
prolonged. But death by starvation can always be
avoided, and it should be pointed out to the patient
or his friends that this is the chief reason for recom¬
mending the operation. In the present case a modifica¬
tion of Franck’s method was done. A vertical incision,
two inches long, was made ihrough the centre of the
left rectus, just below the subcostal angle. A second
incision, one and a half inches away from and parallel
to the first, was made at the outer border of the
muscle, which was split into anterior and posterior
layers between the two incisions. A cone-shaped
piece of stomach was drawn up into the first incision,
and passed between the rectus fibres, so that the apex
of the cone appeared at the second incision. Thus the
whole cone of the stomach was surrounded by muscle.
The apex was stitched to the margins of the second
incision, and a hole large enough to admit a No. 10
catheter was made. The catheter was passed into the
stomach and fixed by a stitch to the skin, to prevent
it dropping in or out of the stomach. The base of the
cone was sutured to the rectus muscle and sheath, and
the skin incision closed. Before leaving the table
four ounces of peptonized milk and ioz. of brandy
were run through the catheter. Mr. Legg said this
operation cannot be done if the stomach is much
contracted and atrophied ; under these conditions one
of the other methods has to be selected. The opera¬
tion just performed gives at least as good results as
the others, and is the easiest to perform. There is
no danger of septic peritonitis from feeding the patient

cn the table if the stitching is done accurately. The
tube is taken out on the third or fourth day, and
subsequently passed when the patient requires feeding.

The patient made a good recovery from the opera¬
tion ; there was no regurgitation through the opening,
and he left the hospital much improved in about a
fortnight’s time. But he died, suddenly, three days
later from haemorrhage.

WESTMINSTER HOSPITAL.

Abdominal Tumour — Laparotomy — Distended
Gall-Bladder, Gall-Stones, Cholecystectomy.—
Mr. Tubby performed laparotomy on a female
patient, set. 35 who had the following history:
She had suffered some time from pain in the
right side below the ribs, and her doctor had
detected a swelling. She had been sent up to
the Westminster Hospital under Mr. Tubby’s care.
On admission she proved to be a somewhat spare
woman, with a good colour; there were no signs of
jaundice. She was able to eat well, and did not at
first seem to suffer any inconvenience excepting a dull
pain in the right hypochondrium, which was always
worse after handling. For three days before operation
she had some pyrexia. The diagnosis ot the swelling,
Mr. Tubby said, at first was obscure and varying, as
its character depended much on the condition of the
muscular contraction of the abdominal walls. At times
it appeared to extend downwards, and to present
characteristics associated with hepatoptosis, more
especially as the dulness over the area was variable;
but when the muscles were relaxed on subsequent
examination, the hands could be made to meet in the
right loin, and between them an elongated, hard, tense
swelling could be felt running downwards and towards
the umbilicus. This swelling was diagnosed as an
elongated gall-bladder, probably containing gall¬
stones. An X-ray examination revealed nothing. TTiree
weeks after admission a laparotomy was performed,
and it was at once evident that the diagnosis of gall¬
stones was correct. As it was probable that the gall¬
bladder contained pus, a trochar and cannula were
introduced, and about three drachms of grumous
material were expressed. The gall-bladder was then
opened, and three gall-stones removed. One measured
half-an-inch in diameter, a second one-and-a-half
inches, and a third one-thjrd of an inch in diameter.
The large one iVas tightly grasped by the walls of the
gall-bladder, and some force had to be used in
squeezing it out. The smallest gall-stone was rounded
at that part which looked towards the duct, but was
facetted where it came in contact with the large stone.
After the removal of the calculi, a probe was passed
down to make sure that the common duct was clear.
The gall bladder was then removed, the stump being
seared with pure carbolic acid, the edges being inverted,
and sutures passed so as to bring the peritoneal edges
in contact. Strips of gauze were packed around the
stump, and the abdominal wound closed, excepting
where a small aperture was left for the ends of the
gauze strips. 'Mr. Tubby said that in this case at first
there had been considerable difficulty in determining
the nature of the tumour, and this illustrated how
essential it was that observation of these cases should
be prolonged for a correct diagnosis to bj arrived at.
In such a case, where the symptoms were not urgent,
there was no necessity for immediate operation. He
thought that sometimes there was undue haste in per¬
forming abdominal sections for exploratory purposes,
and sufficient time was not given to form a definite
opinion of the nature of the case before operation.
The operation itself, he remarked, did not differ in any
way from the procedure usually practised in these
cases, but he considered it was of essential importance
to ascertain that the ducts were free from stones, and
to carefully examine by palpation the duodenal wall
and adjacent ducts, so as to make certain that no
calculus was impacted in these situations.

After the operation the patient vomited for three days
at intervals, and then began steadily to recover.

Oct. 30, 1907.

TRANSACTIONS

TRANSACTIONS OF SOCIETIES.

LIVERPOOL MEDICAL INSTITUTION.

Meeting held on Thursday, October 24TH, 1907.

The President, Mr. T. F. Paul, F.R.C.S., in the
.Chair.

Dr. W. R. Warrington gave an account of the
clinical features of a patient suffering from
acute hodgkin’s disease,

who died within two months of the onset of the
disease. The spleen was considerably enlarged, the
glands only slightly so. There was high fever,
diarrhoea, and marked anaemia, and violent delirium
preceded death. The microscopic examination of the
glands showed the typical structure of lymphadenoma,
as described in the writings of Reed, Andrews, and
others. Dr. Warrington alluded to the classification
of the acute glandular enlargements.

The President, Dr. J. H. Abram, and Mr. R. W.
Murray discussed Dr. Warrington’s Note.

Mr. R. W. Murray related two cases of
EXTROVERTED BLADDER,

in which he had transplanted the ureters into the
rectum. In one of the cases he had, ten years
previously, performed a plastic operation, whereby an
adequate covering for the exposed mucous surface of
the bladder had been made, but as the absence of a
sphincter to the bladder rendered the patient’s life
miserable, it was decided to transplant the ureters
into the rectum. The patient died on the eighth day
after the operation, from ascending ureteral infection.
In the second case a similar operation was performed
with some success. After operation the patient, a
child of 44 years of age, was able to retain his urine
for 4^ hours. For two months all the urine was dis¬
charged into the rectum, but recently urine had
escaped anteriorly from the right ureteral surface of
the bladder. These cases were brought forward to
emphasise the high rate of mortality following upon
such operations, which he thought probably amounted
to 50 per cent.

Mr. R. C. Dun agreed with Mr. Murray that the
rate of mortality following implantation of the
ureters into the rectum or sigmoid flexure was a very
high one. In hu two cases, one patient died of
shock in 24 hours after the operation; the other
patient lived two years and then died of diphtheria.
The child was only seven years old at the time of his
death, but could then hold his water for an hour.

In a third case of extroversion Mr. Dun had per¬
formed the first part of Lilienthal’s operation, but
this had resulted in the patient’s death.

Mr. R. C. Dun reported a case of
URIC ACID CALCULUS

successfully removed by operation from a child six
years old. The symptoms had been indefinite—
slight pain in the hypogastrium and hsematuria.
These symptoms were not aggravated by movement.
While under observation the hsematuria was so slight
that it could only be detected by microscopic exami¬
nation of the urine. There was no enlargement of
the affected kidney. An X-ray photograph, taken
by Mr. Thurstan Holland, very clearly demonstrated
a calculus in the right kidney. Mr. Dun drew atten¬
tion to the rarity of this condition in children, and
to the indefinite nature of the symptoms in the case
under consideration. He emphasised the importance
of radiography as an aid to diagnosis.

Dr. Macalister read a paper on

THE PERSONAL FACTOR IN DIET,
in which he commented upon the great variations
which exist in the dietetic requirements of individuals.
He referred to his experiences among the boys of a
large industrial school, and pointed out the fact that
collective dieting, although suitable enough for the
majority, proved that there is a small minority of
people who cannot live healthily on conventional

OF SOCIETIES. The Medical Press. 473

lines. Having spoken on the other hand of the
danger of arriving at conclusions as to what is good
for all humanity, because a few people thrive on
some specialised lines of diet, he pointed to the
frequency with which metabolic diseases occur, and
that in many cases they result from the introduction
of foods which, although suitable for people having
perfect metabolic capabilities, are harmful to those in
whom they are imperfect. Dr. Macalister directed
attention to the complex and mixed character of the
human diet, and to the fact that the amount of animal
and vegetable food required by different people varies
considerably, some needing much meat, others very
little, and that there are some who should not take
any at all. With reference to these latter, he men¬
tioned a case which had come to his-notice two years
ago of a gentleman who by instinct and habit was a
pure vegetable feeder, and in whom there was a well-
marked pair of adventitious mammillas. He was a
strong, athletic man, a particularly fine swimmer, and
full of physical and mental energy, and he certainly
thrived, and thrives to this day, without taking any
flesh of any description. The polythelia, together with
the metabolic peculiarity, present in this case, had
suggested to Dr. Macalister the possibility of a rever¬
sion to some ancestral type of vegetable feeder which
might be present in this and kindred cates. He re¬
ferred to the normal condition of polythelia present
in the embryo, and to the possibility that its per¬
sistence might be associated with other developmental
peculiarities, rendering the persons different in their
metabolic powers from those in whom more perfect
conditions had been attained to. He thought the
appendix was another vestigeal organ, functionless in
the wholly developed, but which might be very useful
to those perhaps less perfect people in whom it is
long and well-developed, sometimes resembling the
organ as seen in the herbivorous anthropoid apes,
and he suggested that some cases of appendicitis may
result from the constant introduction of unsuitable
fuel into the furnace of the economy.

Dr. T. R. Bradshaw remarked that the theory that
special idiosyncrasies in diet might be explained on
the ground of development was quite new, and he was
not prepared to discuss it. The practical outcome of
the paper was to confirm the adage “What was one
man’s meat was another man’s poison.” The accepted
views on dietary were not satisfactory. The physician
who laid down rules for diet was too apt to be guided
by his own likes and dislikes. Chittenden’s experi¬
ments to show that the accepted minimum of food was
too high was confirmed by clinical observation. He
quoted the case of an elderly lady with pyloric stenosis,
who was liable to kinking whenever the stomach was
distended. For the past six years 9he had lived on
about a pint of liquid food a day with the addition
of a few biscuits, and had maintained her nutrition
and was able to take gentle exercise.

Dr. W. Carter said that the differences in the con¬
stitutional build of men were recognised by the elder
physicians who classified them into bilious, phlegmatic,
nervous, sanguinary, etc., and treated them both
dietetically and medically according to the sub-division
in which they ranked them. Dr. Macalister, in his
interesting and suggestive paper, had given an indica¬
tion of what might prove to be a reliable and scientific
basis for a more correct classification. He drew atten¬
tion to the observations of Mr. W. North, com¬
municated to the Royal Society by the late Sir W.
Burdon Sanderson. Mr. North said that the gist of the
whole matter was that we had to deal with a machine
which had a marvellous power of accommodating itself
to the work put upon it, which rendered the problem so
complicated that the hope of finding any explanation
of the phenomena observed was somewhat distant. One
man would do an amount of work upon a given diet
which to another man would be simply impossible.
If the signs given by Dr. Macalister as possibly indi¬
cating a partial reversion to an earlier stage of evolu¬
tion were found, on further investigation, to be reli¬
able, we should have a valuable clue for. the dietetic
treatment of many cases.

Mr. Harcourt, Dr. W. R. Warrington, Dr. A. G.
Gullan, and Dr. Owen T. Williams also spoke.

y Google

474 The Medical Press.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

rarla. Oct. 37 th,

Treatment of Acute Retention of Urine.

When one is called to a patient who cannot urinate,
it is easy, says Dr. A. Pappa, in the Journal des
Practiciens, by a rapid interrogatory and by feeling the
vesical tumour, to diagnose a case of acute retention of
the urine.

How should the bladder be evacuated is the question.
To resolve the problem we have at our disposition
different means. Some in current use and which, in
the large majority of cases, suffice, others, applicable
in case of failure of the preceding and in certain special
circumstances.

It is indispensable in the first place to understand
the cause of the retention in order to apply a correct
treatment.

If the patient is suffering from an affection of the
nervous system (hemiplegia, ataxy, paralegia, etc.) the
retention should be attributed to this condition, and
after having explored the canal with an olivary bougie,
a flexible or a coude catheter will easily be passed.
But, in general, the obstacle will be found in the
urinary organs themselves, and the diagnosis must be
made between prostatitis, spasm, stricture, hypertrophy
of the prostate, etc. Examination by the rectum is
always necessary to clear up any doubt.

If the prostate is found increased in size, painful,
tense and hot, it is a case of prostatitis; if there is
fluctuation, an abcess is already formed. If the gland
is on the contrary normal, the case is one of spasm or
congestion of the urethra.

In all these cases, catheterism should yield the place
to medical treatment for fear of carrying infection into
the bladder. The better treatment is to order a bath
and a very warm enema with a few drops of laudanum.
If these means failed then the catheter should be used,
but only after the canal had been well irrigated with
some antiseptic solution, as oxycyanide of mercury
(i—4,000). After which a drachm of a solution of
cocain (1 per cent.) is injected to reduce the resistance
of the membranous portion of the urethra. Fre¬
quently, in case of spasm, by this injection alone, the
patient is enabled to micturate and in any case it
facilitates the passing of the catheter.

When the patient confesses having had gonorrhoea
3. 4, or 10 years or more previously, or a traumatism
of the perineum, and if he complains beside of in¬
creasing difficulty in urinating, the diagnosis of
stricture imposes itself. The canal should be explored
by an olivary catheter of a large size, No. 20 ; if it does
not pass, the size is diminished until the right
dimension is found. However, generally, the very
smallest calibre fails, and recourse has to be had to
one or other of Gouley’s whalebone or filiform series.
If one of these pass it should be left in situ, the urine
will pass by the side of it, and the patient will be
relieved.

If the patient is close on the sixties, the retention is
generally due to hypertrophy of the prostate.

For some time, he has had to get up at night to urinate,
the jet was slow in coming; then from some congestion
caused by coition, copious repast, cold, voluntary
retardation in evacuating the bladder, retention
suddenly set in.

Here a catheter coude is indicated. If resistance is
felt, no violence should be permitted, a simple
manoeuvre is generally sufficient to overcome the
obstacle.

The instrument engaged in the posterior urethra and
maintained firmly in the median line by the left hand
near its extremity and the guide held by the right
hand, the catheter is pushed gently towards the bladder,
while at the same time the guide is drawn out. By
this means the curve of the catheter is accentuated, and
the instrument penetrates into the bladder. If the
attempt has not been successful a finger might be

Oct. 30, 1907.

passed into the rectum to guide the catheter by gentle
pressure towards the bladder.

When the catheter has penetrated, should the bladder
be completely evacuated ? If the patient is young and
the retention dates only a few hours, it can be emptied
without inconvenience; but if the retention has been
more prolonged and especially if the patient is of a
certain age, the bladder should not be entirely
emptied for fear of hasmorrhage in vacuo. After with¬
drawing a quantity, more or less considerable, accord¬
ing to the case, six ounces of a solution of nitrate of
silver (1—1,000) should be injected if the urine is not
infected. If, on the contrary, the urine is dirty, it
should be replaced at the same time as it is with¬
drawn by a solution of oxycyanide of mercury. Two
or three quarts are thus injected, modifying the vesical
contents without having emptied completely the
bladder. Complete evacuation should only be per¬
mitted after 24 or 48 hours, but the catheterism might
be repeated every three or four hours.

Another important question is to know if the catheter
should be left in situ. In spasm of the urethra or
prostatitis, never; in stricture, hardly ever, but frequently
in hypertrophy of the prostate, and especially when it
is not possible for the surgeon to repeat frequently the
operation, and when the patient or his attendants
could not be trusted with the catheter.

Where catheritism is absolutely impossible, recourse
should be had to puncture of the bladder with Polain’s
apparatus. The pubis being shaved, a capillary’ trocar
is inserted a quarter of an inch from the edge of the
pubis, in the median line, and pushed into a depth of
from two to two and a half inches. Aspiration of the
urine is made without completely emptying the bladder,
and a drachm or two of a solution of nitrate of silver
(1—500) injected. The trocar is withdrawn sharply,
and the small wound sealed up with collodion.

In general, this operation need not be repeated as
congestion disappears from the organs and micturation
is re-established, otherwise three or four repetitions may
be practised without inconvenience.

There are cases where catheritism should not be
practised. In urinary abscess it is dangerous. The
abscess should be opened largely, and the patient will
urinate through the wound. In grave ruptures of the
urethra, catheritism should only be done in the
operating room, it being the first operation in external
urethrotomy.

In other cases, not only has retention to be treated
but also urinary infection, for which a whalebone
catheter is insufficient to insure the drainage of the
bladder, whereas his indication can be filled by
internal urethrotomy permitting the placing in situ of
a No. 15 or 16 catheter.

Finally, puncture of the bladder is insufficient in
case of infection or grave hasmorrhage in prostatic
patients. Here suprapubic cystomy should be per¬
formed in order to drain largely the bladder by a
suprapubic drainage tube or to arrest the haemorrhage.

GERMANY.

Berlin. Oct. 37 »b, 1907.

The Treatment of Tetanus.

Prof. Tilmann, of the Surgical Department of the
Academy for Practical Medicine, Cfiln, has an article
on this subject in the Deutsche Med. Wochenschrift,
14.07.

A child, aet. 4, was admitted into hospital suffering
from gangrene of the arm caused by a horse treading
on it. Immediate amputation was indicated. There
was no other injury, but notwithstanding this five days
after the injury and two after the amputation, the first
symptoms of tetanus made their appearance, the
1 disease proving fatal in another 36 hours. As there
was no other injury it must be assumed that the elbow
' was trodden on, and that the poison was introduced
into the system in that way. The early removal of
the source of infection had neither cut short the disease
nor rendered its character milder. From this it may
be assumed that amputation does not promise much in
the way of treatment. The case was also of great
interest from a pathogenetic point of view. A tetanus

CORRESPONDENCE.

,GoogIe

Oct. 30, 1907.

CORRESPONDENCE.

The Medicai. Press. 475

poison introduced during the first three days after the
injury had not set up any symptoms until five days
after. This was difficult to explain. Perhaps the
tetanus poison has to develope further in the body
before it can do any harm ; but in cats the disease
shows itself three hours after injection of the tetanus
poison.

The case agreed best with the theory of Brunner-
Goldscheider, which places the point of difficulty in
irritation of the ganglionic cells of the spinal cord.
The poison reaches these ganglionic cells by way of
the peripheral nerves, or in the nerves themselves to
the spinal cord. In this case five days had elapsed
before the necessary quantity of toxine had reached the
spinal centres, and the toxine formed in the wound
during the first three days sufficed to set up the first
symptoms of the disease. The interruption of the
delay did not help.

Herein perhaps lay the reason why antitoxine did
not do much good. Perhaps it was used too late, or
not in the right way. Behring recommended that we
should protect the threatened spinal centres against
the tetanus poison by shutting off the afferent nerves
by antitoxine. The writer had carried out this pro¬
cedure in a case of tetanus following an injury to the
knee. The tetanus of a medium type that followed the
injury rather quickly was arrested after 52 ccm. of an
antitoxine = 28oA.E. in the lumbar region and into both
ischiatic nerves. Along with this the patient had
0.01 grm. of morphia every two hours and 1 grm. of
chloral hydrate. One could not say with certainty
that the case would have been fatal without the serum,
but in any case recovery took place in a week. Other¬
wise the author had never seen a case in which he
could satisfy himself that the antitoxine was of any
value. The cases in which the onset was delayed to
about the sixth day almost all proved fatal, those
commencing after the tenth day nearly all recovered ;
in the cases lying between these dates the prognosis
was according to the quickness of the onset of the
symptoms.

The writer did not make prophylactic injections of
antitoxine. When should the injections be made?
To make injections into the afferent nerves was not
possible. Then it was not free from doubt that injec¬
tions of antitoxine serum into healthy men did no
harm. If tetanus bacilli were found in the wound he
injected at once.

AUSTRIA.

Vienna. Oct. 27th. 1907 .

Retirement of Professor Politzer.

After 46 years practice in the Allgemeinen
Krankenhaus, Politzer has now retired from being the
head of the department of Otiatria. A few days since
a holiday was recognised by his academic colleagues
to present him with a “gold plaquette ” and an illu¬
minated address endorsed with the names of sub¬
scribers from every part of the globe. Politzer was
born on the 1st October, 1835, in Alberti, Hungary,
and studied at Vienna under Rokitansky Skoda.
Oppolzer, and Carl Ludwig, obtaining the doctorate
in 1859.

After a short residence with Ludwig in the physio¬
logical laboratory he travelled to Wurzburg where
TrOltsch was experimenting with the ear;' thence he
went to Paris where Claude Bernard was electrifying
the physiological world with animal experiments in
the spinal cord, and finally arrived in London where
he took interest in Toynbee’s work.

In 1861, when he was only 26 years of age, he
returned to Vienna, and was appointed the same year
to be a Docent in Otiatria by the general consensus of
the Vienna Medical Faculty! His lectures were given
in the Medical Klinik of Oppolzer, by the kind per¬
mission of the professor. In 1870 he was appointed
“ Extra-ordinarius ” lecturer. In 1873 the faculty began
to realise the necessity of a special klinik for ear
diseases, and finally resolved that one should be added
to the Allgemeinen Krankenhaus with Two Extra¬
ordinary Professors, Adam Politzer and J. Gruber;
the latter for the male department, the former for the
females. In 1896 he was raised to the position of

Ordinary Professor of “ Ohrenheilkunde,” but on the
retirement of Gruber next year he was left sole
director of the Vienna Klinik for Otiatria.

From 1873 till 1897 his ward consisted of 12 beds,
where he operated, lectured, and received guests from
every civilised country. He could read and make him¬
self understood in German, Hungarian, French, and
English; and before gotng to the last congress in
Madrid added Spanish to the list.

Vienna claims him as the first in Europe to put this
branch of medicine on a true scientific basis.
Demonstrations of the tympanum and Eustachian tube
lead to the practice of catheterising. In his response
he told in a humorous way how a notable German
"specialist” came to his klinik one day, and after
seeing the students go through their exercise, said he
had been 40 years in practice and never saw the
tympanum before !

His experimental researches and writings are now
classic, and found in different languages, a fourth
edition of his great work, “Diseases of the Ear and
Adjacent Organs ” [a) being now before the profession in
its English translation. But the greatest marvel of
his endurance is the recent completion of the first
volume of the “History of Otiatria” in his 72nd year,
and means to complete the second volume in his 73rd
year of his “Geschichte der Ohrenheilkunde.”

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

Royal Victoria Hospital, Edinburgh. — The
Tuberculosis Problem. —An interesting ceremony
took place in connection with this institution on
Thursday last, in which the principal part was taken
by the Right Hon. A. J. Balfour, who formally opened
the newly erected adminstrative buildings. The pro¬
ceedings took place in a marquee erected in the
grounds, and were presided over by Lord Dunedin,
who, in introducing Mr. Balfour, said that the hos¬
pital, which had been erected as a memorial to the late
Queen Victoria, was recognised as a national, not a
local, institution, and had been fortunate in receiving
the patronage and ready help of their gracious
Majesties the King and Queen. After a brief account
of the history of the hospital from its commencement
as a dispensary for tuberculosis, by Dr. R. W. Philip,
and remarks by Dr. Underhill, President of the Royal
College of Physicians, as representing the medical pro¬
fession, and by Dr. Leslie Mackenzie, representing the
Local Government Board, who dwelt on three aspects
of the crusade against consumption—viz., compul¬
sory notification, hospital isolation for advanced cases,
and curative sanatorium treatment for the early stages
—all three of these existing in Edinburgh—and who
also alluded to the recent Act amending the Public
Health Act so as to make the latter applicable, without
undue hardship to patients, to all forms of infectious
disease, Mr. Balfour addressed the audience on the
tuberculous problem, and in his speech showed that
he had a thorough and statesmanlike grasp of the
problems at issue. He paid a graceful tribute to Dr.
Philip as the inventor of the idea of a tuberculosis
dispensary ten years before it was adopted in any other
locality or country, which is rightly to be looked on
as the central point in the general campaign against
tuberculosis. Most cf those present could remember a
time when tuberculosis was not regarded as an infec¬
tious disease, but since Koch’s great discovery we had
learned that phthisis, like many other diseases, was
due to an invasion of the body by organisms, just as
plague, scarlet fever, and small-pox were. Different
though all the infectious diseases were, methods of
treatment were of three types. We might take, for
example, the method of dealing with them by some
form pf inoculation, long known in the case of small¬
pox, lately introduced with so much effect into the
treatment of other diseases. Then we had the method
of diminishing the danger of infection—one of the
great objects of the medical reformer being by isolation,

(a) Published by Ballllere, Tindall and Cox, and revised by the
author.

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4 76 The Medical Press.

CORRESPONDENCE.

Oct. 30, 1907.

by early treatment, and the like, to save those who are
not infected from such a strength of invasion as will
overcome their natural endowment in the way of
resistance with which no one was wholly unfurnished.
Yet, said Mr. Balfour, I do not anticipate that we
shall ever banish the tubercle bacillus completely from
any great tract of country inhabited by man. But
though this be so, we can, I suppose, reduce its power
of doing evil to an incalculable degree. We have
before us what has been done with regard to typhus;
it may be that our children will live to see the time
when consumption shall be as little known in our
midst as typhus is to-day. We have arrived at a core-
dition of affairs in regard to that particular disease so ;
satisfactory' that the force of resistance of the com¬
munity at large is adequate to prevent its making any
kind of lodgment in our midst. That is the ideal to
which we look forward with regard to tuberculosis.
The third method of dealing with this infectious
disease is by taking those who are attacked and restor- |
ing to them their powers of resistance so that they can .
throw off the disease and return to their ordinary work ;
re-endowed with powers rendering them immune to (
any similar invasion. This is the object of sanatoria,
and we shall never be able to deal adequately with
this subject unless we get into the popular mind the ■
distinction between the various methods of dealing j
with the disease, and not attempt to do in sanatoria
what can only be done in hospitals, or to do in the
hospital what can only be done in the sanatorium.
The fundamental truth must never be lost sight of—
consumption is a disease which can be dealt with if
you take it early, but if you allow it to get a fatal
grip on the organism, all you can do is to smooth the
dying months of the sufferer, but in no sense can you
restore him to his place in society or his work in the
world. After the address, which was frequently
applauded, the Rev. Dr. Macgregor moved a vote of
thanks to Mr. Balfour, and Sir Alexander Kinloch paid
a similar compliment to the chairman. Sir Alexander
Christison presented to Mr. Balfour a silver key with
which to open the new buildings. This concluded the
formal proceedings, and thereafter the institution was
thrown open to the inspection of those present.

Notification ok Births Act. —The Local Govern¬
ment Board have issued a circular in reference to the
adoption by local authorities of this Act. After detail¬
ing the provisions of the measure, the Board observe
that, in their opinion, there is no need to impose the
obligation of notifying births unless steps are taken
to carry out the ultimate object of the measure—viz.,
the giving of advice and instruction to those having
charge of the infants. In ordinary circumstances they
would not be prepared to consent to the adoption of
the Act, unless it appeared that arrangements had been
made for this purpose. Local authorities proposing to
apply for consent for the adoption of the Act ought,
therefore, to be in a position to show that such arrange¬
ments have been or would be made.

Royal Crichton Asylum, Dumfries. —Dr. C. C.
Easterbrook has been appointed Superintendent of this
Asylum, in succession to Dr. Rutherford, whose resig¬
nation was announced some weeks ago. Dr. Easter¬
brook is at present Superintendent of Ayr District
Asylum, previously to which he was senior assistant
at Morningside.

BELFAST.

Cerebro-Spinal Meningitis. —The epidemic of
cerebro-spinal meningitis dies out by slow degrees, two
or three cases being notified each week still. There
are only five cases of the disease under treatment at
the Purdysburn Fever Hospital, as most cases are now
treated at home. It appears that a considerable number
of cases were secretly kept at home even during the
height of the epidemic, when the authorities removed
all cases which were reported to them to the fever
hospital. Cases of deafness are turning up at the
special hospitals, some of which were never recognised
as cerebro-spinal meningitis, or, if they were recognised,
were never reported.

The Prevention of Consumption. —An important
conference took place on Thursday last, when delegates
representing the various sanitary authorities in the

north-west of Ireland met in Londonderry to discuss
measures for the prevention of the spread of tuber¬
culosis. Sir John B. Johnston, chairman of the
Londonderry Committee on Tuberculosis, presided, and
in addition to the leading men of the district Professor
McWeeney of Dublin was present. His Excellency
the Earl of Aberdeen telegraphed his good wishes,
and Lady Aberdeen wrote promising to attend a meet-
ing at a later date to found a local branch of the
Women’s National Health Association. After a state¬
ment by Professor McWeeney on the subject of tuber¬
culosis, various resolutions were passed, including one
advising the adoption of a scheme for providing a
sanatorium. The Mayor entertained the delegates to
luncheon, and in the evening a lecture was delivered
in the Guildhall by the Registrir-General, Dr. Mathe-
osn, B.L., on “Tuberculosis in Ireland.” He stated
that of the deaths registered in Ireland last year no
fewer than 11,756, or 15.8 per cent., were due to tuber¬
culosis, which was in a great degree preventable.

LETTERS TO THE EDITOR.

QUACK MEDICINES—THE DISCLOSURE OF
TRADE SECRETS.

To the Editor of The Medical Press and Circular.

Sir,—I f any further evidence be needed to prove
the necessity for an authoritative inquiry by a Royal
Commission or by any other equivalent means, into
the trade in “ proprietary articles,” it may be found
in the report under the above heading in The Times
of Monday, October 23rd. On Tuesday last Captain
R. Muirhead Collins, the representative of the Aus¬
tralian Commonwealth in London, received a depu¬
tation (introduced by Mr. K. B. Murray, of the London
Chamber of Commerce) of some twenty manufacturers
of proprietary medicines, to protest against the pro¬
posal that their wares should in future be made to
bear labels stating their composition. To assist the
Australian Government in eradicating harmful nos¬
trums the deputation expressed their willingness to
make a declaration that their articles do not contain
any of the drugs which may be prohibited, or any
deleterious drugs in quantities injurious to health.
The deputation was evidently composed entirely of
manufacturers engaged in the preparation of useful
articles, such as recognised vaneties of foods for in¬
valids and infants, disclosure of the composition of
which would evidently destroy legitimate trade secrets.
A declaration such as they proposed to supply would
undoubtedly meet their case, but such a declaration
would have no value, even if true, when emanating
from the deliberately fraudulent concocters of quack
nostrums and panaceas. It seems a pity that the depu¬
tation did not recognise this difficulty and suggest means
to dissociate themselves from a traffic which must be
as repugnant to them as to all honest men who are
acquainted with the facts. The majority of quack
medicines are virtually inert; few of them, whatever
their pretensions, contain anything more potent than
a small cheap purgative dose; whilst many' of them,
including cures for epilepsy, for organic kidney and
liver diseases, and for all surgical diseases, including
cancer, are nothing more than coloured and flavoured
water, perhaps with a few added grains of some com¬
mon drug; or, when in the form of ointments, made
up of cheap lard coloured and disguised, but lacking
any drug of recognisable potency. It is easy for the
proprietors of such compounds to declare that they
contain nothing harmful. The harm they do is by
inducing simple people, misled by cunningly-worded
lying advertisements, to rely upon them when their
disease is due to organic pathological activity. Func¬
tional dyspepsia may sometimes not be made much
worse by delay whilst reliance is placed upon some
“ liver ” or “ indigestion ” cure ; but delay in a case
of gastric ulcer (a very common occurrence among
the poor and ignorant) may lead to a disastrous ter¬
mination. A bogus heal-all ointment, disguised fat,
is harmless in itself, but cases often occur when a
wretched patient with some surgical disease, perhaps
cancer, which in an early stage was amenable to
operation, has allowed the malady to pass into a

,edbyU.OOQle

1 O

Oct. 30, 1907.

SPECIAL ARTICLE.

The Medical Press. 4 77

hopeless phase whilst trusting in the promises of cruel
and cynical knavery. These examples, as no medical
reader needs reminding, could be extended to vast
lengths. Suffice it to say that disclosure of the con¬
stituents of advertised quack medicines, and of the
structure of bogus apparatus, such as sham electric
belts and mechanical cures for deformity, or for deaf¬
ness, would demonstrate at once, not only to skilled
witnesses, but to cultured men of the world, that the
trade is merely a cloak for plunder, and ought to be
mercilessly suppressed. The trade in “baby quieters”
which seems to be enormous in Australia, and which
was specially denounced by Mr. Beale, would not be
stopped by a declaration such as the deputation sug¬
gested. Many of these mixtures are virtually inert
frauds; the harm is done by reliance upon them
instead of attention to the cause of the infant’s dis¬
quiet—nearly always improper food and feeding.
When baby soothing medicines contain narcotics and
anodynes, which perhaps cannot be classed as “drugs
injurious to health,” they help by masking the pain to
lead the infant towards death, or to survival as a
ricketty and “scrofulous” wastrel. They form, as
Mr. Beale pointed out, a potent contributory factor in
the prevailing preventible infantile mortality, and the
direct cause of death in large numbers of instances.

I am, Sir, yours truly,

Henry Sewill.

OBITUARY.

THOMAS MICHAEL DOLAN, M.D.Dubl., F.R.C.S.,
L.R.C.P.Ed., L.S.A., OF HALIFAX.

We regret to record the death of Mr. Thomas Michael
Dolan, of Halifax, which took place on the 22nd inst.,
after an illness of many months, at the age of sixty-
three. Deceased was a native of Cashel, county
Tipperary. His medical training was at Durham and
Steeven’s Hospital, Dublin. In 1869 he was appointed
medical officer of the Union Workhouse, a position he
retained to the time of his death, and in that office
assisted in the carrying out of several reforms, notably
the erection of special hospital wards and the substitu¬
tion of professional nurses for pauper attendants. He
was the author of several works on medical subjects.
One of these, published in 1878, was his “Rabies and
Hydrophobia.” In the hydrophobia competition for a
prize offered by Mr. V. F. Bennet Stanford, in 1879,
and open to all nationalities, Dr. Dolan sent in a
contribution so full of merit that, on the recommenda¬
tion of the adjudicators, the special prize of ^50 was
raised and awarded to him. He wrote a good deal on
life insurance, and in 1881 he secured a prize of ^100
in a competition on this subject instituted by the
Equitable Life Assurance Company of the United
States. The following year he obtained the Roylston
Prize, amounting to^oodols., for an essay on “Sewer
Gas: Its Physiological and Pathological Effects on
Animals and Plants.” and in the next year he won the
prize given by the Medical Institute of Valencia, Spain,
for his essay on “Heart Disease.” In recognition of
these successes his brother practitioners in Yorkshire
entertained him to a complimentary dinner. Dr. Dolan
wrote much in various medical journals on the question
of workhouse infirmaries and their medical service. In
1885 he undertook the editorship of the “Provincial
Medical Journal,” and continued as such until he
established the “Scalpel,” a medical periodical which
attained a high place. He became F.R.C.S. of Edin¬
burgh in 1879, and a Doctor Medicine of the University
of Dublin in. 1883.

WILLIAM HENRY DAY, M.D.St.And.,
M.R.C.P.Lond.

We regret to announce the death or Dr. William
Henry Day, M.D., late of Manchester Square, who
died on October 22nd, at Meopham, Kent, at the age
of seventy-six. After studying at Bristol and King’s
Lollege, London, he was admitted a member of the
Royal College of Surgeons (England) in 1854, took the
M.D. degree of St. Andrews in 1857, and ten years

later became a member of the Royal College of
Physicians (England). In the Crimean war he was
assistant-surgeon to “The Buffs.” He was a member
of several learned societies, had been secretary to the
Harveian Society, and was consulting physician to the
Samaritan Hospital for Women and Children. Dr.
Day was a considerable contributor to medical litera¬
ture, hi3 manual on “Diseases of Children” running
through two editions.

DEPUTY-SURGEON-GENERAL ROWLAND WIM-
BURN CARTER, M.D.Calcutta, M.R.C.S., L.S.A.

We regret to record that Deputy-Surg.-Gen. R. W.
Carter, of the Army Medical Staff, retired, died on
October 20th, at Southsea, in his 77th year. He was
admitted a member of the Royal College of Surgeons,
England, and a licentiate of the Society of Apothe¬
caries in 1854, and joined the Army Medical Service
the same year, serving with the 20th Regt. throughout
the Crimean Campaign of 1854-5, including the Battle
of the Alma, the siege and fall of Sebastopol, and the
capture of Kinbourn. He also took part in the Indian
Mutiny Camoaign of 1858, and was thanked by the
Viceroy and his Royal Highness the Commander-in-
Chief for his ability during the cholera outbreak in
India in 1859. He served in the Afghan War in
1878-80, receiving another medal, and retired in 1884
with the honorary rank of deputy-surgeon-general.

SPECIAL ARTICLE.

A DESTRUCTOR OF DISUSED TINS IN THE
TROPICS.

THOMAS MICHAEL DOLAN, M.D.Dubl., F.R.C.S.,
Acting Medical Offlcer of Health, Freetown, Gold Coast.

To anyone acquainted with the prominent position
occupied by old empty tin vessels in tropical sanita¬
tion, suggestions regarding improvement in the method
of their disposal will not appear unreasonable. The
subject, however, is so closely connected with hospital
sanitation that there need be no hesitation in intro¬
ducing it to the attention of medical readers. The
number of empty tins which have contained sardines,
potted meats, vegetables, cigarettes, oil, etc., etc., and
which will be found in the neighbourhood of houses
in the Tropics is almost incredible unless one has
witnessed it. Many of these tins when first discarded
are appropriated by small dealers and the native
poor, who in turn throw them away after some time
as useless.

In Freetown, Sanitary Inspectors' systematic visits
from house to house, street to street, result in most
of these tins being deposited in dust-bins, from whence
they are removed by the Sanitary Authority 10
“dumping grounds” as half-way houses, or to
“shoots ” for direct deposit in the sea. In other towns
remote from the sea the tins are usually buried in pits.
The chief sanitary objection in the Tropics to empty
tins being allowed to remain as rubbish, is due to
their capability of containing water ami so favour
mosquito breeding. If, then, every tin was crushed as
soon as it was empty of its original contents, its water-
retaining capacity would be almost entirely oblite¬
rated, and it would occupy less space in transport
and disposal, the latter being obviously especially
important if the disposal has to be by burial 1 . Inas¬
much as this crushing on the premises of the indi¬
vidual users would be extremely difficult to arrange
for, the next best thing seems to me to provide means
for crushing the tins at a “ dumping ground.” They
could be “ weeded out ” and so dealt with, while the
consumable (packing) material is burnt.

I propose a very simple form of crusher which
could be easily made in most urban localities, even
in the Tropics. It consists in a lever working on a
tripod stand; to the end of the short arm is attached
a weight which is raised by depression of the long
arm and allowed to fall on the tin placed on a nether
stone set in the ground. I have not seen this sugges¬
tion made for dealing with waste tins in the Tropics,

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478 The M edical Press.

MEDICAL NEWS IN BRIEF. _ Oct. 30, .907^

this distinction by examination, 27 were elected as
members of 20 years’ standing, 17 Fellows by election,
and one Fellow elected ad eundem. There are 17,544
Members, 398 Licentiates in Midwifery, and 2,111
Licentiates in Dental Surgery. The D.P.H. granted
by the Royal Colleges of Physicians and Surgeons is
held by 601. The income from all sources during the
year amounted to £24,3*6 17s. 8d„ the largest item
being derived from fees paid by candidates for the
diplomas of the College, ^15,219. The expenses for
the year amounted to £22,648, leaving a balance at the
bankers of £288 10s. rod. From the Librarian s report
it appears that the supply of books has been well
kept up during the past collegiate year. Early in 1907
a new library with an annexe was fitted up in proxi¬
mity to the gallery of the large library, affording
additional accommodation.

***

though it appears to me such an obvious proceeding
that I can scarcely believe it can be novel. 1 do not
suggest that bottles should be dealt with in the same
way.

LITERARY NOTES.

Messrs. Cassell and Co. announce a new illus¬
trated serial, “ Everybody’s Doctor, ” to be completed
in twenty-four parts at 7d. It promises to deal with
every kind of common ailment, and to provide com¬
mon sense information, and, where possible, plain
remedies. Medical men will have to look to their
laurels!

—

Dr. Seymour Taylor has issued a reprint of his
lectures on “ Acute Pneumonia.” The first deals with
the aetiology, symptomatology, prognosis, and complica¬
tions of pneumonia, and also refers somewhat fully to
the pathology of the disease. The second lecture is
devoted to the consideration of its treatment. These
lectures are interesting reading and give a systematic
account of the whole subject.

#**

The last monthly number of the Canadian
Journal of Medicine and Surgery is published
in connection with the meeting at Montreal of
the Canadian Medical Association. This number
is specially worthy of notice as not only con¬
taining several excellent original communications,
but also on account of the forty pages of half tone
illustrations showing views of hospitals, public build¬
ings, and places of natural beauty in various parts
of the country.

We have recently received a work, entitled “ The
Wife: Her Book.” It is written by Mr. Hadyn Brown,
L.R.C.P.,Edin., and published at 3s. 6d. net by
Messrs. Sisley’s (Ltd.). There is much that is good
and wholesome in the book, but its value is marred
by the introduction of unnecessary details on “ delicate
subjects,” and of nerve-harassing tales of servant girls
who gave birth to illegitimate children. Surely such
stories are not suitable reading for young expectant
mothers, or even for any woman, who may be ex¬
pected to buy a book of this nature.

***

Messrs. Robert Boyle and Son have issued a
booklet in which they plead for a natural system of
ventilation. The plea we imagine will not fall on
deaf ears. As we have often pointed out fresh air is
fresh because it is fresh, and not because it is strained
and filtered and sprayed and pumped. The complaint
usually made by those who live in rooms artificially
ventilated is that they feel heavy and stupid after a
few hours in the atmosphere provided ; which is not
surprising when it is considered that all freshness has
been taken out of the air. The problem of ventilation
is to provide houses with fresh air without draughts,
and not an atmosphere, of whatever degree of purity,
which has as little sparkle as boiled water.

***

From the Calendar of the Royal College of Surgeons
of England just published we learn that there are 1,387
Fellows on the roll of the College,of whom 1,341 obtained

“Royal Leamington Spa: Its Springs, Baths, and
General Attractions.” By John Murray Moore, M.D_,
M.R.C.S., F.R.G.S.. <Leamington Spa: Burgis and

Colbourne, Ltd., 1907.) The latest of the many
brochures written in praise of “leafy Leamington
is a well-intentioned, enthusiastic, and somewhat
egotistical but withal interesting and informing de¬
scription of the ways and waters and other delights
of this justly-favoured of our English inland health
resorts.

•••

The late Sir William Gairdner was the author of a
charming work on “The Physician as Naturalist,
but it has been chiefly left to the surgeons to found
museums which have served as permanent means for
the scientific study of Nature. Mr. Jonathan Hutchin¬
son is not only a surgeon of world-wide distinction,
but he is an enthusiastic clinician of the field as well
as of the ward, and has exemplified in many wavs
his far-seeing wisdom by providing for the needs of
the teacher and the requirements of the student in
the establishment of museums both in town and coun¬
try. Such a volume as that now before us [The Hasle-
mere Museum Gazette , edited bv Jonathan Hutchinson,
F.R.C.S., F.R.S., assisted by E. W. Swanton, Vol. L.
Bale and Sons) gives a glimpse into an encyclopaedia!
mind, and provides a storehouse of facts, a record
of observations, a fascinating realm of treasures, all
of which have lessons or suggestions. It is impossible
to indicate the varied and multitudinous items of in¬
terest in this volume. Here are astronomical and geolo¬
gical notes, anthropometric data, zoological descriptions,
sketches of marine botany, conchological illustrations,
pathological details, and much concerning man and
his doings. Such a wonderful collection of scientific
fragments is rarely brought within book covers. Mr.
Hutchinson in this book gives fresh evidence of his
virility and versatility.

Medical News in Brief.

Charge of Attemptod|AbortIon.

Joseph Tockert, 32, was indicted at the Central
Criminal Court, on October 22nd, for conspiring,
with Agnes Jane Taylor and another person unknown
to use on Taylor an instrument with intent to procure
abortion. Sir Charles Mathews, in his opening state¬
ment, said that Agnes Jane Taylor resided with her
husband at Beckenham. In the summer of 1906 Mr.
and Mrs. Taylor, who were then residing in another
neighbourhood, made the acquaintance of the prisoner.
I.i October of that year Mrs. Taylor made a com¬
munication to her husband, and subsequently left their
house without his knowledge. Subsequently Mr.
Taylor met the prisoner, and Mr. Taylor then informed
him of the communication which his wife had made
to him, which was to the effect that there had been
intimacy between them. About Easter in the present
year Mrs. Taylor made another communication to her
husband, in consequence of which Mr. Taylor wrote
to the prisoner. At an interview, Mr. Taylor told the
prisoner that his wife had gone to Lowestoft with
him under the impression that he was going to pro¬
vide a home for her. The prisoner replied that it was

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Oct. 30, 1907.

PASS LISi'S.

The Medical Press. 479

true that they had done so. Oa hearing that, Mrs.
Taylor, who had been In the room during the inter¬
view, went out, and returning a few minutes after¬
wards, told them that they were talking to a dead
woman, as she had poisoned herself. Mr. Taylor gave
her an emetic, sent for a doctor, and she re¬
covered. She had taken five grains of mor¬
phia. Early in September Mrs. Taylor be¬
came ill, and died. A post mortem examination
disclosed the presence of wounds, showing that an
illegal operation had been performed, which had set
up blood poisoning. The prisoner was arrested, and
said he knew nothing whatever about it. At the con¬
clusion of the evidence for the prosecution counsel
for the defence submitted that there was no case to
go to the jury. There was no evidence of any con¬
spiracy. Mr. Justice A. T. Lawrence said he did not
think that there was a case that it would be safe to
leave to the jury. The facts were quite consistent with
the defence that the woman got the operation per¬
formed without the prisoner's knowledge and against
his wish. He directed the jury to return a verdict of
not guilty. The jury found the prisoner not guilty.
Mr. White said the prisoner had been committed for
trial at the Maidstone Assizes upon the coroner’s
inquisition for the murder of Mrs. Taylor.

Society for the Relief of Widows and Orphans of Medical Mon.

At a quarterly Court of the above Society held
recently, Dr. Blandford, President, in the chair, one
new member was elected and the death of one was re¬
ported. It was decided that a Christmas present of
jC 544 be divided among the annuitants of the Charity,
each widow to receive £10, each orphan ^3 and the
orphans on the Copeland Fund ^5 each. Since the
last court a donation of /ioo had been received from
the executors of the late W. Catlin, Esq. Mr. Catlin
was elected a member of the Society in i860. Five
letters had been received from widows of medical men
who had ryot been members of the Society asking for
relief, but for this reason in each instance it had to
be refused, as relief is only granted to widows or
orphans of deceased members. Membership is open
to any registered medical practitioner, who at the time
of his election is resident within a 20-mile radius of
Charing Cross. Full particulars and application forms
may be obtained from the Secretary, at the offices of
the Society, 11, Chandos Street, Cavendish Square, W.
The Secretary attends there on Wednesdays and
Fridays from 4 to 5 should a personal application be
desired.

St. Vincent’s Hospital, Dublin.

The annual dinner of St. Vincent’s Hospital was
held in the Shelbourne Hotel on the 22nd inst. Dr.
McHugh presided. After dinner, the toasts included
“The King,” and “St. Vincent’s Hospital,” proposed
by the President; “ Our Past Students, ” proposed by
Dr. Cox, and replied to by Mr. Tobin ; “Our Guests,”
proposed by Mr. McArdle, and replied to by his
Honour the Recorder of Dublin, Dr. Magee Finny, and
Dr. McWeeney. The dinner was well attended and
excellently served.

PASS LISTS.

Royal College of Physicians of Edinburgh, Royal College of
Surgeons of Edinburgh, and Faculty of Physicians and
Surgeons of Qlasgow.

The quarterly examinations of the above Board, held
in Edinburgh, were concluded on 22nd inst., with the
following results: —

First Examination, five years’ course.—Of 31 can¬
didates entered the following seven passed the exami¬
nation James Macrae, Caithness; Harold L. de
Jorges Garland, Oamaru, X.Z. ; Haripado Chatterjee,
Calcutta; Ruttonbai Nazir, Bombay; Kathleen Reed,
Calcutta; Thomas Hardie. Glasgow; and Tohn R.
Fleming, Airdrie; and five passed in physics, and
one in chemistry.

Second Examination, four years’ course.—Of two
candidates entered one passed the examination, viz.,
Adeline M. Watts, Travancore.

Second Examination, five years’ course.—Of twenty-
seven candidates entered the following nine passed

i the examination:—Bickford J. Hattam, Melbourne
| (with distinction) ; William M. Thomson, Lisburn;

; Herbert C. Bankole-Bright, West Africa; Henry
I E. K. Fretz, St. Kitts; Conrad J. Arthur, Grenada;

: Ulick J. Bourke, London; Charles K. Carroll, India;
John W. Robertson, Edinburgh; and William G.
Forde, Co. Cork; and three passed in physiology.

Third Examination, five years’ course.—Of twenty,
nine candidates entered the following sixteen passed
the examination:—William T. Lawrence, New York •
Millicent V. Webb, Warwick; William G. Forde, Co’.
Cork; Michael Mulrain, Trinidad ; Sakharam
Bhagwat, India; William Grant, Arbroath; Shiv-
narain Rozdon, Simla; Ian MacLeod, Scotland;
Dakshina R. Das Gupta, Calcutta; Hugh S. W
Roberts, Wales ; Charles W. Kay, Lucknow ; John J.
Huston, Ireland ; Martin Renters, Manchester; Helen
Y. Campbell, Natal; Clement H. Heppenstall, Lin¬
coln ; and Framroz M. Vajifdar, Aden; and one
passed in pathology, and two in materia medica.

Final Examination.—Of eighty-six candidates en¬
tered the following thirty-three passed the examination
and were admitted L.R.C.P.E., L.R.C.S.E., and
L.F.P. and S.G. Shanker P. Gogte, India; Oscar
A. McNichol, Canada; Cecil Berry, Wigan ; Surendra

K. Sen, India; Lionel W. Bradshaw, Wakefield;
Helen Y. Campbell, Natal; Horace J. Williams,
L .S.A. ; Charles A. Ritchie, Nova Scotia; Alban

L. B. Best, Melbourne; Frederick B. Elwood, Bel¬
fast ; Leo Murphy, Midleton; Charles Nyhan, Drom-
garriffe; Samuel T. White, Canada; William P.
Dillon, Canada; Osier M. Groves, Canada; Arthur
Saldanha, India; Percival T. Rutherford, England ;
Roderick McLennan, Australia; Graham Smith, Ash¬
bourne ; Bandla R. Naidu, India; Carunguli S.
Mudali, Madras; Crichton R. Merrillees, Australia;
George S. Williamson, Scotland ; David D. McNeill,
Orkney; Ronald Wingrave Duncan, Edinburgh;
Claribel F. van Dort, Ceylon; James S. R. Weir,
Ireland; Shivshankar R. Soneji, Bombay; Walter
Damms, Sheffield; Henry F. Collins, Madras; John
A. H. Muller, India; Vinayak S. Sanzgiri, Bombay;
and John Miller, Scotland ; and eight passed in medi¬
cine and therapeutics, two in surgery and surgical
anatomy, ten in midwifery, and ten in medical juris¬
prudence.

The following candidates having passed the requisite
examinations of the Conjoint Board in October were
admitted Diplomates in Public HealthWilliam H.
E. Brand, Banchory; Douglas Bell, Barrow-in¬
i' urness ; John Hunter, Cockburnspath; Hubert J.
Norman, Winkleigh; Alexander C. B. McMurtrie,
Edinburgh; John Ritchie, Edinburgh; William A.

Wllson-Smith, Duns; Alice M. Burn, Edinburgh;
Agnes J. Gardner, Edinburgh; Rose Hudson, Edin¬
burgh; Ethel Wiseman, Edinburgh; John McKenzie,
I^eith ; Sohrab M. Plodiwalla, Edinburgh ; and Thomas
R. Smith, Edinburgh.

At the same Sederunt the following gentlemen
passed the first examination in public health David
J. Roberts, Carnarvon; John N. Meade, Caithness;
James S. Edwards, Edinburgh ; Mark S. Fraser, Edin¬
burgh ; Alfred B. Darling, Edinburgh; and William
J. MacKinnon, Biggar.

Trinity College, Dublin.

During Michaelmas Term, 1907, the following can¬
didates passed the Intermediate Medical (Part I.) Ex¬
amination :—David L. M'Cullough, Euphon M Max¬
well, Charles W. M'Kenny, Richard H. Mathews,
Henry H. James, Walter F.. Adam, John Gardiner,
Hans Fleming, William M. Johnstone, Samuel R
Richardson, Francis J. A. Keane, Victor W T
M‘Gusty, Robert V. Dixon, and C.ervase W. Scroope.

Previous Dental Examination.—rhysics and Chemis-
try, Arthur A. Smith; Anatomv and Institutes of
Medicine, James I. Kelly; Materia Medica, Tames I
Kelly and Ernest S. Friel.

Apothecaries’ Society of London.

The following candidates, having passed the neces-
sary examinations, have been granted the L.S.A
Diploma, entitling them to practise medicine, surgerv
and midwiferyH. J. W. Barlee, A. G. Gamble,’
t.. G. Grey, and L Wharton.

Digitize.

480 The Medical Press.

WEEKLY SUMMARY.

Oct. 30, 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT PATHOLOGICAL LITERATURE.

Liver Cirrhosis in Children, following Scarlatina.—

Latterly considerable importance has been attached,
especially by the French physicians, to the aetiological
r 61 e played by the infectious diseases in the production
of cirrhosis of the liver in children. Bi'ngel (Jahrb.
fur Kinderheilk ., h 65, S 393), now refers to several
fatal cases of scarlatina in children, in whom the liver
was investigated, and in all of which there was found
more or less well marked small round celled infiltra¬
tion of the periportal tissue. Here and there also
there were found patches of necrosis and of cloudy
swelling of the liver cells. The further fate of these
necrotic areas has been found to consist in a gradual
replacement by connective tissue, and the con¬
sequent establishment of a genuine cirrhosis. Slight
evidence of regeneration of cells was also obtained in
the presence of very large multinucleated liver cells at
the periphery of the necrosed patches, while a large
increase in the number of the smaller bile ducts was
also noted. M.

Deposition of Fat and Fatty Acids in the Intestinal
and Mesenteric Lymphatic Tissues. —Whipple (Johns
Hopkins' Hosp. Bulletin, September, 1907, p. 382)
writes of “A Hitherto Undescribed Disease”
characterised anatomically by the lesions indicated
above. The patient was a man, aet. 36, who had been
perfectly healthy up to five years previously, when,
on going abroad, he began to suffer from pains in the
joints, which were very persistent, and from chronic
cough. This condition lasted for about four years,
and then a chronic diarrhoea became established, with
some swelling of the abdomen. The motions were
found to contain enormous numbers of fatty acid
crystals, and to be white and creamy in appearance.
The blood was practically normal, as was the urine,
till shortly before death, when some acetone was
detected. There were no tubercle bacilli in the
sputum, and no re-action followed the injection of
tuberculin. A laparoromy was performed, and the
mesenteric glands were found to be greatly enlarged,
but no attempt could be made to deal with them.
Shortly afterwards death occurred with all the
symptoms of acetonaemia. At the autopsy the mesen¬
teric glands were found to be greatly enlarged and
somewhat elastic to the touch, of an opaque pale
yellowish colour, and containing in little cyst-like
pockets small yellowish granules. Microscopically
these granules were composed of fat globules and
numbers of long acicular fatty acid crystals. Numerous
giant cells were seen, and a general increase of the
connective tissue stroma. The villi of the small
intestine were enlarged, the epithelial lining being
normal, and the submucous tissue being swollen and
packed with deposits of fat and fatty acids similar to
what were found in the glands. A peculiar cell with
abundant foamy protoplasm and a pale vesicular
nucleus was found in both glands and intestinal
mucosa. Numerous other changes were found in the
remaining viscera, but nothing specially characteristic ;
some sections of the glands stained by the Levaditi
method demonstrated the presence of a peculiar rod¬
shaped organism which did not stain by the aniline
dyes. The writer discussing the case concludes that
the symptoms were due to some obscure disturbance of
fat metabolism, but of what exact nature it is as yet
impossible to say. He suggests the name Intestinal
Lipodystrophy as the one at present most applicable to
the condition. M.

The Pathology ol Acute Lymphocythaemia.—

Dudgeon and others give an account (Journal of Path,
and Bad., January, 1907) of the pathological changes
found in three cases of acute lymphocythasmia occur¬

ring in young adult males. The most striking feature
in each case was the leucocytic infiltration of the
various viscera, the vast proportion of the cells met
with being large and small lymphocytes. Mitosis in
the lymphocytes was observed, but not to any marked
extent; and coarsely granular eosinophil cells were
almost entirely absent. This change was even notice¬
able in the bone-marrow, in which over 95 per cent, of
the cells present were of the non-granular type. No
free iron was found in any of the viscera. The red
cells of the blood were much diminished in number,
and in one case a large number of nucleated red cells
were found. The white cells were increased, and the
total number steadily increased as the disease pro¬
gressed. Some fine fatty change was present in the
viscera of one case. Microscopically numerous
capillary htemorrhages were found scattered throughout
the body: the spleen was enlarged in every case, and
in one instance contained several infarcts ; the lymphatic
glands were universally enlarged and in one case
somewhat softened; the thymus gland was greatly
enlarged in two cases. M.

The Foetal Circulation Through the Heart.—

Pohlmann reviews the more important theories dealing
with this subject (Johns Hopkins' Hosp. Bulletin,
October, 1907, p. 409). These he points out are three
in number, viz.—(1) Sabatiers’ theory that the currents
of blood in the right auricle cross one another, that
of the inferior vena cava being directed to the foramen
ovale, and that of the superior vena cava entering the
right ventricle. This he characterises as physically
impossible, morphologically inaccurate and develop-
mentally unnecessary. (2) Wolff’s theory that the
blood of the superior vena cava entered the right
ventricle, and that that of the inferior vena cava was
evenly distributed between the two ventricles. (31
Harvey’s theory that the blood from the two vense
cavas became mixed in the right auricle, and that the
mixture was then distributed to both ventricles. This
theory the writer believes to be the most correct, and
to accord best with the results of his own investiga¬
tions. He obtained experimentally answers to the
following queries:—(1) Do both ventricles expect the
same amount of blood? This was answered in the
affirmative. (2) In what proportion does the inferior
vena cava return blood to each ventricle? The answer
to this was that it returned it in equal amounts to
both ventricles. This result favoured both Wolff s
and Harvey’s view, but the answer to the third question
(3) in what proportion does the superior vena cava
return blood to both ventricles? decided finally in
favour of Harvey’s view, by showing that blood from
that vessel was found evenly distributed in the out¬
flow from the two ventricles. M.

The Wood-Tick and Spotted Fever. —Our knowledge
of the relation of insects to the spread of disease is
constantly growing, and Ricketts (Journal of the
American Medical Association, October 12, 19071 adds
to that knowledge by the report of his experiments on
the relation of the wood-tick of the Rocky Mountains
to the spotted fever of Montana. He comes to the
following conclusions:—(1) Infected ticks exist in the
known infected districts. {2) Both the adult male and
the adult female may acquire the disease by feeding
on an infected animal, and may transmit it to a
normal susceptible animal for a period of several
weeks thereafter. (3) During either of its intermediate
active stages, larval or nymphal, the tick may- acquire
the disease in the same manner, retain it during
moulting, and prove infective when it reaches the
subsequent active stage. (4) The infected female may-
transfer the disease to the young through the egg

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(5) The virus exists in both the salivary glands and
the intestine of infected ticks at a certain time; as
it also invades the female generative organs, the con¬
dition is probably one of generalised infection. The
disease is not highly destructive to the tick. Ricketts
concludes by urging the destruction of the tick in the
infected districts by the same means as have been
found effective in dealing with the cattle-tick of the
Southern States. R.

The Pathology of Chorion-Epithelioma. —Schmauch
( Surgery, Gynacology, and Obstetrics, September, 1907)
enters a protest against the current view of the patho¬
logy of chorion-epithelioma. He regards this condi¬
tion not as a true neoplasm, but as what he terms a
‘ cellular infection.” By this he appears to mean an
invasion of the maternal tissues by certain of the cells
or tissues o>f the placenta-villi or syncytium or both.
In some cases this invasion is very slight in degree,
and does not transgress the uterine mucosa, whereas
in others it may infiltrate the uterine wall, or even give
rise to emboli and metastases irt the lung. The question
whether the epithelial cells thus transplanted or
misplaced will be able in any given case to proliferate
or not depends on the reaction between them and the
tissues into which they stray. It is impossible by
microscopic examination of one nodule of the growth
to decide whether it is a harmless embolus or part of
a generalised metastasis. “There is only a gradual
difference,” says the author, “between the simple
invasion of the uterine muscles by villi and their
sequelae, such as adherent placenta, the common and
destructive placentary polyp, and the common and
destructive mole; between the localised chorion-
epithelial growths, limited to the uterus and placental
region, and the villous infarcts, developed by deporta¬
tion of villi; and finally between those cases in which
the lungs were able to retain and master the scattered
fetal cells (mostly syncytial and atypical forms), and
the typical chorioepithelioma malignum, which
becomes generalised through general metastases. Only
the latter two types deserve the name of malignant
chorioepithelioma.” The practical conclusion the
author comes to is that the malignancy of so-called
chorion-epithelioma is to be judged, not by micro¬
scopic examination of part of the growth, but by the
general clinical symptoms. This view is upheld by
analysis of a large number of cases. We are not able
to distinguish, we confess, between what he terms
“ cellular infection ” and neoplasm, in the absence of
knowledge of the fundamental pathology of neoplasms.
A neoplasm may very well be, in the widest sense,
a cellular infection. This point, however, does not
tell against the view that there are all degrees of
chorion-epithelioma from the perfectly innocent to the
definitely malignant. R.

Tumours of the Bladder. —Mandlebaum ( Surgery,
Gynacology, and Obstetrics, September, 1907) furnishes
a valuable paper on the pathology of tumours of the
bladder. He divides tumours of the bladder into three
groups:—(1) An epithelial tissue group, including
papilloma, carcinoma, adenoma, and cysts. (2) A
connective tissue group, including fibroma, myxoma,
and sarcoma. (3) A muscle-tissue group, the myomata.
Primary bladder tumours comprise about 0.7 per cent,
of all tumours, and of bladder tumours 90 per cent,
occur in males. Of the epithelial tumours 65 to 75
per cent, are malignant. McKenna gives a careful
description of the histology of the various forms, which
does not differ, however, from the usual description.
He notes that papilloma of the bladder not uncom¬
monly passes into carcinoma. The distinction can
only be made with certainty by the aid of the micro¬
scope, though a papillary tumour which is tightly
bound to the bladder wall may with certainty be
pronounced carcinoma. Microscopically, the transi¬
tion shows itself by a proliferation of the epithelium
into the stroma, while at the same time it loses its
typical arrangement. When squamous celled carcinoma
occurs in the bladder, it is due, says the author, to a
metaplastic formation of squamous epithelium, the
result of chronic inflammation. He has examined five

SUMMARY. The Medical Press 481

cases of scirrhus of the bladder, four of which, how¬
ever, were secondary to tumours of the prostate. In
two cases of adeno-carcinoma the disease was also
secondary to disease of the prostate. The author holds,
however, with Limbeck that glands may and do occur
in the bladder, and that primary adeno-carcinoma of
the bladder has been found. Cysts of the bladder are
uncommon, and are said to originate from glands or
to be the result of congenital defects connected with
the urethra, the Wolffian bod}-, or Gartner's duct.
Myxoma occurs mostly in childhood, and in structure
resembles the ordinary nasal polypus. An interesting
case of endothelioma infiltrating the base of a
papilloma is described. R.

Anomaly of the Coeliac Axis. —McKenna reports
(Surgery, Gynacology, and Obstetrics, September, 1907)
an anomaly of the coeliac axis of some importance to
surgery. The usual division of the vessel into gastric,
splenic, and hepatic arteries maintains, but the hepatic
artery runs directly into the gastro-duodenal, giving
only a rudimentary branch to the liver. The gastric
artery, normally the smallest of the three, is large and
gives off the large branches which supply the liver.
The surgical importance of the condition lies in the
fact that in resecting a part of the stomach, some
operators are in the habit of doing a preliminary
ligation of the gastric artery. If the latter should be
supplying the liver, the results would be disastrous,
since the arteries of the liver are terminal. It would,
therefore, be well for surgeons, before tying the gastric
artery, to examine the hepatic vessel. R.

Diphtheroid Organisms in General Paralysis.—

Candler (British Medical Journal, September 28, 1907),
from the result of his own experiments, criticises the
findings of Ford Robertson as to the presence of
diphtheroid organisms in the blood, fluids, and tissues
of general paralytics. He examined the blood, cerebro¬
spinal fluid, respiratory, alimentary, and genito¬
urinary traces of the cadaver ; the urine and urethras,
and the blood and cerebro-spinal fluid during life.
The total number of cases examined was 223, 82 of
which were cases of general paralysis, and 131 of other
forms of insanity. The incidence of diphtheroid
organisms in general paralysis was 12.2 per cent., while
in other forms of insanity it was 8.4. The highest
individual percentage of organisms occurred in the
urethras of general paralytics, viz., 16 per cent., com¬
pared with 13.6 per cent, in other forms of insanity.
The number of cases being small, the statistics cannot
be regarded as giving trustworthy results. The
examination of the blood and cerebro-spinal fluid was,
however, entirely negative. In no single instance was
a diphtheroid bacillus observed either in smear or in
culture from the blood or cerebro-spinal fluid. The
examination of post-mortem material Candler regards
as very unsatisfactory, owing to the rapidity with
which all sorts of organism invade the tissues after
death. Moreover, the presence of diphtheroid
organisms on the mucous surfaces of perfectly healthy
people is by no means rare, and the greater frequency
with which it has been found in general paralytics is
insufficient to justify any conclusion as to causal
relation. R.

Primary Cancer of Vagina with Auto-Inoculation.—

Wilson (British Medical Journal, September 28, 1907)
records a case of the rare disease—epithelioma of the
vagina, with the rarer phenomenon of auto-inoculation
or contact infection. The disease was present in the
shape of two ulcerating patches, one on each side of
the entry of the vagina. By the microscope they were
found to be exactly similar in structure, conforming
to the most common type of cancer of the vagina—the
squamous celled. The spread from one side to the
other is best explained as auto-inoculation or contact
infection or implantation. Similar metatasis from one
labium to the other has been recorded more than once,
and implantation in the vagina of adeno carcinoma of
the uterus has also been recorded. R.

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482 The medical Press. NOTICES TO CORRESPONDENTS.

Oct. 30, 1907.

NOTICES TO
CORRESPONDENTS,

ffc.

tm- Corbmpondexts requiring a reply in this oolumn are par¬
ticularly requested to make use of a Distinctive Signature or
Initial , and to avoid the praotioe of signing themaelvea
" Reader,” “ Subscriber," " Old 8ubaoriber,” eto. Muoh con¬
fusion will be spared by attention to this rule.

SUBSCRIPTION 4.

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each year begin on January 1st and July 1st respectively. Terms
per annum, 3ls. j post free at home or abroad. Foreign sub¬
scriptions must be paid in advance For India, Messrs. Thacker,
Spink and Co., of Calcutta, are our officially-appointed agents.
Indian subscriptions are Its. 15.12.

ADVERTISEMENTS.

Fob On* Insertion:—W hole Page, £5; Half Page, £2 10g.;

Quarter Page, £1 5s.; One-eignth, 12s. 6d.

The following reductions are made for a series:—Whole Page, 13
insertions, at £3 10s.; 26 at £3 3s.; 52 insertions at £3, and
pro rata for smaller spaoes.

Small announcements of Practices, Assistanoies, Vacancies, Books,
Ac.—8even lines or under (70 words), 4s. 6d. per insertion;
6 d. per line beyond.

Rbfbiktb.—R eprints of artioles appearing in this journal can
be had at a reduoed rate, providing authors give notioe to the
Publisher or Printer before the type has been distributed. This
should be done when returning proofs.

M.R.C.S.—Atropine was first recommended by Trousseau in
the treatment of asthma. In some cases it acts most beneficially,
and has even effected permanent relief. But there is no certainty
as to its results.

Enquirer. —Your letter shall reoeivo an early answer.

Pensator.— We cannot express an opinion upon the case
without knowing more of the facts. If our correspondent will
communicate further wirh us we will endeavour to advise him.
The position, we gather, is an involved one. but whether the
ethical point raised can be maintained or not is apparently
doubtful.

CURE-I-CAN COMPANY.

The following note from the Financial Netce is not without
a certain interest and significance of its own. Company regis¬
tered by Jordan and Sons, Limited, 120, Chancery Lane, W.C.
£20,000 (£1). To acquire the business of preparing and selling
•'Cure-I-Cnn ” ointment carried on by R. K. Hull, F. W. Daw¬
son, E. Bush, and P. Macdonald, at Leicester, as the Macdonald
” Cure-I-Can ” Company. No initial public issue. First directors
(not lees than three nor more than seven): R. K. Hull, F. W.
Dawson, E. Bush, nnd P. Macdonald. Qualification (except P.
Macdonald, who requires none), £1,000. As fixed by oompnny.

Student.— The alcohol question, just like vivisection and vac¬
cination nnd other debatable subjeots, will never be settled by
argument. Statistics improperly used can always be mnde to
prove nnything.

Mr. R. Stewart. —We shall be pleased to give space to a
reply to our correspondent.

Dr. Adolf Erdos.—W e have made inquiries, and find a com¬
pany which will. We are communicating with you privately,
enclosing prospectus^^^ Qp ^

A writer in the Journal of Health of Paris geeks to plan out
the course of life ns follows:—First year—infantile complaints
and vaccination; second year—teething, croup, infantile cholera,
nnd convulsions; third year—diphtheria, whooping-cough, and
bronchitis; fourth year—scarlatina and meningitis; fifth year-
measles. By now half the children are dead. The others live
on as follows: Seventh year—mumps; tenth year—typhoid; six¬
teenth year—chlorosis and spinal irritation; eighteenth year-
neurasthenia; twentieth year—cephalalgia, alcoholism, and ver¬
tigo; twentv-flfth year—marriage (considered, presumably, as a
disense). In the twenty-sixth year—insomnia; thirtieth year-
dyspepsia and nervous asthenia; thirty-fifth year—pneumonia;
forty-fifth year—lumbago and failing sight; fifty-fifth year-
rheumatism and baldness; sixtieth year—amnesia, loss of teeth,
hardening of arteries; sixty-fifth year—apoplexy; seventieth yenr
—amblyopia, deafness, general debility, loss of tone in the diges¬
tive ogans, gouty rheumatism. For the seventy-fifth year is
given death— i . e ., if there is any body left alive.

Jamaica.— It is rather beyond our ken to -ay whether there
are any hospitals in British Colonies solely officered by coloured
doctors and nurses without reference to any European, but we
imagine this may be the case in some of the more unhealthy
Colonies. It may, however, be a point to refer to the emergency
hospital which was exhibited last May at Jamestown (Virginia)
at the celebration of the tercentenary of the landing of Captain
John Smith. This hospital had negro dootors and nurses en¬
tirely, and was provided with the most up-to-date fittings of
every description.

Jfoetings of the gtirielies, ICeetures, &c.

Wednesday, October 30th.

Medical Graduates' Colleoe and Polyclinic (22 Chenies
Street, W.C.).—4 p.m.: Mr. H. L. Barnard: Clinique. (Surgical.)
5.15 p.m.: Lecture: Mr. T. Collins: Myopia.

North-East London Post-Graduate College.— Cliniques : —
2.30 p.m.: Medical Ouf-patient (Dr. Whiphnm); Dermatological
(Dr. G. N. Menchen); Ophthalmological (Mr. R. P. Brooks).

Thursday, October 31st.

Harveian Society of London (Stafford Rooms, Titchborne
Street, Edgware Rond, W).—Papers:—Dr. B. H. Spilsbury: Lym-
phntism in Relation to Death under Ann-sthcties. Dr. S. Phillips
and Mr. G. French: Cases of Lymphntism.

Medical Graduates' Colleoe and Policlinic (22 Chenies
Street, W.C.).—i p.m.: Mr. Hutchinson: Clinique. (Surgical.)

5.15 p.m.: Lecture:—Mr. E. W. Brewerton: Sympathetic Oph¬
thalmia.

North-East London Post-Graduate College.— 2.30 p.m.:
Gynaecological Operations (Dr. Giles). Cliniques:— Medical Out¬
patient (Dr. Whiting), Surgical Out-patient (Mr. Carson), X-Ray
(Dr. Pirie). 3 p.m.: Medical In-patient (Dr. G. P. Chappelli.
4.30 p.m.:—LectureMr. H. W. Carson: Surgical Disorders of
Digestion.

St. John’s Hospital fob Diseases or the Sein (Leicester
Square, W.C.).—6 p.m.: Chesterfield Lecture:—Dr. M. Dookrell:
Seborrhoea and Psoriasis dealt with as Stages of the same Der¬
matitis in Symptoms, Diagnosis, and Treatment.

Hospital fob Sick Children (Great Ormond Street, W.C.).—
4 p.m.: Lecture:—Mr. Comer: The Irreducible Inguinal Hernia;
of Female Children.

Friday, November 1st

West London Medico-Chiruboical 8ociett (West London
Hospital, Hammersmith Road, W.).—8.30 p.m.: Clinioal Meeting.
Cases will be shown at 8 p.m.

Medical Graduates' Colleoe and Polyclinic (23 Chenies
Street, W.C.).—4 p.m.: Mr. C. A. Parker: Clinique. (Throat).

North-East London Post-Graduate College. —10 a.m.:
Clinique: —Surgical Out-patient (Mr. H. Evans). 2.30 p.m.:
Surgical Operations (Mr. Edmunds). Cliniques:—Medical Out¬
patient (Dr. Auld), Eye (Mr. Brooks). 3 p.m.: Medical In¬
patient (Dr. M. Leslie).

Great Northern Central Hospital (Holloway Road, N.).—
3 p.m.: Clinical Lecture:—Dr. Horder: Some Points in Con¬
nexion with Oral Sepsis (Illustrated).

Central London Throat and Ear Hospital (Gray'* Inn Road.
W.C.).—3.45 p.m.: Demonstration:—Mr. Stuart-Low: Middle F.ar
nnd Labyrinth.

JtppoitttmenTf.

Dinole, Percival A., L.R.C.P.Lond., M.R.C.S.. Medical Radio¬
grapher to the North-Eastern Hospital, Huckuey Road.
Hatherell, Robert Ratclifpe, M.R.C.S., L.8.A., Medical

Officer and Public Vaccinator for the Topsham District by
the St. Thomas's (Exeter) Board of Guardinns, and also Cer¬
tifying Surgeon under the Factory and Workshop Act for the
Topsham District of the counry of Devon.

McCollum, J., M.B., Pathologist 1o the City of London Hospital
for Diseases of the Chest.

Pratt. J. H., M.R.C.S., L.R.C.P.Lond., House Physician to the
City of London Hospital for Diseases of the Chest.

ItantcxtB.

King Edward VII. Sanatorium, Midhurst, Sussex.—Pathologift.
Salary, £250 per annum, with board, lodging, and attendance.
Applications to the Hon. Secretary, 19 Devonshire Street,
Portland Place. W.

Carlisle Non-Provident Dispensary.—Resident Medical Officer.
Salary £150 per annum, with apartments (not board). Appli¬
cations to the Honorary Secretary, Mr. G. A. Lightfoot, 23.
Castle Street, Carlisle.

Leicestershire and Rutland Asylum.—Junior Medical Officer.
Salary, £130 per annum, with board, lodging, and washing.
Applications to W. J. Freer, Esq., 10 New Street, Leicester.
Down County Infirmary.—House Surgeon. Salary, £60 per
annum, with board, etc. Immediate application to Dr. Tate,
Infirmary House, Downpatrick. (See Advt.)

House of Recovery and Fever Hospital, Cork.—Junior Assistant
Resident Medical Officer. Salary, £50 per annum, and board.
Applications to John Marshall Day, Medical Superintendent.
(See Advt.)

Rovnl National Hospital for Consumption for Ireland.— Resident
' Medical Officer. Salary, £300 per annum, with house. Appli¬
cations to Hon. Sec., 13 South Frederick Street, Dublin. (See

Advt.)

Births.

Gould.— On Oct. 24th, at Castle Hill House, Shaftesbury, the
wife of Harold Utterton Gould, M.B., B.C.. of a son.
Gbeenf..— On Oct. 21st, at 124 Crossbrook Street, Cheshunt, the
wife of William A. Greene, M.R.C.8., of a son
Haines.— On Oot. 23rd, at Winfrith, Dorset, the wife of Frederick
H. Haines, M.RC.S., L.R.C.P., D.P.H., of a daughter.
Horder —On Oct. 19th, at 141 Harley Street, London, the wile
of Thomas J. Horder, M.D., F.R.C.P., of a dnughter.

JHarriagcs.

Dawson—Platt.—O n Oct 22nd, at St. Anselm's. Davies Street
London, George W. Dawson, F.R.C.S.I., of Portman Street,
to Amy Melliar, widow of Frederick Platt, of Barnby Manor,
Newark, nnd eldest daughter of the late Rev. P. O. Warn,
vicar of Braughing, Herts.

Gwtn.n—Downward.— On Oct. 22nd, at The parish church, Whit¬
church, Salop, Charles Henry Gwynn, M.D.. to Caroline
Mary Downward, only daughter of the late John Downward.

Es<| <

Moss— Parker.— On Oct 24th, at St. Thomas’ Cathedral. Bom-
bav. Edward L. Moss, R.A.M.C., only son of the late Mwara
L.' Moss, F.R.C.8.I., staff-surgeon R.N., to Eileen Emily,
younger daughter of Colonel Parker. R.E., retired.

BeathB.

Dat.—O n OcT. 22nd, at Meopham, Kent. William Hcniy Day.

M.D., late of 10 Manchester Square, London, aged 76-
Hodo80\. —On Oct. 21st, at Malvern Wells, in his 90fh year.
William Pritchit Hodgson, M.R.C.S.E., L.8.A., late TJra

Lightfoot —On Oct. 23rd. at Trevor House, Leyburn, John Parker
Lightfoot, M.R.CB., L.B.C.P.. aged 39.

by Google

The Medical Press and Circular.

“SALUS POPULI SUPREMA LEX."

Vol. CXXXV.

WEDNESDAY, NOV. 6 , 1907.

No. 19

Notes and Comments.

In an interview with “ General ”
Materialism Booth, some few months ago, the
v. great Salvationist was asked whom

Medicine, he considered the most dificult people
to convert. We feel a little ashamed
to say that he did not show much hesitation in re¬
plying “ Doctors; and nurses next.” Apparently,
therefore, medical men are not only obdurate to the
“General’s ” arguments, but they infect their subor¬
dinates with their disbelief. It is, of course,
impossible either to prove or to rebut such an
indictment, but it is a great pity that good people
do not leave medical men to enjoy that liberty of
conscience which is one of the greatest blessings of
the realm. A religious contemporary deplores the
fact that “ medical science appears more than ever
inclined to find a physical basis for moral qualities
—a statement which seems to show that the organ-
in question has less grasp of the relativity of mind
and matter than even medical scientists themselves.
And that, alas, is little enough. But perhaps if there
is one prominent factor in the situation, it is the
almost complete extinction of the old materialism,
which is as rare as the old unbridled individualism
of the type that opposed the Factory Acts on the
ground of their interference with the liberty of
trade. Exact scientific knowledge of the body may
keep medical men from falling into the extravagant
idealism of Christian Science, but it equally does not
land them in the morasses of Kraft und Stoff.

It is not often that one has the
.. . pleasure of recording practical evi-
Medlcal r « r •« - -:— ——

Thrift.

dence of the growing popularity of
orthodox medicine in the community,
but there was an announcement in
the papers last week which shows appreciation in
a quarter in which it was little expected. “ Burg¬
lars,” it ran, “have broken into South African
Institute of Medicine, at Johannesburg, and stolen
a quantity of medicine.” We do not remember ever
having seen crime take this particular form before,
but we may congratulate ourselves that in these
davs of “ therapeutic nihilists,” when even the most
cherished beliefs of our forefathers are called in
question, the virtues of drugs still exercise a strong
hold on the imagination of the Bill Sykes of South
Africa. We would that more detailed information
had been furnished, as it would have been interest¬
ing in the extreme to learn how the robbers
disposed of their plunder. Did they devote them¬
selves to an orgy of calomel and castor oil? Or did
they merely select a few items of arsenic and prussic
acicl for their inconvenient friends? We must
await the verdict of history on these questions, but,
in the meantime, we are inclined to fancy that the
pursuit of pharmacological experiment must have
thrown its spell over them, as it does over the eager
youths who are induced to enter at the medical
schools in the month of October.

It will be impossible in the future
for any medical man to sing, without
Flower severe scientific reservations,

Cure. “ The flowers that bloom in the

spring, tra-la,

Have nothing to do with the case.

It appears, indeed, likely that they will have a great
deal to do with the case, that is, if it be one of
insanity. The discovery of the therapeutic value of
flowers have been made at the very’ appropriately
named “ Bloomingdale ” Institute for the Insane,
White Plains, U S.A. Rows of lovely sweet-
smelling flowers are placed in rich profusion before
the inmates of that asylum, and it is found that the
weaker their minds the stronger the influence of the
flowers upon them. A few sniffs and a gaze or two
have an astonishing effect; paroxysms are calmed,
violence evaporates, and philosophical discourse re¬
places the incoherent mutterings of mania, btatis-
fics as to cures and as to their permanency are not
vet obtainable ; perhaps the flower treatmenthas not
been sufficiently long on trial; but probabty by the
time they are forthcoming'the Americans will have
discovered something even more efficacious, and
the figures will be no longer needed. At least the
craze-we should say treatment—is harmless, so.
long, that is, as the flower-pots are not used as
weapons of offence, and as evidence of humanity
to the insane we are glad to hear of it. What we
should like even more to hear is that some steps ot
a very drastic nature had been taken to make im¬
possible the shocking barbarities lately r ®P° r ^‘
with regard to the way the insane are treated in the.
reputedly civilised State of Illinois.

The transition from a flower asylum-
to a fruit hospital is not an abrupt
And a one. It is announced that a bazaar
Fruit Cure. ; s shortly to be opened in aid of the
“ Fruitarian Hospital " in Kent. We
confess to an almost reprehensible degreeof
ignorance as to what a fruitarian hospital
is. We know of hospitals for animals for
domestic pets, and even for boots and shoes,
but we have never yet come across one for
sick apples and sleepy pears. ™ere may for
aught we know, be a “ felt want ” for such a new
innovation,” but the institution in question appa¬
rently is not to supply it, for mention is specifically
made of funds being wanted to build a children s
ward. Are the children then to be fed entirely on-
fruit—and, if so, on what fruit? Our own know¬
ledge of pediatrics suggests several conditions m
which it would be difficult to advise a purely fruit
diet, and others in which it would prove distinctly
disadvantageous to be cut off from such animal pro¬
ducts as milk or such vegetable ones as bread.
However, we see that Lord Llangattock is honorary
treasurer of the hospital, and we know that his
lordship has sympathies already wide enough to m-

Digitized by Google

484 The Medical Press.

CURRENT TOPICS.

Nov. 6, 1907.

elude anti-vivisection propaganda and pheasant
battues. Perhaps from the products of the latter
he is able to supply nitrogenous nutriment when
needed.

If there is one principal more than
Inquisitorial another necessary for health authori-
Methods at ties to recognise, it is that they rule
Manchester, as representatives of the people, and

that the efficacy of their administra¬
tion depends entirely on how far they carry the
people with them. Medical men who pass much of
their time in the bedrooms of the poor are far more
in touch with the sentiments of the working class
than political organisers and party journalists, and
we may add, usually far more in sympathy with
their just complaints. It appears from what passed
at the reception by the Sanitary Committee of the
Manchester Corporation of a deputation from the
Manchester Medical Guild, that officials of the health
department of that city have been acting in a high¬
handed, offensive, and inquisitorial fashion to
patients supposed to be suffering from various in¬
fectious diseases who prefer to remain in their own
houses, and under the care of their own medical
men. Sanitary inspectors, it seems, frequently
have the impertinence to enter the bedrooms of sick
people, to cross-question them, and even to over¬
ride the diagnosis of the patient’s own doctor.
Such proceedings, let us say at once, are insuffer¬
able, and none the less so because done in the name
of hygiene. To call them un-English is the mildest
term that can be applied ; to call them outrages on
the privacy, decency, and self-respect to which the
meanest are entitled would not be at all too strong.
We are delighted to see the medical men of Man¬
chester protesting against methods which, apart
from everything else, can only bring into loathing
and disrepute everything connected with sanitation.

LEADING ARTICLE.

FIRES IN HOSPITALS.

Last week an alarm of fire arose in the largest
of our London hospitals. Fortunately, the out¬
break, which took place in a laundry on the ground-
floor, was promptly extinguished by fire hydrants
brought into operation by members of the staff and
by the timely arrival of the Fire Brigade. Had the
conflagration involved the rest of the hospital the
consequences must have been terrible indeed. The
wards are large, old, and are more or less con¬
tinuous from one end to the other of a most exten¬
sive and irregular pile of buildings. This incident
obviously suggests the desirability of guarding
against such disasters by the abundant provision of
fire extinguishing appliances, and by the periodical
drilling of the whole of the staff in their use. The
real lesson, however, to our mind lies far
deeper, and we venture to draw the attention of the
Metropolitan Hospital Funds to the necessity of the
proper construction of all buildings used for the
housing of sick persons. Of recent years great
strides have been made in the scientific construction
of fire-resisting buildings. Wood has been to a
great extent replaced by iron, and, given iron
girders, it requires little additional outlay to supply
floors of incombustible material. The simple addi¬
tion of stone staircases to such floors constitutes a
virtually if not an actually fireproof building. At
any rate, the safety of the helpless patients within
the walls of a hospital would be enormously
enhanced by the adoption of precautions that are
suggested by considerations of ordinary prudence

| and humanity. Of what use is it to provide succour
and shelter for the sick poor if we pack them into
combustible buildings where they may at any
moment be burnt alive. It is no answer to say
that such occurrences are rare. Several disasters of
the kind have occurred in the United Kingdom,
notably one within the past few years, but others
of considerable magnitude have happened in other
parts of the world. It may be asking too much that
all old hospital buildings be demolished and
replaced by properly-constructed fire-resisting struc¬
tures. On the other hand, we can, and do, demand
that henceforth no additional hospital premises be
erected unless they comply with modern require¬
ments as regards safety from fire. We trust that in
future the King Edward VII., the Hospital Sunday,
and the Saturday Funds will adopt this condition as
one of the chief planks of their policy. Further, as
medical charities are universal, it is to be trusted
that a similar attitude will be assumed by governing
bodies in every part of the United Kingdom. Apart
from voluntary supervision, there is another aspect
of the question. Why should not local authorities
assert their right to control the structural stability
(as regards fire risks) of hospital premises? Theatres
and other places of public amusement are most
carefully and rigorously controlled in this respect.
If theatres, why not hospitals, which are per¬
manently inhabited by a manifestly helpless popula¬
tion? If the law of the land be insufficient, so far
as the powers of local governing bodies are con¬
cerned, then let it be strengthened so as to confer
upon those responsible for the protection of the
community this elementary capacity for increasing
the safety of hospital buildings. It is for the public
to insist that henceforth all hospitals shall be built
of fire-resisting materials and be properly con¬
structed on fire-resisting lines.

CURRENT TOPICS.

A Costly f Asylums Report.

The eleventh annual report of the Asylums Com¬
mittee of the London County Asylums has just been
issued. It is a bulky volume 224 pages large folio
size. It includes a great number of reports and an
immense mass of statistical information, some of
it doubtless of value for future reference, but we
venture to assert that a large percentage of the
detailed information is absolutely useless to the out¬
side w'orld. If we turn to p. 41, for instance, we
find among the accounts sent in from individual
asylums an item of 3s. 9d. for “providing and fix¬
ing a small shelf in the surgery.” The mere print¬
ing and publication of this item must cost the rate¬
payers a considerable proportion of 3s. 9d.. A more
absurd and indefensible extravagance it would be
hard to imagine, for after the bills are passed by
committees and accountants there is surely no need
to print details. A little wise pruning w’ould cut
down the substance of the book considerably with¬
out detracting from its scientific value, or from
its efficiency as a control over expenditure. Then,
again, we cannot imagine that any practical pur¬
pose is served by the printing of many charts (some
coloured) and tables on interleaved sheets. The
cost of this volume must have been great: we
imagine it cannot have been less than ,£1,000 or
£1,500, if we include the work of editing and dis-

Google

Diqitiz.

"Nov. 6, 1907.

CURRENT TOPICS.

The Medical Press. 4^5

■tribution. As a curious commentary on the diffuse
elaboration of this production we may say that we
have looked in vain among the mass of accounts
for a statement of the cost of production of the
.annual report. The only presumable entry bearing
on the point is that of expenditure on “ stationery,
printing, postage,” etc., to the various asylums
•amounting to a total of .£4,775 7s. iojd. The
ratepayers have themselves to thank if they per¬
mit this extravagance to continue without protest.
The London County Council, although a non-
-elective body, has a number of strong and powerful
•delegates from the various metropolitan boroughs.
For many years past The Medical Press and
•Circular has pointed out the extravagance of the
Metropolitan Asylums Board, although at the same
time it has been freely admitted that the public, on
the whole, has been fairly well served in the matter
•of infectious disease accommodation, and extreme’y
well so far as ambulance is concerned. In our
opinion it is desirable that the constitution and
methods of the Board should undergo a Govern¬
mental inquiry.

.Mr. Birrell and the Tuberculosis Problem.

The deputation from the General Council of
Irish County Councils which waited on the Chief
'Secretary for Ireland last week in reference to the
tuberculosis problem in Ireland, received a certain
amount of reward for their trouble. They can
'hardly, indeed, have expected that the full extent of
their demands—the provision of sanatoria by the
Government—would be granted, since the Treasury
'is notoriously shy of taking new responsibilities.
Mr. Birrell, however, promised that he would
•strongly urge on the Treasury to contribute to the
■ cost of sanatoria if erected by the local authorities.
We are glad to note that the Chief Secretary dis¬
tinguished carefully between two classes of sufferers
from tuberculosis for whom relief is necessary—
'those in the incipient stages and those who are in¬
curable. Much confusion has arisen from careless-
mess in not noting that the nature of the relief re¬
quired is very different for these classes. Mr.
■Birrell made the useful suggestion that the derelict
workhouses throughout the country might be used
-.as sites for the requisite hospitals and sanatoria.
He also promised his support to the proposal to
make tuberculosis a compulsorily notifiable disease,
though we do not quite see his objection to attaching
the usual penalties to breach of the law in this re¬
spect. In conclusion Mr. Birrell approved of the
suggestion that the Local Government Board should
be authorised to send lecturers throughout the
•country, who should educate the people in the means
-of preventing tuberculosis. The various measures
will, if carried into effect, start the campaign against
. tuberculosis in good earnest.

A Bishop upon Toothache.

The relation of the teeth to the general health is
now becoming recognised generally by the “ man in
the street.” A most striking object-lesson was
given to that interesting person in the wholesale
-rejection of recruits during the South African war
on the score of defective teeth. It is well that he
should have settled convictions upon so important a
subject, inasmuch as the destinies of the nation
must in the long run be guided by his intelligence.
.As a sane and reasonable person, he will at once

endorse a recent utterance of the Dean of Man¬
chester to the effect that everybody should visit the
dentist twice yearly. The justification for that
general rule is to be found in the omnipotent maxim
which declares prevention to be better than cure.
Bishop Welldan, when headmaster of Harrow, used
sometimes to say that if any boy complained of tooth¬
ache, he would give him a hundred lines, on the
ground that either he or his parents had not taken
the trouble to guard against a perfectly preventible
pain. This homespun wisdom is clearly capable of
wide extension. Were it applicable to public health
an enormous preventive field would at once be
thrown open, inasmuch as the major part of disease,
according to scientific views, is preventible. Un¬
fortunately, the relations of health authorities to
their populations are not quite on all fours with
those of headmasters and scholars.

Certificates in Tropical Medicine.

The Royal Colleges of Surgeons and Phycisians
of England have decided to grant certificates in tro¬
pical medicine to students of the London School of
Tropical Medicine who have passed certain special
examinations. The certificates are endorsed by two
assessors appointed by the colleges, who restrict the
privilege to their own diplomates. The wisdom of
this new departure appears to be somewhat question¬
able. The new diploma—for that is virtually the
result—simply adds to the chaos of existing qualifi¬
cation ; nor is it altogether obvious why the
diploma of full medical qualification should not
include a knowledge of tropical diseases. The
nearest analogous special distinguishing title is
that of D.P.H., but the specialism of public health
and that of tropical medicine are poles asunder.
Then, again, the fact that the London colleges
restrict the certificate to their own diplomates em¬
bodies the spirit of exclusiveness and of the close
corporation that is hardly worthy of the present
days of liberal enlightenment. It is tolerably
certain that the powerful School of Tropical Medi¬
cine which was the first to appear on the medical
horizon, will not permit its students for any length
of time to remain at any disadvantage that may be
attached to the absence of a certificate of proficiency
in their special subject.

Boric Acid in Sausages.

Last week a London grocer was fined £5 and
costs for selling sausages containing twenty-six
grains of boric acid to the pound. Apart from the
fact that boric acid may be in itself injurious, there
is the obvious objection that by its use the maker
may be able to palm off tainted meat upon his
customers. In any case, the deliberate finding
both of the legal Bench and of the scientific sani¬
tarian is against the use of boric acid as a preser¬
vative, a verdict which has the tacit approval of
the medical profession. Under such circumstances
it is somewhat surprising that a prosecution of
the kind under consideration should be of sufficient
rarity to attract special attention. There must be
an enormous number of sausages adulterated
with a similar preservative in other districts of
London, where the health of their inhabitants
should be no less a matter of solicitude than it is
in Wandsworth. As a matter of fact, the infre¬
quency of prosecutions for adulteration of food and
drugs suggests a lack of proper public supervision
in that particular direction. There are many ways

Digitized by GoOgle

CURRENT TOPICS.

486 The Medical Press

in which local authorities might be brought to book.
It would be within the power of any ratepayers’
protection society, for instance, to collect and
analyse a certain number of samples of various
articles bought at random, and to regulate their
action according to results thus obtained. Without
any great stretch of imagination, it may be sur¬
mised that data of considerable practical interest
might in many instances accrue from such a step.

Professor Koch and the Crocodiles.

Some reoent reports of the work of Professor
Koch in East Africa bids fair, if confirmed, to
lead to results of a far-reaching nature. He has
found that the glossina palpalis breeds not only
on the banks of lakes, but also along the streams
in the interior right up to their source. He has
also observed that the fly in question feeds mainly
upon the blood of crocodiles, whereby the deadly
trypanosome is spread among those reptiles, and
in turn conveyed to man. The energetic glossina,
it appears, is able to pierce the skin of the crocodile
between the joints of an armour that is impene¬
trable to an ordinary rifle bullet. The outcome of
these investigations is likely to have a vast influence
in the future of Central Africa. At present we are
able to make an exact diagnosis of the malady of
sleeping sickness, and further, thanks to an
English medical man, to cure it by injections of
atoxyl. It is obviously impossible, moreover, to
exterminate the disease by medical treatment
alone. It seems equally out of the question to hope
to rid a continent of an insect of the wide distribu¬
tion of the glossina. The logical plan is to attack
the crocodiles, and that plan has already been ex¬
perimented on by Professor Koch. In any case,
the crocodile is a creature incompatible with
modern civilisation. At the same time, it must be
admitted that the reptile undoubtedly serves a
useful purpose as a scavenger of African rivers.

A Sea Water "Cure.”

Of late a good deal has been heard of a system
of treatment of various diseases by the injection of
sea water subcutaneously. There may or may not
be virtue in the method—that point must be settled
by future investigation, but there can be no doubt
whatever in the minds of medical men on this side
of the Channel as to the undesirable way in which
publicity has been given to the system. All kinds
of sensational statements have been made as to the
results obtained by the discoverer. Dr. Quinton,
and enthusiasts foresee nothing less than a revolu¬
tion in therapeutics by its application. Amongst
other things sea water used in the way indicated is
said to act as a specific in eczema and kindred
diseases in children, and to yield marvellous results
in the early stages of tuberculosis. If those claims
be only partially justified Dr. Quinton should earn
the gratitude of mankind. In the meantime a
serious disaster has attended the treatment in the
shape of the death from sepsis of a young German
noble, who, much against the wish of his friends,
submitted himself to the treatment. An accident of
that kind, however, does not necessarily detract
from the value of the method, whatever that may
be. In these days of manifold new cures, it is well
for the man in the street to possess his soul in
patience before he parts with his money, and sub¬
mits his corpus vile to the hands of the enthusiastic

Nov. 6, 1907-

discoverer who is often, maybe, better described,,
perhaps, as an experimenter.

A Medical Motor Club.

The medical men of Vienna, it is reported, have
started a kind of Co-operative Automobile Club.
The object is not so much social as that of providing
some sort of organisation which would place the
acquisition of a motor within the reach of medicar
practitioners on reasonable and convenient terms-
One good proposal is that manufacturers should be
persuaded to build cars specially suited to the re¬
quirements of the medical profession. The general
idea of purchase is that a moderate sum should
be paid down, and the balance settled by monthly
instalments until the whole amount is covered. It
is stated that the monthly payments will be actually
less than the present cost of hiring a carriage by
the month. The club is to have its own garage,
and branch garages will be opened in various dis¬
tricts as required.. The idea seems so good as to be
worthy of serious consideration amongst members
of the medical profession here at home. The motor¬
car has come to stay—of that there can be no doubt
—and its place in medical practice is becoming
more assured day by day. It has often occurred
to us that a little timely co-operation might serve
to lighten the burden upon professional shoulders
in many directions other than the motor-car.

Consumption in West Wales.

The average man is apt to get weary of statistics r
especially in such diseases as consumption, which he
regards more or less as the visitation of God. The
following figures from West Wales, however, are
calculated to give pause to the most cynical philo¬
sopher. They are taken from the last return of the
Registrar-General—for 1906—of the death-rate
from phthisis in the three counties comprised in the
West Wales area, viz., Pembroke, Carmarthen, and
Cardigan. It appears that in two out of the three
coun t ies the mortality is higher than in 1905, and
in the third lower than in the previous year,,
although higher than in 1901. The following table
will make it clear :—

DEATH-RATE FROM PHTHISIS, PER MILLION
PERSONS LIVING IN THE COUNTIES OF
PEMBROKE, CARMARTHEN, AND CARDIGAN
IN THE YEARS 1901—1906.

(From the Registrar-General’s Reports.)

County.

1901.

1902.

1903. 1904.

1905.

1906

Pembroke ...

1,298

1,296

*, 53 6 1,326

1 459

*, 3 ia

1,446

Carmarthen

1,681

1,688

1,487 1,641

1 » 39 1

Cardigan ...
England and

2,178

2,478

2,121 2,294

2,1x2

2,316.

Wales

1,264

*.233

1,203 1,236

1,140

*_..

* Not yet published.

It will thus be seen that in Pembrokeshire the-
mortality is higher than in 1901, in Carmarthen¬
shire lower than in 1901, but higher than in 1905,
while in Cardiganshire it has reached a higher
point than in either of the preceding years except
1902. The necessity of abundant open-air sanatoria
in West Wales is evident. Further, it would be
well to impress upon the ratepayer of that part of
the municipality the necessity of weeding out tuber¬
culous cows from farms and dairies.

Hammersmith and Lady Health Visitors.

Although our lamentable infantile mortality has-
been prominently before the public for some years-

ed by Google

Diqitizi

Nov. 6, 1907.

PERSONAL.

The Medical Press. 4^7

PERSONAL.

past, it cannot be said that many practical remedies
have so far come to the front. Among the most
promising proposals has been the appointment of
lady health visitors, whose duty it is to visit the
households of the poor and to instruct them in the
-elements of child-nursing and of general whole¬
someness of environment. The Borough Council
of Hammersmith, however, have been recom¬
mended by their private Health Committee to dis¬
miss their lady health visitor, appointed in 1906 at
a salary of £100. The reasons for this attitude
•are not known to us, but they must have been
somewhat cogent to have prevailed against various
protesting deputations of ratepayers. It is dis¬
appointing, moreover, to learn that the suggested
abolition of office is supported by the Medical
Officer of Health. That gentleman is necessarily
aware of the excessive mortality of Hammersmith
and of the difficulties attached to sanitary problems
in so large a poor population. It would be interest¬
ing to know what alternatives he has in his mind
for effecting a reduction in infantile mortality.
Whatever be the ultimate decision of the Ham¬
mersmith Council as regards the lady visitor, it is
somewhat comforting to reflect that they can
hardly be influenced by the paltry reduction of ^100
effected thereby, for the whole world has recently
been astounded by the revelation of the stupendous
sums of money expended on the local workhouse
buildings, which in some respects may, without
exaggeration, be called fabulous. Truly modern
life is full of sharp contrasts!

The Administration of Anaesthetics for
Unqualified Persons.

A somewhat remarkable communication has
recently been addressed to the Morning Leader
by Mr. H. A. Barker, a bonesetter, or person who
professes to treat bodily injuries and deformities
-without the guarantee of a surgical qualification.
In the course of a sort of semi-scientific harangue
upon displaced semi-lunar cartilage in the knee-
joint, occurs the following remarkable passage :—
“ I have treated many thousands of these cases by
purely manipulative measures under anaesthetics,
and with almost invariably good and permanent
results.” Incidentally it may be remarked that any
practitioner should be able, in the majority of cases,
to obtain good results in the kind of injury in
-question, but permanency of cure is another matter,
and he would be a bold surgeon Indeed who would
prophesy anything of the kind, short of tethering
the cartilage to the bone or other radical operation.
The question we should like to raise is whether
Mr. Barker has the temerity to administer anaesr
thetics himself or by the aid of an assistant? If
'he be his own administrator then he exposes his
patient to risks that it is not pleasant to contem¬
plate, to say nothing of his own position in the case
of an anaesthetic death. If his assistant be un¬
qualified, a charge of manslaughter is not an
altogether improbable contingency. Lastly, if his
administrator be a qualified medical man—but,
•even in view of the fact that registered practitioners
have recently been found administering anaesthetics
for unqualified dentists, we should refuse to believe
without absolute and overwhelming proof that such
a thing could happen in the case of bonesetters.

H.R.H. Princess Henry of Battenberg opened
the new children’s block of the Rugby Hospital on
October 26th.

The Sultan of Turkey has conferred on Sir A.
Conan Doyle the Second Class Order of the Medjedieh.

Dr. John H. Dauber has been elected President of
the Chelsea Clinical Society for this year.

Dr. George Carpenter has been elected Chairman
of the Council of the Society for the Study of Disease
in Children.

The Merchant Taylors Company have given a dona¬
tion of 30 guineas to the Samaritan Free Hospital for
Women.

Dr. C. F. Bryan, of Leicester, has been elected
President of the Association of Certifying Factory
Surgeons for the ensuing year.

Her Excellency Lady Aberdeen has sent a letter
to certain general hospitals suggesting the formation
of tuberculosis dispensaries in Ireland.

Mr. John Lentaigne, Vice-President of the Royal
College of Surgeons in Ireland, has been appointed a
Member of the Board of Superintendence of the
Dublin Hospitals.

Sir James Barr, M.D., delivered the Bradshaw
Lecture yesterday at the Royal College of Physicians
of London, the subject being “ The Pleurae; Pleural
Effusion and its Treatment.”

Dr. Burton Brown, President of the Therapeutical
and Pharmaceutical Section of the Royal Society of
Medicine, took the chair at the first meeting of that
section on October 22nd.

Professor Sherrington, of Liverpool, delivered the
inaugural lecture to the Royal Medical Society of
Edinburgh at the opening of its 171st session. Dr.
A. M. Drennan, President, was in the chair.

Dr. John Carswell, of Glasgow, has been pre¬
sented with a handsome testimonial and a cheque for
^415 by a large number of friends in recognition of
his services to the town.

Dr. E. M. Grace, the County Coroner of
Gloucester and brother of the famous cricketer, was
last week married to Miss Brain, daughter of the late
Mr. James Brain, of Cardiff.

The Rt. Hon. Sir Herbert Maxwell, Bart.,
F.R.S., has been elected Chairman of the Council of
the National Association for the Prevention of Con¬
sumption. Dr. C. Theodore Williams, M.V.O., has
been elected Vice-Chairman.

A meeting of the Board of Management of the
Manchester Royal Infirmary was held on October 29th.
The retirement of Dr. Mould was announced. Dr.
Mould entered the service of the Infirmary at the
Cheadle Hospital 45 years ago, and had been con¬
stantly associated with the work ever since.

Sir Alfred Keogh, K.C.B., will address a meeting
of hospital physicians and surgeons at the Royal
College of Physicians, London, asking for their co¬
operation in working the Territorial Army Medical
Scheme. Sir R. Douglas Powell will be in the chair.

I . fi

e

488 The Medical Press.

CLINICAL LECTURE.

Nov. 6, 1907.

A Clinical Lecture

ON

A CASE OF TRAUMATIC EPILEPSY TREATED BY OPERATION.

By THOMAS SINCLAIR,

Professor of Surgery In Queen's College, and Surgeon to the Royal Victoria Hospital, Belfast.

Gentlemen,— The patient before you illustrates
the effects of the deliberate removal of a portion of
the motor area of the brain in the treatment of
traumatic epilepsy—the proceeding _ sometimes
designated Horsley’s operation of excision of the
epileptogenic centres. It is now more than a year
since the operation was performed, and no recur¬
rence of the epileptic fits has taken place. More¬
over, the patient is now able to work, and is eager
and willing to do so, though during the prevalence
of the fits he was incapable of exerting himself
with any resolution or continuity of purpose,
mentally or bodily.

The personal history shows that the patient was
a healthy man, of regular habits, and set. 33 at the
time of the accident in October, 1903. He was
struck on the left side of his head by a heavy
falling plank. He was unconscious for 27 hours.
There were no surface signs of cranial damage,
and he left the infirmary, where he had been first
treated after a stay of five weeks, fairly well, only
a tender spot over the left parietal bone remaining.

After several weeks he was admitted to the
Royal Victoria Hospital, having developed the
following symptoms:—Insomnia, general weak¬
ness, frontal headache, dizziness, very frequent
vomiting, and night sweats. Under treatment by
rest and bromides the vomiting ceased, and the
headache and insomnia had so much improved that
he left hospital in three weeks.

Relapses occurred at short intervals during the
ensuing eight months, and marked tremor of leg,
arm, and tongue appeared, associated with much
muscular feebleness, but without atrophy or
rigidity. By the autumn of 1904 this amounted to
right hemiplegia, and he could neither stand nor
walk. In October, 1904, on rising from a chair he
had a fit. He fell, and was unconscious; his eyes
twisted up towards the left, twitchings, com¬
mencing in the right leg and arm, developed,
followed by stupor, lasting for two hours. He had
no warning sensation or aura. The fits occurred
daily for two months, and to a great extent re¬
placed the vomiting of the former time. He declined
operation, which was urged, at this stage. Gradu¬
ally the fits lessened, and so much improvement in
the hemiplegia followed that he became able to
stand and walk, but he still dragged the right foot
markedly. Some trophic changes arose in the right
knee, which moved stiffly, with much noisy intra-
articular crackling; and his teeth, previously
sound, underwent rapid decay. He had nine of
them extracted during the next year. In January,
1906, he complained of constant vertical headache;
the vomiting and fits were less frequent, he ate and
slept well, his hearing, vision, and general sensa¬
tion were good, and there were no oculo-motor or
facial symptoms. His left pupil was larger than
the right, and the left optic disc was hyperaemic.
His knee jerks were exaggerated, but there were
no ankle clonus, atrophy or contractures. He
dragged the right foot considerably, but could walk
fairly without stick or support. The tremor was

then much abated, but still noticeable in the right
hand. No urinary symptoms ever arose, and the
pulse and temperature were normal.

The propriety of subjecting him to operation at
this late stage, and in the face of some amelioration
of his symptoms, was debated, but ultimately it
was undertaken, on the ground that no further
improvement was in progress, and the constant
severe headache, tremor, and dejection rendered
him quite unfit for any duty. Accordingly, in
February, 1906, a large disc of bone was raised
over the leg and arm centres on the left side of the
brain. No fracture or thickening of the bone
existed, and the dura mater showed no pachy¬
meningitis, nor was there any arachnoidal
bloodcyst or false membrane to be found. The
cortex was discoloured over a small area, and con¬
tained some old blood clot, the pia mater was
tougher and more adherent, and the density of the
cortical area involved was firmer than natural. An
exploration through and around this area was
made in order to exclude the presence of abscess or
underlying cyst, and finally a portion of the cortex,
about the size of half-a-crown and nearly half an
inch in depth, was excised. The disc of bone was
re-implanted, contrary to Kocher’s advice, and a
perfect restoration of the cranial vault was
obtained, after a normal healing, without drainage..
The headache ceased almost immediately, and the
other svmptoms underwent rapid improvement
even the artificial hemipleglia caused by the ex¬
cision of the convolutions passed off in a few weeks.
So encouraged was the patient, that one had to
restrain him from a too early resumption of work,
which is unwise in these head cases after trephining
operations. For a kindred reason the clinical
demonstration to you of the result has been post¬
poned for a year or more in order that the per¬
manence of the improvement may be better ascer¬
tained and attested.

In analysing the symptoms before operation, t>
frame a diagnosis, it appeared probable, from the
un-and-down character of these, that the cortical
irritant was not of a bony nature, either osteitis or
fracture of the internal table, which, it must be
remembered, can occur without obvious change in
the outer table of the skull. The likelihood of a
small cortical abscess having formed was also not
manifest, unless the night sweats of the early period
might appear to suggest it. These perspirations
lasted only a few weeks, and were not associated
with the subnormal temperature and emaciation
generally found in suppurative conditions of the
cerebrum. Moreover, an abscess, though it may lie
dormant for months, when it begins to cause
irritative signs advances from irritation and con -
vulsions to greater compression and coma. The
improvement in the hemiplegia seemed inconsistent
with the theory of abscess. On the whole, an
arachnoidal blood cvst adherent to the brain in the
motor area, or a blood clot in a contused cortical
area associated with variations in the local circu¬
lation from time to time, appeared the most
probable construction to place upon the clinical

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ORIGINAL PAPERS. The Medical Press. 4^9

Nov. 6, 1907.

signs. The latter condition was found at the
operation, and a degree of condensation or
sclerosis with adhesion of the pia mater, resulting
from a local non-suppurating cerebritis in the
involved area, had evidently followed the original
damage. That this damage, contusion, or lacera¬
tion, had been considerable was clear from the
long duration of the so-called concussion signs at
the beginning, extending the unconsciousness to
27 hours, as already noted. It was this patch which
was extirpated at the operation.

In traumatic, or Jacksonian, epilepsy with local
symptoms, the earlier the operation is carried out
the better, for the longer the fits have lasted the
more likely are they to become habitual and
approach the status epilepticus ; hence the condition
becomes less amenable to treatment as time wears
on- The prognosis should not be too sanguine as
regards the epilepsy, even in apparently favourable
operation cases. A probationary period of at least
one year should elapse after an operation before
an estimate is formed of the result, for experience
shows that there are numerous cases of relapse and
consequent disappointment in this branch of
surgery. Even the contraction of the cerebral scar,
which necessarily forms after an excision like the
one above described, has to be reckoned with as
potent for mischief in this regard.

The possibility of supplying a bony irritant by
the re-implantation of the bone disc must not be
lost sight of in epileptic cases. Kocher says it is
best, as a general rule, not to re-insert the disc, or
fragments of bone, as grafts in these cases. The
harsh edges presented to the brain by fragments or
tilting of the disc may readily reproduce the con¬
vulsions. Certainly the practice of re-insertion
should be avoided when the undersurface of the
disc is irregular from fracture or osteitis, or when
it cannot be adjusted flush with the surrounding
vault for want of a good foundation. In the pre¬
sent instance, the conditions being all favourable,
the re-implantation was adopted, and for so far
there appears to be no cause for regret. Finally,
it may be advised that patients who have been
operated upon for epilepsy should not be allowed to
engage in laborious work involving stooping,
worry, or excitement for many months, no matter
how gratifying the immediate results may appear.

Not*. —A Clinical Lecture by a well-known teacher
appear* in each number of this journal. The lecture for
next week will be by Fdred M. Comer, B.Sc.Lond., M.C.
Cantab., F.B.C.S., Surgeon in Charge of Out-Patients
St. Thomas's Hotpital; Senior Assistant Surgeon, Hos¬
pital for Sick Children. Subject: “ Deformities of the
Foot Associated with Abduction .”

A Supreme Health Authority-

It is proposed to hold a conference of representa¬
tives of sanitary authorities in London to consider the
question of the establishment of a permanent union
of sanitary authorities of the United Kingdom. The
Court of Common Council of the City, at its meeting
last week, asked the following gentlemen to represent
the Corporation:—Mr. S. Pollitzer (the Chairman of
the Sanitary Committee), Mr. H. F. Hepburn (the
late Chairman), the Medical Officer of Health for the
City, Mr. H. S. Dove (the Chairman of the Port Sani¬
tary Committee), Mr. R. Stapley, J.P. (the late Chair¬
man), and the Medical Officer of the Port of London.

A case of smallpox has been notified to the ambu¬
lance department of the Metropolitan Asylums Board
from St. Pancras and removed to the hospital.

ORIGINAL PAPERS.

ABSTRACT OF

THE BRADSHAW LECTURE

ON

THE PLEURA; PLEURAL EFFUSION
AND ITS TREATMENT, (a)

By SIR JAMES BARR, M.D., LL.D., F.R.C.P.,
F.R.S.E.,

Senior Physlclaii, Liverpool Royal Infirmary; Visiting; Physician,
Haydock Lodge and Tuebrook Asylums.

The first part of the lecture dealt fully with the
anatomy and physiology of the pleura, with the im¬
portant question of intrapleural, intrathoracic and intra-
pulmonary pressure. After an exhaustive considera¬
tion of aetiology and diagnosis, the learned lecturer
proceeded: In the treatment of pleural effusion the
question often arises when should you withdraw
serum? Effusion is a natural process which, if it
continue till after the inflammation has subsided,
lessens the risk of pleuritic adhesions; it also keeps
the collapsed lung quiet, which is very desirable if
there be any active tuberculosis in the lung. A large
proportion of cases of pleurisy are tubercular, and the
early withdrawal of fluid causes vascular turgesence
of the lung, often hastens the dissemination of the
tubercle bacilli, and kills the patient. Before I began
the substitution of one fluid for another by the intro¬
duction of air into the pleural cavity, I was much
more chary about early tapping than I am at present.

I can now remove the whole of the effusion, even in
tubercular cases, at an early stage, with perfect im¬
punity. A considerable number of deaths have fol¬
lowed the complete withdrawal of effusion in elderly
persons with rigid chest walls. The danger in such
cases arises from establishing too great a negative
pressure, which leads to hyperasmia and oedema of
both lungs ; this can be obviated by the introduction
of air. I now recommend the complete withdrawal of
the effusion in all cases, but before any great ne'gative
pressure is established, and before the patient feels
any discomfort, I stop the siphon and introduce about
an equal quantity of air to the amount of fluid which,
I have withdrawn. I then re-establish the siphon,
and complete the withdrawal of the effusion. When
all the liquid is withdrawn I inject four cubic centi¬
metres of adrenalin solution (1 in 1,000), diluted with
eight or ten cc. of sterile normal saline; and if I think
it necessary I introduce more sterile air, so as to make
the total amount equal to a half or three-fourths of
the bulk of the fluid withdrawn; the larger quantity
of air is introduced in tubercular cases. By this
method the patient suffers no discomfort, except from
the slight thrust of the trocar. I prefer the siphon to
the aspirator, because you can readily regulate the
force of the suction, and as your tube only reaches
to a receptacle on the floor, practically your negative
pressure never exceeds one pound to the square inch ;
this force is greatly exceeded by the aspirator, and the
greater the negative pressure the greater the risk of
secondary hypersemia and oedema. It is an advantage
to introduce a manometer in the air tube, as you can
thus avoid producing any positive pressure in the
pleura. Of course all aseptic precautions are taken.

The adrenalin solution is introduced to contract the
blood-vessels and lessen the secretion. According to
Schafer, Elliott, Brodie and Dixon, adrenalin only
acts on unstripped muscular fibre which is innervated
by the sympathetic; the pleural vessels belong to the
systemic system and are thus innervated, but its effect
is not very prolonged ; consequently you cannot expect
it to lessen the secretion for any great length of time
if there be a great negative pressure in the pleura.
Although I had good success from its use, before I
commenced the introduction of air, I soon recognised
the limits of its usefulness. When you remove four
or five pints of serous fluid from the pleura, there is
a potential or actual cavity left which cannot be filled

NOT ) 5th ,l 19o7 d “ th ® K ° yBl C °’ hg * 0t Ph ^ cl(uli °f London.

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The Medical Peess.

ORIGINAL PAPERS.

Nov. 6, 1907

•ssjm b s

“1*» ^ P S m eV e »t, m{y /o. »S ,0 fill the

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MWI

PUc-iBsig

0n n'r W Ewart of London, has recently been inject-
teg adrenalin Boln.ion into tee {““S

:Slissiifg|

timeto*e^e^ into* the*n^Mous 1 *Mp^atoty eJ*r^*s
wSch I from time to time recommend, but there is

££m 3*?5

S^days^ave passed for ever 1^have £ toldyou

I dav and the fluid disappeared as if by magic, you
canenvy such credulity, but it is impossible to

ad Wh^n i !here is a large quantity of effused fibrin, such

^^now'gi^you a'shorTaccount of.the history
of tfe in^rodiitio/ of adrenalim and air into^the
pleural cavity. In August, 1902, I saw reg^y,
consultation with Dr. Chisholm, Mr. F. T. Paul, ana
Mr. R. A. Bickersteath, a lady who was suffering from
secondary cancerous deposits in the pleura
effusion^ The fluid had to be withdrawn every four
•days, and it re-accumulated so quickly that she ha
scarcely a day free from distress in breathmg between
the aspirations, and I saw that this state of matters
could not continue long. Necessity is the mo&«: of
invention, and I began to consider how ^lessen this
secretion. I came to the conclusion to try ^mjec
tion into the pleura of suprarenal extract, and I fixed
upon Parke, Davis and Co.’s adrenalin chloride, 1 in
1,000, as being a sterile preparation. I empirically
fixed one drachm or 4 c.cm. as the amount to be in¬
jected, and after the fifth aspiration this quantity was
used. There was no further secretion, consequently
no further tapping, and the old lady spent the re¬
mainder of her life in perfect comfort, so far as the
chest was concerned. In her memory her husband
contributed .£12,000 to establish the Liverpool Cancer
Research Fund.

Since this case I have injected one drachm of
adrenalin solution into every pleura which I tappe^
and in only two cases have I had to draw off Jbefluid
a second time. Soon after I began this method-to
which no one has laid ^y prior claim-I commenced,
in addition, the introduction of sterilized air to re¬
place the fluid which I had withdrawn. I was led to
adopt this procedure by the distress frequently caused
to die patient by any attempt to withdraw all .the
serum; by the usually rapid re-accumulation,
especially when there was any negative pressure left
in the pleura, or there was a large potenUal or actual
cavity owing to the lung being so collapsed or bound
down that it could not expand; by the great. nsk of
collateral hyperdemia and oedema of one or both lung ,
especially in those persons with rigid chest-walls;
and by the fact that in tubercular cases there is apt
to be a rapid dissemination of tubercle through the
lung when the pleural pressure is removed. As four-
fifths of the air is nitrogen, which is only slowly
absorbed, this air pad tends to prevent or
pleural adhesions. Since I began the substitution of
air for serum I have been able to withdraw the whole
of the liquid with perfect impunity.

I exhibited my first and second apparatus for the
introduction of adrenalin and air into serous cavities
at the Liverpool Medical Institution on November 5m,
1903: and the following week there was a notice of
my apparatus in the proceedings of the Medical In
stitution published in the weekly medical journals.

In the British Medical Journal of March 19th, 1904,
I published a Clinical Lecture on the Treatment of
Serous Effusions, in which I fully described my
method and apparatus for treating effusions into *U
the serous cavities. At that time the idea of injecting
sterilized air was quite original, so far as I was con¬
cerned, and some of the leading “embers of the
medical profession to whom I spoke on the subject
had never heard of any such practice, but I afterwards
found that some others, to whose writings I shall
presently refer, had been in the field before me.

In the Edinburgh Medical Journal of November,
1886, Dr. Theobald A. Palm published an account ot
three cases where he allowed air to be sucked into the
pleural cavity after aspiration. One case recovered
after one tapping, another after two, and the thinl
“case took an unfavourable course, and in the cours
of some months the patient died.” .

On April 24th, 1888, M. Potain communicated to the
Academy of Medicine, Paris, a successful case of pyo¬
pneumothorax treated by the injection of stenlued
air after the removal of the liquid. His object was
to keep the lung compressed until the pleura-pui-
monary fistulae had healed, and to prevent the repro¬
duction of the liquid.

In Italy several papers appeared between i»»
and roo2 on the introduction of aiT into the pleural
cavity by Drs. G. Lava, G. Cavallero, S. Riva-Rocci,
and Professor Forlanini.

About or before 1900, Professor Ayerza and his
pupil, Dr. Bunge, of Buenos Aires, treated cases 01
acute and chronic tubercular pleurisies by the abstrac¬
tion of the liquid and the injection of oxygen gas.
They used oxygen as a specific medication against the
tubercle bacilli, but as oxygen is more readily aD-
sorbed than nitrogen, in no case did the pneumothorax
last longer than 14 days. Recently Professor Fop
lanini has advocated the treatment of phthisis by the
repeated introduction of oxygen gas into the pleural
cavity, so as to maintain an artificial pneumothorax
and thus rest the lung. About a century ago a some¬
what similar treatment of phthisis was earned out in
Liverpool by the late Dr. Carson and Mr. Robert
Bickersteth. They produced a pneumothorax by an
external opening into the pleura, but they soon gaie

over the practice. . . •

In addition to cases in foreign literature, there is in
the Lancet , November 10th, a reference to a case
reported at a meeting of the Soci6t6 M6dicale d
Hopitaux de Paris, on October 12th, 1906, by ■
Dufour and M. Foix. They successfully «®oved a
large chronic pleural effusion and injected sterile am

This systematic treatment of pleural effusion bv
combined method of the complete withdrawal of the

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Nov. 6, 1907.

The Medical Press. 49 1

ORIGINAL

liquid, and the introduction into the pleural sac of
adrenalin and sterile air which I may lairly claim to
have originated, will, I hope, be more appreciated as
it becomes better known. The adrenalin solution is
better diluted with two or three times its bulk of
normal saline solution.

Empyema.

This is one of those numerous diseases which the
surgeons have taken under their own special care, and
they have done nothing to advance its treatment, I
presume because physics seem to have formed no part
of their education. In the case of a child with elastic
chest-walls you could not easily mismanage a case of
empyema. A considerable number of cases get well
in spite of treatment. When a surgeon has to deal
with a purulent effusion in the chest, about the only
idea which he can get into his head is free drainage^
and forthwith out comes a piece of rib and in goes a
large drainage tube, expecting it to suck up the liquid
from the most to perhaps the least dependent part of
the cavity, and utterly reckless as to whether the
collapsed lung ever expands again or not. Dr. Otto
Griinbaum has devised a useful appliance for assisting
the lung to expand in these mismanaged cases, but I
do not know of any surgeon who has taken it up.
Mr. Arthur Edmunds, to whose valuable work I have
previously referred, insists on the anaesthesia being
very light when operating on an empyema, so as not
to abolish the pleuro-laryngeal reflex, and thus the
vocal cords are enabled to play their part in maintain¬
ing the pressure within the lungs.

If I were a surgeon, and had to deal with such a
case, I would use a local anaesthetic, such as eucaine ;
or, if thought necessary in any particular case, light
general anaesthesia as recommended by Mr. Arthur
Edmunds. I would make a free incision in a very
dependent spot, about the eighth or ninth intercostal
space, in a line with the lower angle of the scapula.
If the ribs were close together it would be well to
take out a long piece of one rib, and then make a free
incision into the pleura. An assistant should firmly
compress the side so as to drive the purulent matter
out, and allow as little air as possible to enter the
chest during the operation. A strip of gauze may be
inserted in the wound to keep it open, but no tube
should be introduced. I would then apply a large
piece of sterile oiled silk over the wound to act as a
valve, so as to allow the fluid to escape, and no air to
enter. Large aseptic dressings should be applied over
the valve. The affected side may be well strapped to
prevent movement. I would make the patient lie on
or towards the affected side, so as to lessen movement
and encourage drainage, prevent him taking any deep
inspirations, and tell him to take deep nasal expira¬
tions, so as to expand the affected lung, and drive the
purulent fluid out of the cavity. He should be in¬
structed to inspire through the mouth and expire
through the nose. I would also make him frequently
practise the Valsalva method, or blow through a small
tube. If the pus be very offensive, or not draining
well, the patient can be treated in a continuous bath,
and then no dressings will be required.

In these cases the pus is usually fairly fluid, is
neutral, or may even be slightly acid in reaction, con¬
tains some peptone and a ferment which seems to
have the power of digesting fibrin, and thus the lung
is not likely to be irreparably collapsed or bound
down by adhesions; there is therefore a fair chance of
success if the operation be adopted early, and the after
treatment intelligently carried out.

The variety of micro-organisms in the pus should
be ascertained, and an appropriate vaccine, after the
method of Sir A. E. Wright, should be used. Even
the stinking empyemata from the bacillus coli often
do very well. Tubercular cases are the most trouble¬
some, and usually when the fluid becomes purulent
there is a mixed infection. Cases of pyo-pneumothorax
are best treated by drawing off the fluid and filling
the cavity with sterile air or oxygen. Where the
empyema is loculated the surgeon may remove a piece
of rib if he choose; he cannot do much harm. Un¬
fortunately Estlander’s operation is often necessary,
partly owing to early mismanagement of the cases.
There must be some effort made to place the treat¬

PAPERS.

ment of this disease on a more scientific basis than
that on which it at present stands.

I have spoken strongly about the surgeons, because
I feel strongly, and I am anxious that they should
remove this blur from their fair escutcheon. The old
wheeze about the physicians not handing the cases
over scon enough is now played out. There is still,
however, plenty of work for the physicians; preven¬
tion is better than cure, and I think in the future
their work should lie more and more in that <hrec-
tion. Our aim should be to protect the individual
from the ravages of disease and the onslaught of the
surgeon, and make the very existence of that in¬
dividual less and less of a necessity.

DEATH FROM HEMORRHAGE
FROM A MEDICOLEGAL POINT OF
VIEW.

By PROFESSOR HENDRICK, M.D.,

Ot Hamburg.

Part I.

Death from haemorrhage takes place when, in con¬
sequence of a solution of continuity at any particular
part of the body, such a large quantity of blood is
withdrawn that the amount left in does not suffice
to carry the necessary amount of oxygen to support
life to the various organs, especially the brain.

The quantity of blood lost necessary to cause death-
from haemorrhage bears no relation to the amount in
the whole system, but is dependent first upon age; the
relative quantity of blood the loss of which could be
borne by adults without injury to health will kill a
child. Secondly, on the general condition of the indi¬
vidual. Persons of weakly constitution, especially
with a diseased condition of blood—such as often
comes on after exhausting diseases—as well as those
with pulmonary and cardiac diseases, which hinder
oxydation of the blood and the rapid blood supply of
the body, bleed to death more rapidly than healthy
individuals. In such cases a disease accompanied by
hasmorrhage will result in death, when it would not
under normal circumstances. Thirdly, the loss of
blood necessary to cause death is dependent on the
kind of blood lost, whether arterial or venous. Arterial
blood contains nutrient material indispensable to the
life of the tissues (oxygen) ; venous, on the other hand,
contains the cast-off materials of the tissues (carbonic-
acid). It i9 at once clear that the body bears a loss
of venous blood better than that from an artery.
Fourthly, the amount of loss required to cause death
depends on the length of time the bleeding lasts,
whether it is rapid and continuous, or whether there-
are interruptions of hours or days. This, as the ex¬
periments of Juergenson have shown, is explained by
the fact that a loss of blood is quickly compensated
by reflux of lymph out of the tissues, and so when
the bleeding is interrupted, a substitute for the lost
blood takes its place, and so losses with interruptions
are borne when without a break they would be fatal.
In this way a man may gradually lose a quantity
greater than the whole quantity originally present in
the body.

In general it may be said : To bring about death
from haemorrhage, the loss of a very considerable part
of the whole of the blood of the body is necessary;
the loss of half of it causes death in most cases; the
loss of still greater quantities does so with certainty
(Oesterlen). Experiments on dogs on bleeding have
shown : dogs survive a loss of blood when 4 per cent,
of the body weight, = 52 per cent, of the whole quan¬
tity of blood, is withdrawn ; they die with a loss of
blood of 5.5-6 per cent., = 64-72 per cent, of the total
amount of blood. To bring forward decided figures,
Seydel, amongst more recent authors, gives a loss of
1,500-1,800 grammes as the average amount that would
prove fatal for a medium-sized man. BOrntrager and
Berg give 1,800 ccm. as a mean for internal haemor¬
rhage. There are variations from 1,500-3,000, but
extremes are rare. Casper-Liman consider it idle to
fix the amount necessary to cause death for medico¬
legal purposes, however interesting for physiology. It
is not so important in practice to determine the amount

Digitized by GoOgle

49 2 The Medical Press.

ORIGINAL PAPERS.

Nov. 6, 1907.

of blood accurately as one would at first think, as the
quantity of blood comes into question diagnostically
only in internal haemorrhage ; in external haemorrhages
the amount cannot be measured.

The diagnosis of death from haemorrhage may some¬
times be determined before the body is opened on the
•evidence of unbiassed witnesses who have witnessed
the occurrence. The symptoms under which death
takes place from external haemorrhage under ordinary
-circumstances are the following : A large stream of
blood spurts out of the wcund, the wounded man sinks
with a cry to the ground, a pallor spreads over the
features, the tongue becomes pointed, the breathing
stertorous, the limbs cold; the sufferer throws bis
limbs about, then clonic convulsions supervene, and
at last death. In such a case a post-mortem examina¬
tion only confirms the diagnosis already made. In
other cases in which eye-witnesses have not been pre¬
sent, but the body has been found some time after the
death has taken place, when it has taken place from
external haemorrhage, numerous traces will lead to a
diagnosis. The blood may lie in great pools upon the
floor, or it may have sunk into the soft soil; it may
have spurted against walls or other objects ; the clothes
may be soaked through, or the blood may have run
•down the body. The forensic surgeon must carefully
mote all traces, and from them estimate the amount
lost. For this it may be necessary to examine the soil,
the clothes, and other objects as regards saturation,
df the blood is dried in. However, the quantity of
blood that has escaped, as has been mentioned, can
•only be imperfectly estimated. Moreover, it has to
be considered that the blood may have been washed
away; the body may have been removed from the
place where the death took place ; and in this way all
traces of blood may have been lost. In such cases,
a3 in all cases of death from internal haemorrhage,
the diagnosis can only be made from what is seen
on opening the body. The findings on doing this are
the following: The skin is a waxy white; Seydel
describes it as a whitish yellow ; the colour of the
mucous membranes of the lips and conjunctive is
almost white. According to Caspar-Liman, exceptions
to the waxy white colour are not infrequent (“cases
are not rare where a practised observer would not
think of death from hemorrhage, the colour of the
body being' quite the usual one ”). One result of the
skin being empty of blood is the imperfect formation
of discoloured patches ; they may be absent altogether.

Views differ on this point. According to Divergie
(quoting from Sachs), the death patches are always
absent, whilst Maschka and Caspar-Liman describe
them as rarely so. Hoffmann saw them repeatedly ;
'Chlumsky had the opportunity of noting their absence
on three successive days after death. He remarks
that Divergie's case is not conclusive ; it is not stated
at what time after death the autopsy was made, and
whether it was not before hypostasis could have taken
place. Borntrager and Berg describe the total absence
of discolourations as rare. Seydel speaks of slight
patches. If, with Sachs, one draws the actual con¬
clusions from these various views, we come to the fol¬
lowing as regards the patches: (a) hypostasis is slow
in the bodies of those who have bled to death ; (b)
in rare cases the discolourations may be absent alto¬
gether ; (r) the patches are smaller and paler. Rigor
mortis in these cases does not differ from the ordinary.

Examination of the body internally shows general
anaemia of the vessels and parenchymatous organs in
a varied but always high degree (Oesterlen). We
should not look upon the bloodlessness as if every drop
of blood had left the body, as the quantity that has
escaped depends, as already mentioned, on a number
of factors. Bdrntrager and Berg also, in their latest
work on the subject, remind us that we must not
expect a complete emptying of the body. It has also
often been shown by experiments on animals that in
deaths from haemorrhage all the blood does not leave
the organs. All the larger venous trunks are blood¬
less, or at least show a want of blood ; but it is to
be noted that the veins of the pia mater from gravity
are rarely empty, but generally visibly filled. Caspar-
Liman give a special warning not to doubt from this
fact that death has been the result of haemorrhage.
The cavities of the heart are generally empty, but they

may contain a small quantity of blood. It is rarely
that the so-called sub-endocardial ecchymoses are
absent {Hofmann, Puppe). The paleness of the mucous
surfaces of the oesophagus, stomach, intestines, and
trachea, amounting to a whitish yellow, is very pro¬
nounced. The quantity of blood in the glandular
organs varies. The lungs and brain show remarkably
little blood, the spleen and liver are generally very
pale, whilst the kidneys often show a considerable
quantity. On section the organs are dry. The lungs
are gray in colour, the brain yellowish white, the spleen
a pale reddish, the kidneys are from a clear grey-red
to clear grey, the liver pale brown if pigmented, or
pale yellow if fatty.

The general absence of blood, however, is not an
absolutely certain sign of death from haemorrhage, as
even when pronounced, it may be found in the bodies
of those who during life have suffered from poorness
of blood, conditions of lingering exhaustion, from
tuberculosis, malignant tumours, or long-continued
suppurations. In the latter cases accompanying
symptoms—dropsy, emaciation, decubitus—will ap¬
pear, whilst on the other hand the source of the bleed¬
ing is conclusive as regards diagnosis. Further,
general bloodlessness is met with in bodies in which
decomposition has taken place, in which, in conse¬
quence of putrefaction and permeability of the vessels,
the blood has trickled through and left the vessels, or
has evaporated, whereby diagnosis is rendered more
difficult.

Death from haemorrhage may therefore be assumed
when signs of internal or external bleeding are pre¬
sent, and a solution of continuity in the vessels is seen
as the source of the haemorrhage, the latter with the
limitation that, according to Caspar-Liman, the dis¬
covery of the source of the haemorrhage is not always
possible in internal haemorrhage, and therefore not
always necessary; further, if the above described
general bloodlessness is present, the body is not decom¬
posed, and all other causes of death are excluded.

The following forms of death from haemorrhage are
distinguished: It may be from internal or external
bleeding; it may be acute and uninterrupted ; or it
may take hours; it may have intermissions of days
(aneurysm 66, self-help or aid from others, ana¬
tomical conditions); it may follow direct from the
injury or after the lapse of some time from an inter¬
current cause (suppuration, development of aneurysm),
and therefore be mediate. The solution of continuity
causing it may be spontaneous from morbid changes
in the organ, or from only slight violence, or when
the organ is sound from the action of considerable
violence; or, finally, it may be from simple loss of
blood, or as the result of a secondary action of such
loss (paralysis from pressure on the brain, heart, lungs,
blocking of the respiratory tract from poured-out blood
into the air passages, air embolism). In the latter case
we speak of complex death from haemorrhage. This
mode of death borders on that from suffocation, but
is reckoned as death from haemorrhage, but is distin¬
guished from it as complicated “ verblutungstod.’ -
This distinction, however, is not strictly carried out
in the larger text-books (Hofmann, Strassmann). Com¬
plicated death from haemorrhage differs from the
simple in important points—cause of death, quantity
of blood lost, the amount left in the organs—very
considerably, and must therefore be kept distinct from
it. Very closely allied, and in reality belonging to it,
are those causes of death of persons whose blood is
poor in consequence of diseases of the heart, lungs,
or of the blood itself. By theoretical conclusions, in
the absence of certainty, it must be assumed that in
these cases the loss of blood causing death is consider¬
ably less than in normal bodies, as paralysis of the
brain, the ultimate cause of death, takes place earlier.
In such cases death would follow from haemorrhage—
as in abortion—when it would not otherwise. From
a purely anatomical point of view death from bleeding
from an artery is distinguished from that from a vein.
When the bleeding is from an artery the course is
quicker than when from a vein. A partial severance
of a vessel is more dangerous than a total one, as in
the latter case a plug can form readily; a transverse
division is more dangerous than a longitudinal one

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ORIGINAL PAPERS.

The Medical Press. 493

from the gaping of the edges of the wound
.(Oesterlen).

For the exhaustive treatment of a case of fatal
hasmorrhage the forensic surgeon must obtain the
■clearest possible idea of things from the witnesses,
and from the wounds—from the infliction of the wound
to the death of the patient. If a person with an ex¬
ternal wound is found dead, the surgeon must know,
if no other cause of death is evident, whether such a
wound could cause fatal haemorrhage, whether, if
.such is the case, the fclood flowed internally or ex¬
ternally, in order, in the latter case, to search for
traces of blood; he must be able to decide whether
death has followed immediately from the discoveied
or suspected 1 cause, or whether some time may have
©lapsed between the injury and the death, and how
long a time, and especially whether the injured man
could have performed any action ; further, whether
the bleeding has been continuous or interrupted, and
thus whether death has resulted from primary or
secondary or late haemorrhage, and by what factors
this was caused (especially anatomical conditions, the
formation of aneurysms, any aid that has been ren¬
dered by the deceased himself or by others, the pre¬
sence of wound infections); further, in case of in¬
ternal haemorrhage, when a solution of continuity is
found on examination, whether it may be spontaneous,.
when the morbid cause must be looked for, or whether
violence has been inflicted, and the nature of it
(traumatic); further, whether the case is one of simple
or complicated fatal haemorrhage, and what condition
of body may be expected to be found ; then what signs
for solving the question as to whether the case is one
• of murder, suicide, or accident; whether self or any
•other aid was possible; whether it was given, or
whether intentionally or unintentionally omitted;
finally, whether and how proof is to be adduced of a
causal connection between a death from haemorrhage
and a wound inflicted at an earlier period, especially
in cases where survivors will benefit from property
left by the deceased.

The various forms of death from haemorrhage must
be considered from these points of view. These,
according to Sachs, may be classified in the following
manner:—(1) Death from haemorrhage from solution
•of continuity of the heart; (2) From solution of con¬
tinuity of the great vessels, arteries, and veins ; (3)
From parenchymatous bleeding; (4) From rupture of
internal organs; (5) From bleeding to death at birth;
(6) From fatal bleeding from the female genital
■organs.

I.—Death from Haemorrhage from Solution of
Continuity of the Heart.

Death may take place from solution of continuity
■of the heart in various ways. The simplest is that
where the heart receives a stab from without; a great
stream of blood gushes out, and the wounded man
gives up the ghost in a very short time with the
symptoms mentioned above. Friedberg (Gerichtsart-
liche Gutachten, Seite 144) draws attention to stretch¬
ing of the arms upwards (in die Hohe strecken ), as
pathognomonic of wound of the heart. In other cases
the wound opening is not free, and the blood escapes
inwards into the pericardium, the pleural cavity, a
haemato as well as a pneumothorax is formed, and
death may be less rapid.

A third mode is when the bleeding takes place into
the pericardium. This occurs when rupture of the
heart takes place, and there is no external wound,
but it may also occur when punctured wounds of the
heart are present, when the pericardial wound does
not correspond in position to that of the heart itself.
The blood expands the pericardium more and more,
a sort of shell forms around the heart, and gradually
paralyzes it (Rose’s tamponnade). The blood here lost
amounts to about 300-000 ccm. Death from hasmor-
rhage is therefore complicated in these cases by
paralysis of the heart. Whether the final cause of
death in these is the loss of blood or the paralysis
is disputed (Fischer, FrieriCh, Streifensand, Gerard,
Richter, Friedberg). Richter and Placzek have also
•gone into the question experimentally as to whether
death takes plaoe slowly or rapidly, without, how¬
ever, arriving at any decisive result. A fourth method

is that in which the wound of the heart is closed by
blood clot, the bleeding ceases, and after a time the
clot, which may heal in completely, becomes softened
by suppuration, and a late haemorrhage soon leads to
death. The case is therefore one of late bleeding set
up by the intermediate cause of suppuration. It may
be difficult to prove a connection between this bleeding
and the previous injury. Finally, cases of death from
wounds of the heart occur where the death cannot
be explained by either loss of blood or compression of
the heart; general shock or wound of the cardiac
ganglia must be taken as the cause (K6nig, Lehrbuch,
1885, Bd. I., S. 75). That such nerve injuries can
cause death, punctured wounds made by needles show,
which kill at once without reaction (KOnig). The
amount of blood lost varies, naturally, very much,
according to the nature of the nerve injury. In such
cases we should have to speak of death from haemor¬
rhage complicated by paralysis of nerves.

Corresponding to these varieties, of course, the time
that elapses after the injury is also very varied ; it may
be five minutes, or it may be several hours, or even
days. Hofmann collected 29 cases of punctured
wound of the heart, in which death took place in 50,
24, and 1J hours (one case e^ch respectively) ; in 5 cases
after a few minutes ; in 13 no time was stated. In a
case of wound of the heart reported by Ruth, death
took place on the fourth day; Picht mentions a death
from punctured wound of the heart after 6 days;
Bartikowsky after 1J hours; Leonpacher after 3 days.
Sachs brings forward a case of punctured incised
wound of the anterior wall of the heart where several
days elapsed after the injury. The varied interval of
time between the injury and death is explained by
the varied course, but is not based on it. We are not
sufficiently clear as to the precise causes. According
to Richter, it may be a question of local causes—the
part of the heart affected, the size of the wound, the
course of the canal of the wound, the direction in
which the muscular fibres are severed, or the form
of the wound. In the meantime the special influence
of these factors has not yet been established. On the
other hand, it might be thought that the clotting power
of the blood would have an effect, and it is also to
be borne in mind that individual conditions (age,
general state of the health, morbid conditions of the
heart) would have some influence on the rapidity of
death. In late death after wounds, the wounded man
may do something whereby the inquiry into the facts
may be rendered very difficult. Fischer brings for¬
ward a number of such cases (“Die Wunden des
Herzboundldes Herzbeutels,” Archiv. f. Klin. Ckir .,
Bd. IX., 1868). Richter illustrates these cases very
clearly by examples. In one case the medical witnesses,
denied the possibility of a man with a wound of the
heart being able to run through a street, so that the
official who was making the inquiry came to the con¬
clusion that the deed was committed at the spot where
the body was found, and that something was being
kept back on the part of the witnesses. In another
case, a suicide, no doubt for the purpose of mystifying,
after stabbing himself in the heart, had put the knife
into his pocket, whereby naturally the inquiry was
rendered much more difficult.

A solution of continuity of the heart may occur
spontaneously in diseased organs, or traumatically in
healthy ones. The diseases of the heart that lead to
spontaneous rupture are, according to Eichhor^t,
myocarditis and its sequelae, abscess of the heart (acute
and chronic), cardiac aneurysms, valvular disease, dis¬
eases of the cardiac orifices, the main vascular trunks,
of the coronary arteries, new growths, and echino¬
cocci in the muscles of the heart. Meyer (Virchow-
Hirsch, 1888, II. Bd., S. 172) has collected 24 cases of
cardiac rupture, and as the most frequent cause of it
has found: narrowing or closure of the coronary
arteries (descending branch of the left coronary
artery). The consequence of these are patches of
softening of the muscles of the heart, haemorrhagic
infarcts, with sudden blocking of the blood supply,
fatty degeneration of the myocardium, with gradual
closure, wheal-like cicatrices after the healing of
infarcts, most frequently on the lower part of the left
ventricle. If the heart is changed in this way, rupture
may unexpectedly take place as a natural consequence

494 The Medical Press.

ORIGINAL PAPERS.

Nov. 6, 1907.

of the progress of the pathological condition, or slight
bodily or mental disturbance may be required As
such have been observed: the lifting of a weight, a
fatiguing dance, cold water bathing, straining at stool,
too full a meal, coition, epileptic attacks, the bolting
of a big piece of meat. In the same way, naturally,
the slightest external violence may cause a diseased
heart to rupture. According to Drenckhahn’s col¬
lection, the slightest observed traumatic causes have
been a kick, or a blow of the fist. Elten rightly says,
“ Spontaneous and traumatic ruptures of the heart in
cases of degeneration of the muscles of the heart pass
immediately into one another.” To decide whether a
case is one of traumatic or spontaneous rupture, the
following diagnostic aids must be made use of: Ex-
perience has shown that the right auricle is most
exposed to rupture, whilst spontaneous ruptures there
show where the cardiac diseases present are the most
readily developed. According to Klein the rent in
spontaneous rupture of the heart is mostly small,
jagged, the margins infiltrated with blood, with fatty
degeneration in the immediate surroundings. In
traumatic rupture the opening is smooth and large;
the margins show no sanguineous infiltration, and
there is no adjacent myomalacia. The solutions of
continuity of the heart produced traumatically, like
those of the blood vessels and organs generally, are
caused by stabs incised, and gunshot wounds, or a
blunt force (falls from a height, being run over,
crushing between two fixed or moving objects—for
example, the buffers of railway wagons—a blew,
push, or fall). They become the object of medico¬
legal inquiry, as grave bodily injury, murder, suicide,
and in the form of the daily occurring accidents of
all sorts (Sachs). The implements that come into con¬
sideration in such cases are the incising, stabbing,
gunshot implements in general use. That with such
gross violence to the heart it happens occasionally that
there are no marked external signs of injury is shown
by an interesting case (Zeitschr. f. Med. Beamte, 1899,
No. 16), where a four-year-old healthy child fell from
a wagon, struck the fore part of its body, and died
in 20 minutes. At the autopsy there were only skin
abrasions over the eighth and ninth ribs of the left
side, and on the hips, whilst 120 ccm. of blood were
present in the pericardium, partly clotted and partly
fluid, and a large opening n cm. in length in the right
ventricle.

On having to decide whether a case is one of murder
or suicide in punctured wounds of the heart, conclu¬
sions may be drawn from the course of the wound.
A perfectly horizontal course is in favour of murder
(Maschka). The direction from above downwards is
rather in favour of design than accident. Caspar-
Liman mention a case in which, from the course of
the wound, the question could be answered whether
the deceased was stabbed or whether, as declared by
the accused, he ran on to the knife.

(To be continued.)

RECUMBENCY IN THE TREATMENT
OF INFANTILE PARALYSIS.

By ADONIRAM B. JUDSON, M.D.

In the ever-changing treatment of disease the
influence of environment is receiving unusual atten¬
tion, as is seen in the management of tuberculosis
of the joints. The influence of the lapse of time is
also better understood. Medicines are given in
small doses for very long periods and the effects of
time on the body are more clearly seen to influence
the course of disease and the action of remedies.

In the treatment of infantile paralysis I propose
a method which relies exclusively on the influences
of environment and the lapse of time. It is applic¬
able only in the very early stage, before the case
is likely to be seen by an orthopaedic surgeon. As
soon as the disease is recognised I would limit the
patient to the recumbent position till there is no
possibility of further recession of the paralysis. The
period of spontaneous recession extends over several
months. During this time the difficult task must

be undertaken of keeping a child, well in every-
other way, off his feet at an age when he should,
be learning to walk. In some cases eighteen
months should be occupied in this way. The com¬
mon belief that such a patient requires exercise,
especially of the affected limbs, will give rise to-
criticism and objections. A simple argument will
not prevail in the family circle, and the physician’s
word will hardly prevent the little patient from
having many a romp. And when the case ends-
there will be differences of opinion. If some lame¬
ness results, it may be said that the patient should
have had more exercise; and if there is no dis¬
ability at all, after the strict observance of re¬
cumbency, it may be said that there had been very
little the matter with the child.

The argument is as follows. It will be recalled'
that the ill-effects of joint disease are seen more
commonly in the lower extremities than the upper,
because tuberculous action is subject to resolution
in the epiphyses of the shoulder, elbow and wrist,
but often goes on to destruction of the articulating
surfaces of the hip, knee, and ankle. And when it
is noted that the arms are free, while the legs bear
the weight of the body, it is reasonably inferred that
the joints of the lower extremities when affected,,
or even suspected, should be protected by either
recumbency or appropriate apparatus. The conclu¬
sion is a plain proposition, and needs no discussion
or verification. It shares the simplicity of Jenner’s
argument when he traced the relation of cause and
effect and prescribed vaccination. In another field
Finlay, walking with his eyes open, apprehended
the relation of cause and effect and prescribed the
sequestration of the mosquito.

The necessity of reforming the environment of the
lower extremities having been derived from clinical
observations of joint disease, can practical conclu¬
sions be drawn in a similar manner from observing
the course of infantile paralysis? Disability from
this disease is seen eight times as often in the lower
as in the upper extremities, and yet in the early
stage the paralysis is found in all parts of the motor
nervous system. The muscles of the recumbent
patient are in very moderate use and in a position-
entirely favourable to spontaneous recession of the
paralysis. The arms and hands retain this
advantage when the patient is erect, but impaired
muscles in the legs and feet give way at once when
they meet the resistance of the weight of the body.
They rapidly become elongated and attenuated, and
could not well be placed in an attitude more destruc¬
tive of the possibility of restoration.

When prescribed recumbency shall give to all
parts the same environment, recession of paralysis
will be equally encouraged in the lower and upper
limbs, the disproportion of 8 to 1 will disappear, and
the sum of deformity from this disease will be
materially reduced.

The value of the method is thus proved, but it is
not readily demonstrated. Wnen comparing
methods it is not easy to show that one is better
than another. It may always be said that a case
cited on behalf of a certain method may have beerr
one that would have done well under any treat¬
ment. Tables of carefully recorded cases might
lead to correct estimates, but studies of this kind
are difficult and have not escaped criticism. Dr.
Gaillard Thomas said, with wit and wisdom, that
if there is anything more misleading than facts it
is figures. Medicine and surgery are still outside
of the realm of exact science. Therefore we wel¬
come every logical and reasonable resource of pre¬
vention and treatment.

Passive motion, resistance exercises, electricity,
massage, local applications, and judicious medica-

zed by Google

Nov. 6, 1907.

TRANSACTIONS OF SOCIETIES. The Medical Press. 495

tion should be continued. They cannot interfere
with the treatment proposed, and their observance
may make it easier persistently to maintain
recumbency—the most important agent of all.

OPERATING THEATRES.

GREAT NORTHERN HOSPITAL.

Cystotomy. — Epithelioma of Bladder, with
Massive Clots.—Mr. Arthur Edmunds operated on
a man, aet. 68, who was admitted suffering from in¬
tense pain in the hypogastrium and along the penis.
These symptoms had only been present for a couple
of days, previous to which the patient had been in
complete comfort. On examination he was seen to be
enfeebled and emaciated, and obviously in intense dis¬
comfort, with occasional paroxysms of severe pains.
He was able to pass his water, but only in small quan¬
tities at very frequent intervals, the water itself con¬
taining a considerable quantity of blood. Per rectum,
the prostate could be felt very slightly enlarged. A
full-sized catheter could be passed with the greatest
ease, but very little urine came away, although percus¬
sion above the pubes indicated that the bladder was
a good hand’s-breadth above the symphysis. A few
drops of fluid were obtained, which resembled the con¬
tents of an old haematoma, being almost treacley in
consistency and consisting mainly of blood. It was
obvious that the case presented different characteristics
from those of a simple retention of urine. While it
is possible in some cases, Mr. Edmunds said, to pass
a catheter into the bladder without relieving the
patient’s symptoms, it is usually because the eye of
the catheter has not entered the actual cavity of the
bladder, but in this case a large curved prostatic
catheter was used, and also a soft rubber catheter, the
latter being passed almost to its whole length, and in
neither case was there any resistance. Under the im¬
pression that the catheter might be blocked, a stylet
■was passed down, and a clot removed from the lumen
of the catheter, which was a complete cast of its in¬
terior. Even after repeated attempts, and repeatedly
clearing the catheter, the patient could not be relieved,
and a diagnosis of a bladder distended with blood
clot was made. In cases where the bladder is thus
distended, Mr. Edmunds said there are, of course, two
methods of procedure. In the first the urethra is
dilated, and an attempt made to remove the clots by
means of Bigelow’s evacuator. The other method,
which was adopted in this case, was a suprapubic
cystotomy, a method which is to be preferred when
the source of the bleeding is unknown, as it enables
the surgeon not only to remove the clot but also to
deal with the bleeding-point. In opening the bladder
the anterior wall was found to be excessively thin,
and only a few drops of fluid escaped. On passing
the finger into the bladder it at once met with a large
solid mass the size of a foetal head attenae, completely
filling up the viscus. This at first appeared to be a
solid growth, but more careful inspection showed that
it was a very old blood clot, covered with a certain
amount of phosphatic deposit, and intimately
adherent to the bladder wall at one point in the neigh¬
bourhood of the opening of the left ureter. The mass
was accordingly broken up and removed. At the point
of its attachment to the bladder, it was very firmly
adherent, and upon separating it the base of an epi-
theliomatous ulcer was disclosed. The bladder was
then closed, excepting at the point of insertion of a
drainage tube. There were two points of interest, Mr.
Edmunds pointed out, in this case:—(1) The method
of causation of this enormous polypoid clot. The
clot itself on section was very firm, almost a9 firm,
indeed, as the clot which is found in the cavity of

an aneurysm, but there was no lamination. A large
area of it was decolourised, and it was obvious that
it represented the fibrin deposited from a number of
successive haemorrhages, the haemoglobin being washed
out from the network of fibrin by the urine. (2) The
question of the procedure to be adopted when
an epithelioma of the bladder is discovered
after a cystotomy. The bladder is perhaps, he
said, one of the most hopeless situations for
malignant disease, and although many efforts have
been made to eradicate disease in this situation, the
results have by no means been encouraging. In the-
present case excision was obviously out of the ques¬
tion, as the patient’s condition was far too bad to-
allow of any further operative interference, and it was
doubtful if it will be ever advisable to attempt such a
procedure.

The drainage tube has been left in position
for a week, and it is proposed to maintain it as a
permanent suprapubic drainage. The man stood the
operation well, and has experienced complete relief.

TRANSACTIONS OF SOCIETIES.

ROYAL SOCIETY OF MEDICINE.

Neurological Section.

Meeting held Thursday, October 31ST.

The President, Dr. C. E. Beevor, in the Chair.

Dr. Beevor showed a case of

MYOTONIA CONGENITA.

Female, aet. 20 months. General wasting and marked
flabbiness of muscles, especially of legs. Passive
movements could be carried out through an excessive
range. Active movements could all be feebly per¬
formed. Trunk muscles stronger, the child could sit
up well. No deep reflexes obtained. To electrical
currents the muscles were less excitable than normal,
but there was no polar change. This was the second
case of Oppenheim’s disease recognised in this
country. Dr. Beevor gave a short account of the
condition.

Dr. Jas. Collier referred to two cases he had seen.
Dr. S. A. K Wilson mentioned Baudouin’s recent
findings in an autopsied case; the anterior horn cells
and nerve roots were diminished in size, but not in
number. Dr. Gordon Holmes considered that these
changes did not point to neural degeneration, but
might be secondary to disease of muscle. Drs_
Campbell Thomson and Wilfred Harris also discussed
the case.

Dr. Beevor also showed a case of

TOXIC AFFECTION OF MUSCLES AND LOWER NEURONES.

Male, aet. 64, shoemaker. History of illness.—
February, 1007, gradual loss of power in hands and
feet, beginning in left hand, then right hand, left leg
and right leg in the course of two months. On ad¬
mission in July, 1907, patient was helpless and unable
to turn in bed. Slight nystagmoid jerkings on extreme
deviation, weakness of both sterno-mastoids. Trapezii,
spinati, teres, acted well. Latissimus dorsi, deltoid,
biceps, supinator, triceps, flexors and extensors of
wrist all profoundly paralysed, the extensors more
than the flexors. Fingers could be flexed slightly, but
not extended. Flexion and extension of thumb ab¬
sent; abduction, adduction and opposition just pos¬
sible. Intercostals strong, diaphragm weak, abdominal
recti and erectores spinas strong. Flexors of hip.
weak, extensors strong. Flexors and extensors of
knee fairly good. Ankle and toe movements very
poor. All muscles show rippling fibrillation start¬
ing at one end, usually the upper, and spreading to
the other. All forms of sensation perfect. All deep-
and superficial reflexes absent. Electrical reactions.—
Upper limb, very marked diminution or absence of
reaction to faradism in all muscles; with galvanism
a strong current is required, and R.D. is present in
most of the muscles. Pathological report on excised-
portion of muscle by Dr. Gordon Holmes: (1)

Digitized by GoOgle

496 The Medical Press.

TRANSACTIONS OF SOCIETIES.

Nov. 6, 1907-

•Vitreous degeneration of fibres in various stages,
'hyperplasia of sarcoplasm and nuclear proliferation ;
<(2) simple atrophy of small numbers of fibres; (3) no
affection of the intra-muscular nerve fibres. Pro¬
gress.—Steady improvement from the beginning ot
treatment by massage and faradism.

Dr. S. A. K. Wilson described a similar case lie
had seen at Queen’s Square. Dr. Gordon Holmes said
that the vitreous change in the muscle was indica¬
tive of toxic degeneration of the muscle, and was
never secondary to nerve disease.

Dr. Wilfred Harris showed a case of

SLOWI.V PROGRESSIVE HEMIPLEGIA.

A woman, aet. 35, in September, 1905, had some pain
in muscles of the left upper arm, and noticed that
the hand became very blue and cold. In January,
1906, she began to lose the use of the index and
middle fingers. When first seen on January 23rd,
1906, the hands were intensely cyanosed, and there
was marked weakness of the movements of the whole
of the left upper limb, especially of the fingers. There
was no muscular wasting, but extreme spasticity of
the wrist and fingers, with increased deep reflexes of
the fingers, wrist, and elbow. Knee-jerks were equal
and brisk. Pulses very feeble on both sides. There
was no weakness of the legs or any abnormality, ex¬
cept that she complained of the left foot feeling colder.
Sphincters normal. No headaches, optic neuritis,
sickness, or any other intracranial symptom. Since
January, 1906, the symptoms have slowly progressed,
until in February, 1907, the left hand had lost all
power of movement, with only slight movement of
the elbow. In February, 1907, the first trace of in¬
volvement of the left leg appeared, transient weakness
and dragging, with left knee-jerk +, but flexor
plantar. In May, 1907, she dragged the left leg, and
the left plantar was absent. Now, in October, 1907,
there was permanent dragging of the left leg, and
the left plantar was now extensor. There was never
any trace of anaesthesia on the hand or foot, or any
sign of intracranial lesion. The spine, neck, and
thorax appear normal.

Dr. Parkes Wf.ber had published a similar case
Dr. Weber and Dr. Beevor thought the condition was
one of progressive cerebral sclerosis.

Mr. Percy Sargent showed a case of

nerve-root grafting.

Male, aet. 19. Shown by Dr. F. E. Batten, before
the Neurological Society, in July, 1906, as a case of
brachial plexus palsy, following influenza two months
previously. Two weeks after the illness pain in right
shoulder and arm. Power in right arm suddenly lost
at this time. When admitted to hospital in June,
1906, there were weakness and wasting of deltoid,
spinati, triceps, and biceps. An area of anaesthesia
and analgesia over shoulder and outer side of upper
arm. The fifth cervical root exposed and tested
with faradic current. The root was split longi¬
tudinally into an upper part which alone gave feeble
contractions of deltoid and spinati; and a lower,
which gave contractions of biceps and supinator
longus. The upper portion was divided and its
peripheral end turned down and implanted into the
sixth root. Three weeks later some affection, both
sensory and motor, of the sixth root area, which
passed off in two or three months. Now, fourteen
months after operation, deltoid and spinati were
much increased in bulk, and can be used voluntarily
with considerable degree of power. Deltoid and
spinati reacted to faradism.

Dr. Henry Head pointed out that the recovery was
probably due to nature and not to the operation. The
muscles were already improving when the operation
was performed. Dr. Wilson, who had watched the
■case, said that the triceps and serratus magnus had
equally improved in spite of no operative measures.
Dr. Wilfred Harris related a similar case that had
improved after operation.

Dr. Ernest Jones showed a case of

ISOLATED PARESIS OF RIGHT SERRATUS MAGNUS.
Male, aet. 4. Family history.—Negative. Previous

history.—Mother discovered two years ago that right
shoulder blade was prominent. No previous illness
or accident. Present state.—Healthy boy, with no
signs of diease except as follows: right scapula ele¬
vated, not tilted. Vertebral border and angle
prominent at rest, but greatly more so on flexing
shoulder joint. Protrusion of right upper limb weak;
elevation above head fair. Serratus magnus not
palpable. , , .

Dr. C. E. Beevor said that the weakness of the
serratus was incomplete, as elevation of the limb was
possible. He considered that the condition was a
congenital one.

Mr. Kilgour showed a case of

MUSCULAR ATROPHY WITH DELAYED THERMAL
SENSATION.

jEt. 20. In February, 1906, first noticed slight wast¬
ing of hands. This had increased since. Previous
to this had frequently blistered fingers while smoking
cigarettes. Although no pain was felt at the actual
moment of injury, a few seconds later a sensation,
similar to that caused by a burn on any other part of
body, was experienced. Present condition. The
hand muscles are atrophied, and react sluggishly to
faradism. Skin of fingers glossy. No anaesthesia or
analgesia. Over arms and upper part of chest heat
and cold are frequently confused. There is delay of
a few seconds before thermal stimulus is appreciated.
This is best marked on hands. There is blunting to
the faradic current over the dorsal and palmar sur¬
faces of both hands, and along inner sides of fore¬
arms and upper amis. 0*ver the ulnar sides of hands
this amounts to anaesthesia. Scoliosis present.

Mr. Kilgour considered the case one of syringo¬
myelia.

Dr. S. A. K. Wilson showed a case of

SEGMENTAL PAN-HYPERTROPHY.

Female, aet. 26. This congenital hypertrophy of cer¬
tain parts of the body was as follows. At present the
left arm was much larger than the right; the left
thorax was rather larger than the right, and so was
the left breast ? the left leg was slightly larger than
the right. The right foot and leg could not be con¬
sidered normal, and the first two fingers of the right
hand were larger in proportion than the others of that
hand. The hypertrophy was a true one, affecting
bones and soft tissues alike, and Dr. Wilson proposed
the term “segmental pan-hypertrophy” for the con¬
dition. The telangiectatic and pigmented areas of
the skin occurred generally.

Dr. Parkes Weber had collected the published
cases of this condition recently, and recorded some of
his own.

Dr. Farquhar Buzzard showed a case of

HUNTINGTON’S CHOREA.

Male, aet. 49. Healthy until two yearn ago, when he
had a “ nervous breakdown ” lasting about two
months, during which he had difficulty in speaking.
Six months ago first noticed involuntary movements
of the legs and trunk, associated with some pain in
left leg and abdomen. Movements had continued
with varying intensity. Latterly he has become
stupid, memory failing and some depression. Present
condition.—Choreic movements, affecting chiefly the
trunk and large limb muscles. Some mental
deterioration.

Dr. Buzzard also showed a case of

DISEASE OF THE CERVICAL VERTEBRAE ; WITH PRESSURE
SYMPTOMS.

Girl, aet. 15. January, 1906. The neck gradually be¬
came stiff, and she noticed a small swelling about the
size of a walnut, which was rather tender. In the
course of two months she became unable to move her
head at all, except slightly to flex it, and by June,
1906, the swelling had increased to its present size.
At the end of 1906 came a gradual return of move¬
ment in the neck, and she has been able to move it
more or less freely ever since. In March, 1907, the
right arm began to feel numb and gradually weakened,
and a week or two later the right leg began to drag.

Digitized by GoOglc

Ncrv. 6, 1907.

TRANSACTIONS

For three months these limbs were more or less com¬
pletely paralysed. In June there was retention of
urine for three weeks. There was a large rounded,
"hard, painless swelling occupying the back of the
neck below the level of the hairy scalp. This part
of the neck was rigid, but the movements of the head
■were remarkably free. Strings of firm, discrete,
■slightly-swollen glands might be felt in the cervical
triangles. The right arm was immobile at shoulder
and elbow; the hand was of the main-en-griffe type.
The left arm was rather weak, and there was slight
♦wasting of the small muscles of the hand on this
side. Both legs were weak, especially the right.
There was a diminution of the sensation of pain in
"both legs, more on the right side, and in both arms,
more on the right side. The deep reflexes were every¬
where brisk, with double knee clonus, and a double
extensor response.

Dr. Henry Head, Dr. Wilson, Dr. Grainger
Stewart, and Mr. Donald Armour discussed the re¬
sults of operative treatment of Pott’s disease.

Dr. James Taylor showed a case of the Landouzy-
Dejerin type of myopathy. The patient, a woman of
28, had first suffered from facial weakness, about
eight years previously.

SOCIETY FOR THE STUDY OF DISEASE IN
CHILDREN.

Meeting held October i8th, 1907.

Mr. R. Clement Lucas, F.R.C.S., in the Chair.

A paper on the

SIMULATION OF SOME OF THE SYMPTOMS OP PRIMARY
AMAUROTIC IDIOCY

by a tumour of the interpeduncular space, by Dr.
E. C. Williams, of Bristol, was read. The patient
was a girl, at. 15 months. For three months she had
been gradually failing to take notice of objects, and
had been getting weaker. On admission she lay quite
still and motionless, was somnolent, and not disturbed
by any sounds, even though quite close to her ears.
Her eyes were firmly closed, and when sat up in bed
her head rolled either backwards or to one side. The
arms were slighty spastic, the wrist-joint was flexed,
and there were slight athetoid movements of the fingers.
The legs were spastic, and remained extended when
the patient was raised from the bed. The knee-jerks
and plantar reflexes were exaggerated on admission,
but towards the end the spasticity decreased and
nearly disappeared. Babinski’s sign was present; sen¬
sation was diminished. The pupils were dilated and
fixed ; the right was divergent. There were no fundal
-changes, the disc and macula both being normal. The
child died 19 days after admission from oedema of
the lungs and heart failure. Post-mortem. —A cauli¬
flower growth the size of a walnut was found spring¬
ing from the pituitary body ; microscopical examina¬
tion showed it to be a round-celled sarcoma. There
was also a small similar growth in the parietal region.
The case resembled primary amaurotic idiocy in the
paralysis of the greater part of the body and the
muscles of the neck, in the diminution of vision, lead¬
ing to absolute blindness, and in the marasmus and
fatal termination. It differed in that it did not present
the characteristic fundal changes, and in its more rapid
progress.

A case of Associated Movements of the Upper Eyelid
and Jaw was shown by Mr. Sydney Stephenson.
There was slight ptosis on the left side, and when the
child moved the jaw the lid of the unaffected eye
showed rhythmical movements upwards and down¬
wards. An unusual feature in his case was that the
movements affected the eye which had no ptosis. The
explanation commonly received, assumed that the
levator palpebr® superioris was not supplied entirely
from the third nucleus, but also by fibres from the
fifth nerve nucleus, so that when certain of the
muscles of mastication were thrown into action, the
upper eyelid participated in the movements of the jaw.

Mr. Stephenson also showed a case of Tuberculosis
.of the Iris and Ciliary Body, with reference to Cal¬

OF SOCIETIES. The Medical Press. 497

mette’s ophthalmo-reaction. The eye had been in¬
flamed for six months. The anterior chamber of the
left eye was more or less filled with solid-looking
yellowish-grey exudation, so that only a faint indica¬
tion of the position of the pupil could be obtained.
The eye was reddened, flushed easily, and dreaded the
light somewhat.

A case of Congenital Ptosis Treated by Motais's
Operation of Tendon Transplantation , very slightly
modified, was also shown by Mr. Stephenson. The
patient was a girl, set. 2 years and 10 months. None
of her nine brothers and sisters had any deformity.
Family history unimportant. The left eye was the
subject of incomplete ptosis, the pupil being practically
covered by the drooping upper eyelid. There was no
epicanthus, and no associated deformities. Upward
movements of the eyeball were good, and no synkinetic
movements were noted. The superior rectus was
divided into two parts; the outer was stitched into the
upper eyelid, and the knot tied on the skin surface of
the latter. Seven days later the stitches were removed.

A case of Lupus Vulgaris of the Face , due to inocu¬
lation by a finger-nail, was shown by Mr. George
Fernet. It was the result of an accidental scratch by
another child.

The Chairman alluded to three cases which had
been under his care. One man scraped his knuckle by
striking a man in the mouth; another man was bitten
on the forefinger; and the third case followed circum¬
cision.

A case of Multiple Lupus Vulgaris following an
attack of measles was also shown by Mr. Pernbt. It
had previously been brought before the Society by
Dr. Poynton for lichen scrofulosorum.

The Chairman remarked that in many cases the dis¬
ease was spread in the same person by scratching.

A case of Generalised Alopecia in a Mongolian idiot
was brought forward by Mr. Pernet to demonstrate
the good growth of hair on the scalp, as the result of
persevering local treatment, and the exhibition of
thyroid extract.

An unusual case of Infantile Paralysis was shown
by Mr. Lockhart Mummery. The child, aet. 18
months, lost the use of all its limbs during an illness
12 months previously, though the arms were only
slightly affected. Since then the child had recovered
the use of the arms, but the flexor action of the fingers
of the right hand was not quite normal. There was
very slight extensor power in the right thigh, but none
in the left limb. The adductors on both sides were
completely paralysed.

A case of Genu Recurvatum was also shown by Mr.
Mummery. The child, aet. 3 months, was born with
legs bending the wrong way. Both legs were hyper-
extended to an angle of 30 degrees, and could not be
flexed beyond a straight line.

A case of Synostosis of the Upper Ends of the Radius
and Ulna was shown by Mr. Hugh Lett. Both arms
were involved, and skiagrams showed that the radius
and ulna were united by bone for about an inch at
their upper ends. The right radius was much curved.
The right arm was in a position of nearly complete
pronation, the left arm midway between pronation
and supination. Flexion and extension of the elbow
joints were perfect.

The Chairman said that congenital ankylosis was
very rare; some explanation such as intra-uterine
fracture, or an arthritis very early in life, seemed neces¬
sary to account for the condition.

A case of Osteogenesis Imperfecta was shown by Dr.
Langmead. The child was born after an easy labour
seven weeks previously, and was brought to the hos¬
pital on account of the deformities four days later.
The legs and thighs were sharply bent, the arms and
forearms were also bent, but not so much. Amniotic
dimples were seen on both legs, and on the right thigh.
The post-anal dimple was well defined. Skiagrams
showed fractures of the right humerus radius and ulna,
of both tibi® and fibulx, and of each femur in two
places, making eleven in all. There was marked callus
formation about some of the fractures, especially those
of the leg and thigh bones. The shadow given by the
bones was no less dense than normal. There were
nine other children in the family, all well, and there
was no evidence or history of syphilis in the parents.

uy

e

49& The Medical Press.

CORRESPONDENCE.

Nov. 6, 1907.

Mr. Hugh Lett alluded to a similar case he had
brought before the Society last session, and asked
whether there was any suggestion of heredity or sign
of hydrocephalus in Dr. Langmead’s case.

Dr. Langmead replied that there was no hydro¬
cephalus or history of heredity.

A case of Congenital Heart Disease in a boy, aet. 5
years, was shown by Dr. C. W. Chapman. The only
symptom he had had was some shortness of breath on
exertion. He had had no illness beyond an occasional
bronchial attack, one being so severe as to require
confinement to the room for six months. He was ex¬
ceptionally well developed, and his mental condition
was beyond the average. The cardiac dulness was not
increased. In the pulmonary area there was a harsh
systolic murmur which was conducted upwards and
outwards. Over the midsternum there was a loud,
blowing systolic murmur which could be traced in all
directions, and was faintly audible in the midscapular
region. The aortic sounds were normal. There was
no cyanosis, and the finger-tips were not clubbed.
Dr. Chapman considered that the interventricular
septum was patent, with stenosis of the pulmonary
artery. The points of interest were the absence of usual
symptoms (with the exception of shortness of brerth
on exertion), and the boy’s excellent development.

Dr. Carpenter agreed with the diagnosis of con¬
genital malformation of the heart and stenosis of the
pulmonary artery. The murmur which was heard all
over the front of the chest was better heard on the
left than on the right, and it was also heard in the
great vessels of the neck. When the murmur was so
conducted, he looked upon it as a sign that the septum
ventriculorum was perforate, but unfortunately it was
not an infallible sign. He did not agrce that there
was no right-sided hypertrophy, and pointed out that
an X-ray examination would determine the point. It
was not uncommon for cases of congenital heart mal¬
formation to give no physical indications of their in¬
firmity until an initial attack of bronchitis or
broncho-pneumonia, from the onset of which, cyanosis
and other signs often dated. Mild varieties of narrow¬
ing of the pulmonary artery, such as this appeared to
be, were not incompatible with long life. The dangers
lay in the balance of the circulation being upset by
lung troubles, and by the onset of endocarditis further
complicating matters.

Dr. Cautley remarked that the patient was a good
illustration of the fact that in these cases the prognosis
depended on the general health of the chili and the
circulatory effects, rather than on the loudness and
distribution of the murmur.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Parte. Nov. 3rd, 1907.

Acute CEdema of the Lungs.

The treatment of acute oedema of the lungs must be
prompt to be successful. The best authors (Hayem,
Huchard, Dieulafoy) are agreed on the necessity of
blood-letting whenever practicable. From 10 to 12
ounces of blood should be drawn, the procedure to be
renewed the following day if necessary. Under its in¬
fluence the threatened asphyxia disappears with
Tapidity. If for certain reasons general blood-letting
is not accepted, or possible, wet cupping or leeches
should be employed, although not to the same
advantage.

Spartein or strophanthus is useful to strengthen the
action of the heart; digitalis should be reserved for
the sub-acute or chronic form depending on cardiac
origin. Champagne might be freely given, while
chloride of calcium has been recommended by
Sztahovszky. Ipecacuanha is useful in oedema com¬
plicated wtih general bronchitis.

Oxygen gas may be respired with benefit. M.
Huchard recommends injections of camphor and oil
(1—10) and strychnine is very beneficial, and should
be preferred to cafein. Morphia is absolutely counter-

indicated and dangerous. The same may be said of
blisters. As to iodide of potassium, it should be sup¬
pressed as soon as the first symptoms of oedema set
in.

In rheumatism complicated with pulmonary
trouble, salicylate of methyl as an external application
is dangerous, as it possesses marked oedematogenic
properties.

Suppression of salt in food is absolutely indicated
in acute oedema, as oedema is one of the consequences
of the retention of chlorides.

Treatment of Hemophilia.

At the recent meeting of the Congrfes de Medecine r
M. Carriere (Lille) read a paper on the treatment of
haemophilia. The patient should, if possible, be
ordered a change of climate, either to the seaside or
to the mountains, to renovate the blood. A tonic
regime should be instituted (eggs, meat, vegetables),
iron or arsenic is useful against anaemia, but has no
direct action on the haemophilia itself. For this,
chloride of calcium, gelatine, serotherapy, constitute
the most favourable treatment. Chloride of
calcium might be given in »Sgr. doses four
times a day (adult), and continued for some time.
Gelatine is less satisfactory. Serotherapy was recom¬
mended recently by Weill. An ounce of the serum
of the horse might be injected every 10 or 15 days.

When an operation seems necessary on a patient
suspected of haemophilia (vegetations, amygdalotomy,
avulsion of a tooth), the coagulation of the blood
should be examined befoie operating, and the patient
submitted to a preparatory treatment several days be¬
fore the operation. Injection of an ounce of animal
serum every day; enemas of half-an-ounce of gelatine
three times a day; administration of a mixture, con¬
taining from one to two drachms of chloride of
calcium.

In case of hemorrhage, the usual local methods of
arresting it, according to the region, should be em¬
ployed ; plugging for cpistaxis, obliteration of the
dental cavity with wax, after avulsion, etc.

The Continental Anglo-American Medical Society.

The annual meeting of this Society was held re¬
cently in Paris. Dr. Coldstream (of Florence) was in
the chair, and the following members were present:
Mr. G. H. Brandt and Dr. Egerton Brandt (Nice and
Royat), Dr. Cormack (Vichy and Hyfcres), Dr.
Cafferata (Spa), Dr. Douty (Cannes), Dr. Heinemann
(Bad Nauheim), Dr. Johnston Lavis (Beaulieu), Dr.
Trfev&s-Barber (Geneva), Dr. Sillery Vale (Arcachon),.
Dr. Bull, Dr. Maguin, Dr. Gros, Dr. Jarvis, Dr.
Rividre, Dr. Marucheau, Dr. Turner, Dr. Warden, and
Dr. Leonard Robinson (Paris), hon. secretary.

After the presentation of the annual report it was
announced that a brass tablet to the memory of the
late Dr. Alan Herbert, Officier of the Legion
d’honneur, had been erected to his memory by mem¬
bers of the Society in the chapel of the Hertford
British Hospital, Paris.

On examination of the voting papers to fill the
vacancies on the Executive Committee, it was found
that Dr. G. Sandison Brock (Rome), Dr. Maguin, and
Dr. Warden (Paris), and Dr. A. Hugh Gibbon
(Naples) had been elected. The following five candi¬
dates for membership were duly elected: Frederik
Michael Bishop, M.R.C.S., L.R.C.P. (Varenna 3,.
Cadenabbia) ; Marc de Levis, M.D.Lyons (Nice);
Bryden Glendining, M.B., B.Ch.Durham (Madrid);
Frederick Aylmer Hort, M.R.C.S., L.R.C.P., M.D.
Montpellier (Nice and Aix-les-Bains) ; Arthur Gerald
Welsford, M.D., B.C.Cantab, F.R.C.S.Eng., D.P.H.
Cantab (Rome). There were no fewer than eight
motions down on the business paper, but these were
mostly withdrawn after full discussion. It was, how¬
ever, generally considered that it would be an advan¬
tage to members of the Society and to the travelling

ublic, if a list could be made as complete as possible

y the inclusion in it of all duly qualified and eligible
British and American practitioners on the Continent,
of Europe and North Africa. It was also decided
“that no members shall be eligible to hold any office
in the Society unless the full amount of his annual
dues be paid.” The motion that “five black balla

Digi

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CORRESPONDENCE.

The Medical Press. 4Q9

Nov. 6, 1907.

shall be considered sufficient to exclude a candidate,”
gave rise to considerable discussion, but it was ulti¬
mately carried.

Dr. Heinemann said that as a result of the dis¬
cussions on the various motions he proposed that the
Society appoint an ethical committee j the proposal
was seconded by Dr. Maguin, and will be discussed
at the next annual meeting. A hearty vote of thanks
to the Chairman brought the meeting to a close. In
the evening the annual dinner of the Society was held
at the Hotel du Palais D’Orsay, when twenty members
-of the Society were present, besides many guests, the
gathering proving a most enjoyable function.

Rontgen Rays in Malignant Tumours.

The influence of X-rays in malignant tumours was
set forth by Dr. B6clese at the recent surgical con¬
gress. It is well-known that the neoplastic cells are
more sensitive to the action of the rays than healthy
cells; the former are destroyed while the latter resist.
This properly explains the curative action of the rays
which succeed very well in certain maladies, producing
a complete cure; at other times the improvement is
-only temporary, and in many cases the effect is
absolutely nil.

Complete cures are observed in cutaneous epithe¬
lioma provided it does not penetrate further than the
skin.

Complete disappearance is also observed in certain
tumours of the breast. The slow development of a
.neoplasm of the breast, when it is movable under the
skin and well in front, has a chance of being cured
by radiography. Even when the tumour is ulcerated
-superficially, and to more or less extent, success may
be hoped for. Tumours of the breast that have
returned after operation, under the form of indurated
ganglions, limited to the cicatrices of the operation or
in its immediate neighbourhood, easily disappear.

However, when the relapse attacks the deep tissues,
the rays are without effect.

In epithelioma of the mucous membrane, the results
are not satisfactory. Exception might be made, how-
-eyer, for epithelioma of the mucous membrane in con¬
tinuity with skin and in the neighbourhood of the
natural orifices; lips, arms, external genital organs,
prepuce flaws, labii; neoplastic ulcerations of the lips
'have frequently disappeared as well as the submaxillary
glands which accompanied it. A few isolated cases of
cancer of the tongue have been cured, at least for a
time, consequently radiotherapy should be "tried, at least
at the beginning when the surgeon hesitates to pro¬
nounce the word “ operation.” Later it will be simply
a complement of the operation to destroy the visible or
invisible germs which escaped the action of the knife.

In the treatment of sarcoma, for which the bistomy
is given the first place, the rays complete the operation
and prevent relapses more successfully than in other
forms of cancer.

During the discussion which followed the statistics of
107 cases were examined: Cutaneous epithelioma fur¬
nished 23 cures out of 28 cases (82 per cent.); epithe¬
lioma of the mucous membrane, one temporary im¬
provement out of 17 cases, in other words, completely
unsuccessful; tumours of the breast: two small fibroma
cured, 11 characterised cases of cancer, uninfluenced ;
2 successful cases out of 7 relapsing cancers. Some sar¬
comata and osteo-sarcomata (five cases) notably im¬
proved.

To resume, the X-rays cure almost with certainty
cutaneous epithelioma, improve sarcoma, and certain
tumours of the breast, especially recent relapsing
cancers, and fail completely in all other neoplasms.
Nevertheless, the treatment, exercising a moral action,
at least, can be employed with precaution in those
cases where surgery has declared itself powerless.

GERMANY.

Berlin. Nov. 3 rd, i*o7.

Is Opium Useful or Harmful in Acute Peritonitis?

This is an exceedingly important question discussed
by Prof. Pel, of Amsterdam, in the Berliner klin.
Wochenschr. (32/07).

He says that during the last few years many prac¬
titioners, especially those inclined to surgery, have

objected to the employment of opium in acute peri¬
typhlitis, and have rejected it as unsuitable. And now
matters have advanced so far that even physicians—
Dieulafoy, of Paris, for example, Bourget, of
Lausanne, Albu, of Berlin, and others—have ranged
themselves as opponents of opium.

Although thoroughly convinced of the high import¬
ance of theoretical considerations and experiment, he
takes his stand on this: that questions such as the
above can only be solved by clinical observation at
the bedside and experience. From observation of

S cases the writer is convinced that opium should not
rejected in treatment of acute perityphlitis. He
considers the useful influence of opium in this disease
as one of the best founded facts in medicine. The
injurious effects of vomiting on the heart and ab¬
dominal cavity afe partly eliminated by it; the rest¬
fulness in bed, so urgently needed, is aided; rest at
night is assured, and the tormenting feeling of thirst
is diminished. The spasmodic peristaltic contractions
which tear away adhesions and further the extension
ot the mischief are quietened, and the limitation or
encapsulisation of the inflammatory process is assisted,
thus the healing art assists nature in its endeavours
to limit the spread of the disease, and at the same
time the humane aims of medicine are brought into
piay, and the three requirements of our wise fore¬
fathers of an ideal method of treatment— tuto, cito et
jucunde —receive their fulfilment.

The author gives the opium in the form of laudanum
or tinct. opu, in doses of 10 or 15 drops every hour
or every two hours, diminished as soon as the patient’s
condition will allow. With suitable applications of
ice, small doses of opium will often answer the pur¬
pose. If the pain has to be mastered quickly, it will
be proper to begin with a subcutaneous injection of
morphia. Small rectal injections of a few drops of
laudanum also act favourably. Moreover, the patients
bear opium even in large doses remarkably well. Any
possible constipation accompanying the opium is not
a contra-indication. The writer has never seen any
trace of intestinal paresis, meteorism, or abnormal
decomposition of abdominal contents or absorption of
intestinal poisons in consequence of the opium treat¬
ment. Neither can he agree with Albu’s assertion that
opium often leaves a tendency to constipation behind
it. Not infrequently one gets the impression that, as
in lead colic, opium has the effect of furthering in¬
testinal evacuation by its anti-spasmodic powers. He
is quite convinced that purgative treatment is the worst

curft” ^ hCre U may ** 9aid ’ UQui ? ur Z at > male
A second objection brought mainly by the surgeon
against the use of opium in acute perityphlitis is that
it masks symptoms. The author does not share
even this view The bowel is not paralysed (as be-

irr^nl opium ’ but 1116 undesired,

irregular, and painful contractions are relieved by

su itable—-» .e., therapeutic, non-poisonous doses of the
drug. The subjective feeling of well-being is increased,
the patient rests better, the vomiting becomes less tor-
menting, and, of course, the abdominal pain becomes
less severe. He cannot understand how a “good ”
observer can be deceived if he watches all the
symptoms of the disease (pulse, tongue, temperature
respirations, general condition, blood, urine, abdomen,’
etc), buch deception could only occur to one who was
not a good clinical observer, or one who treats his
patients with really poisonous doses of opium.

NaturaHy, absolute rest in bed, ice applications, and
the strictest dieting are necessary. In the most acute
cases m which the diagnosis is assured and the other
conditions are favourable, the so-called early opera-
*J on . 1S rat i°nal and should be recommended during
the first 24 or 36 hours. This method of treatment can
scarcely be carried out in one-third or one-fourth of
the cases. As soon as the general and local symptoms

E oint to suppuration, the abscess should be opened,
ut this will only be in a comparatively small number
of cases.

The writer thinks it a great pity that the general
practitioner who has the great advantage of meeting
all classes of cases, mild and severe, and in all stages
from the earliest to the fully developed, should have
taken so little part in the solution of this important

500 The Medical Press.

CORRESPONDENCE.

Not. 6, <907.

problem, as they are in the best position to give a
reliable opinion on the immediate and subsequent
results of any method of treatment.

The author would lay down two propositions scarcely
in accordance with the spirit of modern medicine, but
in agreement with the words, Vidi quid seripsi: —

(1) With proper treatment, acute perityphlitis (appen¬
dicitis, periappendicitis) will run a favourable course
in 90 per cent of the cases.

(2) The physician who treats his cases of peri¬
typhlitis on these principles by no means neglects
them. The disadvantages of giving opium, and the
advantages of a laxative line of treatment, are
theoretical rather than based on accurate clinical
observation. That physician who withholds opium
in suitable doses from his cases of acute perityphlitis
(exceptis excipiendis) is guilty of the sin of omission ;
he who treats them with laxatives, of malpraxis.

Amongst the numerous subjects discussed at the
International Congress for Hygiene and Demography
held in Berlin was that of the

/Etiology of Tuberculosis.

Prof. Arloing, of Lyons, believed there was only one
bacillus of the disease. The supposed different kinds
or types were temporary varieties whose special forms
lasted only as long as the circumstances that gave rise
to them.

Strictly defined types were rarely found. The bacilli
comprised an almost unlimited series of individuals
whose forms gradually passed into each other. This
changeableness sufficed to explain the usual dis¬
tinguishing signs of tuberculosis in mammals and
birds. Both from a medical and hygienic standpoint
there was a real danger in laying down principles for
the prevention of tuberculosis on such slight differ¬
ences.

Dr. Ravenel, Philadelphia, said the digestive tract
was frequently the point of entry of the bacillus. The
bacillus could penetrate the uninjured mucous mem¬
brane of the intestines without causing any wound.
This occurred mostly during the digestion of fatty
foods. The bacilli passed with the chylo along
the lymph tracts, and through the thoracic duct into
the blood, which carried it into the lungs, where by
the filtrating action of the lung tissue they were to a
great extent retained. Infection through the digestive
tract was particularly frequent in children. The milk
of tuberculous cows was the cause in many cases.

The disease could be conveyed by touch, by kissing,
unclean hands in cleaning up after cases of death, by
the washing of vessels that had been used by tuber¬
culous patients, etc. These kinds of infection, how¬
ever, played only a subordinate r 61 e in the spread of
the disease.

Hr. Fliigge, Breslau, was of opinion that the disease
was spread mostly by inhalation of tuberculous dust.

Prof. Ribbert, Bonn, concluded from the examination
of cadavers that the disease was localized most fre¬
quently in the bronchial glands and in the lungs. In
the majority of cases that in the glands was the only
gland tuberculosis in the body. It could be of only
aerogenous origin. Intestinal infection was of far less
importance.

Prof. v. Schroetter, Vienna, said the lungs were most
frequently the first affected.

Hr. Dieterlen said that if bacteria were injected
into animals by the rectum they were found in the
lungs four hours later. The germs ascended the
intestinal tract, and passed into the lungs through the
oesophagus. When the oesophagus was ligatured, they
were never found in the lungs.

AUSTRIA.

Vienna, Nev. jrd, 1907.

Tuberculosis.

SchrOtter had a paper on the necessity of notifica¬
tion in tuberculosis. This subject had been fully
discussed at the International Conference, and a re¬
solution passed (a) that all recognised cases of tuber¬
culosis, (b) all dying of the malady, (<•) and all re¬
movals of the disease should be carefully notified.
He said (a) had been objected to on the ground of its
scope; it is too extensive, and includes many cases

not at all dangerous to the public, while (£) and (c)
were accepted by both the International Congress and
the Hague Committee. Now, if all cases be not
notifiable, at what stage must we notify—those who
are dangerous or those who are likely to become
dangerous. We have often cases coming before us of
such a light character that no notice is taken of thent
till they burst into a conflagration. We have often
cases of local condition of the nose that end fatally
in meningitis. These are cases equally as dangerous
as if pleurites pneumothorax or other lung trouble
had occurred. The social position is certainly one to
be considered, where every care and cleanliness would
be exercised.

All that authorities have to go on hitherto are the
statistics of the dead, which must be accepted with
some reserve, as many bronchitic, pleuritic, etc., cases
may come under this category. This is now changed.
There is no excuse for a false diagnosis with Pirquet’s
cutaneous or Calmette's ophthalmic test, which can be
made in a few hours without any danger of injury to
the patient.

It is not for us to point out the utilitarian side of
the question to authorities, but it must be left in their
hands, with the possibility of determining every’ case
of this character within their area.

It is evident from our present knowledge of the
disease that notification must come in its most com¬
prehensive form, and that the more advanced cases
must be isolated in sanatoria, or provided with hos¬
pital accommodation. When we examine the objec¬
tions to notification we must admit they are weak and
against the interest of the patient, but it must also be
admitted that if such knowledge were made public it
would injure many of the more healthy and less
dangerous in their social and industrial life. It must
not be forgotten that this information is confidential,
and not for the public, although it is for the public
good. If the subject affected be not dangerous,
no particular notice would be taken, although
the knowledge would be useful in important
offices. It is interesting in this direction to

read the accounts of Philip, Calmette, and
Kayserling, of Norway, who have educated the
authorities to take every care against the spread of this
malignant disease. Here general notification is ob¬
served, and what is possible in this country can surely
be carried out by other cultivated nations. It is im¬
portant, however, that every effort should be made by
the authorities for the proper treatment of every one
so notified, and that reasonable regulations should be
laid down for their observance. Raw, of Liverpool,
advocated notification for the so-called severe cases
which would be dangerous to the community. Milder
or latent cases should not be pressed for notification.
Obligatory notification existed in Sheffield on these
linei, and appear to work satisfactorily. Glasenapp,
Berlin, proposed an amendment that all cases dying
from lung or throat tuberculosis should be notified,
and the dwellings disinfected, and added that these
diseases in life should be carefully observed. Teleky
thought that obligatory notification of all cases of
tuberculosis was impracticable, and would be resisted
by the people. He thought a more obligatory disin¬
fection of dwellings where advanced tuberculosis bad
been located, particularly in sanatoria or watering-
places where lung diseases were treated, should be
thoroughly supervised. Hermann, Prague, as a
jurist, welcomed the general obligatory notification as
a reasonable and effectual method of checking the
diease. Every individual was a member of the
State, and claimed its protection from infectious
diseases such as tuberculosis and syphilis.

Tuberculosis.

At the recent conference Fliigge supported Weichsel-
baum in the belief of infecting by the bowel easier
than the lung. The subcutaneous injection was no more
potent than the inhalation, but acted quicker, while the
alimentary canal conveyed a million times more bacilli
than either of the other two portals. He admitted,
however, that his experiments showed that fewer bacilli
were taken in by the lung, but they acted more
violently and virulently than inoculation or alimenta¬
tion. But we must make an allowance for morals and

Digitized by GoOgle

Nov. 6, 1907.

customs when comparing animal experiments with
human results. Children may be more easily infected
by cheese, butter, milk, and unclean fingers, etc., than
elderly persons, but the latter cannot escape the
fomites or the organism in the dry dust from sputa,
etc. The “Trfipfchen” or drop theory is quite
plausible and possible. A patient suffering from the
disease coughing causes the finer part of coughed
matter to combine with the floating dust that is directly
wafted to the healthy lung where it is deposited to
germinate. This may be the mode of infection where
long associations are kept up, such as between mother
and son or man and wife, but in communities or large
assemblies it is not so likely from the rapid oxidation
in the fluid state weakening the potency of the virus.

HUNGARY.

Budapest, Nov. 3 rd, 1907*

According to the educational number of a leading
medical weekly, the number of medical students has
been increasing steadily since 1896. The University
of Budapest had then about 500 students, whereas this
this year it counts about 1,000. The standards of
preparation of study and of graduation have been
raised considerably, showing that there is a disposition
on the part of all concerned to elevate the standard of
the profession by bringing into it men and women
who are better prepared to practice medicine, and who
will be a credit to the profession in every way.

Public Lecture on Small-pox.

From the occasion of the small-pox epidemics in
Vienna, Dr. Becsey gave a lecture to the lay people
on the importance of second vaccination of adults.
On the same day he discussed in the Medical Society
the symptomatology and differential diagnosis of
small-pox, and showed lantern slides made from
photographs taken of patients at the Isolation Hos¬
pital. He also quoted the statistics of the Vienna
Department of Health, showing the incidents and
death-rate of the disease in vaccinated and unvacci¬
nated persons, and described the methods of vaccina¬
tion. He emphasised the necessity of using virus
-which was efficient. Failure to obtain a take was
usually due to inert virus, and sometimes to im¬
proper technic in vaccinating.

Symptoms of Hereditary Syphilis.

Dr. Selley, in a lecture held at the Royal Medical
Society’s recent meeting, stated that in establishing a
diagnosis of hereditary syphilis there were three points
known as the triad of syphilis, which had long been
looked upon as of the greatest value. These were
Hutchinson’s teeth, interstitial keratitis, and a par¬
ticular form of deafness. These points were con¬
sidered in their order. He reported several cases of
late hereditary syphilis gleaned from the literature,
and others that had occ aired in his own practice.

Agglutination of Typhoid Sera.

Dr. Sz&kacs has made the observation that the serum
of patients suffering from typhoid will also agglu-
tinate the paratyphoid germs, and it may be difficult
to say whether the patient suffers from typhoid or
paratyphoid. He pointed out the necessity of always
determining the highest dilution in which agglutina¬
tion will still take place. It may also happen that the
typhoid bacillus will not be agglutinated by typhoid
serum in low dilution; while with high dilution clump¬
ing will be perfect. In a case mentioned a dilution
of 1 to 80 was tested against both typhoid and para¬
typhoid. The latter was clumped actively, the former
not at all. A diagnosis of paratyphoid, therefore,
seemed probable, yet, on further testing the serum,
active agglutination was obtained with typhoid at 1
to 640; while the paratyphoid was not at all agglu¬
tinated in this dilution. The microscopic test is
always more delicate than the macroscopic.

On the Value of Thkophyllin.

Dr. Kollarits analysed a series of 728 cases, which
had been treated with theophyllin, with the following
results:—In 326 cases the drug accomplished the de¬
sired effects; in 40 cases the improvement was only

The Medical Press 5 01

relative, and in 62 no good results were seen. In 85,
patients theophyllin brought about a satisfactory
diuresis after most other diuretics had failed, and in
55 diuresis was much more marked with theophyllin
than with the other drugs. No difference in action
could be detected between the pure drug and the
various salts on the market. After effects were seen
in as high as 31 per cent., but in the great majority
these were very * light, and chiefly gastric (vomiting,
diarrhoea and nausea). Two patients died soon after
taking a powder, but it is impossible to decide if the
latter was really responsible, since the cardiac weak¬
ness was extreme in each case. Collapse was observed
three times, and in a large number such minor dis¬
turbances as languor, insomnia, and general nervous¬
ness. The best results were seen in cardiac hydrops,
and (contrary to some observers) in acute nephritis ;
but good can also be accomplished in chronic
nephritis, cirrhosis of the liver, and in exudative
pleuritis. Often the first dose is not well borne, but a
tolerance is soon established. At first no more than
0.1 grains should be given.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

Training of Defective Children. —The first
special school for the training of defective children in
Edinburgh was opened on October 28th by Mrs. Burg-
win, Superintendent of Special Schools under the
London County Council. Mr. W. H. Mill, Chairman
of the School Board, remarked that in Edinburgh they
had been somewhat dilatory in providing a school of
this kind, and they were indebted to Mr. T- W.
Gulland, M.P., for having initiated the movement
among them. In the school they intended to teach
beth mentally and physically defective children, and
they had provided ambulance wagons to bring the
scholars in the morning and take them home at mght.
They had two teachers, one trained to instruct mentally
defective, and one trained to deal with the physically
defective. A nurse would also be in attendance.
Mrs. Burgwin, in the course of an interesting address,
explained the methods adopted, and tho class of
children dealt with, in such schools. Imbeciles
should be excluded. They would deal with those
who manifested the first deviation from the normal—
the child who could not read, but could sum, who had
fits of temper, who was not quite right, but in regard
to whom you could not say what was wrong. These
children were very often nervous, untruthful, desirous
of saying anything that would please, and dirty in
their habits. In her own special schools many pupils-
who had seemed almost hopeless were now earning
good wages; it was cheaper to spend money on
schools than on penitentiaries and poor houses. She
was almost hopeless about such cases when they
reached adult life. The proportion of defective
children was about 1 per cent., boys being more
numerous than girls. In London about one-third of
the children could always earn after leaving school;
about one>-third were doubtful. She advocated in
connection with the least impressionable cases the
establishment of good, bright, working colonies. A
vote of thanks was moved by Dr. Clouston, and
seconded by Mr Leslie Mackenzie.

Care of Feeble-minded Children in Glasgow.—
The first annual meeting of the Association for thel
Care of Defective Children was held on October 31st,
Provost Bilsland in the chair. He moved a resolu¬
tion commending the work of the institution to the
public to obtain funds for the extension of the present
institution at Kirkintilloch. At present only girls
were dealt with, and the directors were most anxious
to include boys. Sir John Tuke seconded, and spoke
in terms of high praise of the management of the in¬
stitution. Dr. John Macpherson, H.M. Commissioner
on Lunacy, proposed a resolution recognizing that the
work of the Association was much hampered by lack
of statutory powers to retain feeble-minded children
under its care against the wish of parents. He re-

CORRESPONDENCE.

502 The Medical Press.

CORRESPONDENCE.

Nov. 6, 1907.

minded his audience that the State was proverbially
slow to interfere until philanthropic effort had paved
the way for it, and that the whole of the great lunacy
system of Scotland had been initiated by private
enterprise and charity. Excellent as the work of the
defective schools was, it did not protect the children
or follow them through life as it ought. Perhaps
when something like ample accommodation was found
all ever the country for feeble-minded children people
would begin to talk about an increase of imbecility
as they now did about an increase of insanity. At
present they had no power to keep these children after
a certain age, with the result that many of them at the
most critical age of their lives went back to unsuitable
guardians, and lost all the moral and physical good
they had gained. In seconding the resolution, Miss
K. V. Bannatyne pointed out that at present they had
actually more power in the case of a normal child
who lived in dangerous surroundings at home than
they had in the case of the feeble-minded ; it was
necessary that the legislature should rectify this, and
give them powers of compulsory detention.

Royal Medical Society. —The inaugural address
of the 171st session of this ancient Society was de¬
livered in their hall on October 24th by Professor
Sherrington, Liverpool, who took as his subject “In¬
hibition.” The lecture was illustrated by lantern
slides, and was much appreciated. In replying to a
vote of thanks, Professor Sherrington spoke of the
extraordinary vitality of the Society—he thought it
must be unique. In London there was the old Aber-
nethian of St. Bartholomew’s, but that, though more
than 100 years old, was a mere youngster beside the
Royal Medical Society.

Presentation to Dr. Carswell. —On October 24th
the Lord Provost publicly presented Dr. John Cars¬
well with a cheque for £415, and a silver salver bear¬
ing the following inscription, “Presented in token of
their regard for his personal qualities, and in recog¬
nition of his services to the community, as a member
of the Town Council and other philanthropic and
public boards, and of his eminent services to the
special department of medical practice to which he
has devoted his life.” Appropriate speeches were
made by the Lord Provost, Sir John Batty Tuke,
M.P., and Dr. Oswald.

St. Andrews University Rectorial Election.—
Two nominations for the Lord Rectorship had been
made, namely, Mr. Andrew Carnegie and Lord Ave¬
bury, and the poll had been arranged for
November 2nd. On the day preceding »he polling
day, however, considerable surprise was occasioned
by receipt of the intimation that Mr. Carnegie had
declined to allow his name to go forward. Lord
Avebury has therefore been returned unopposed. It
should be stated that Mr. Carnegie had been nomi¬
nated without his consent having been obtained.

BELFAST.

Visit of their Excellencies the Lord Lieutenant
and Lady Aberdeen. —Daring the past week we have
had a three days’ visit from the Viceregal party, who
spent a busy time in visiting various institutions in
the city, and attending meetings. Lady Aberdeen was
specially active in her interest in health affairs, address¬
ing the opening meeting of the Belfast Branch of the
Women’s Health Association, speaking at a meeting
of the Ulster Branch cf the Irish Nurses’ Association,
and opening a bazaar for the Belfast Hospital for Sick
Children. At the first-named meeting the chair was
taken by the Lord Mayor, the Earl of Shaftesbury,
and the attendance was very large and representative.
Lady Aberdeen gave a stirring address on the problems
of physical deterioration, and the awakening of the
national conscience in health matters. She also put
in a word for the Tuberculosis Exhibition shortly to
visit Belfast. A resolution approving the formation
of a local branch was moved by the Dowager
Marchioness of Dufferin and Ava, who since her illus¬
trious husband’s death has lived at Clandeboye and
interested herself deeply in local philanthropic move¬
ments. The High Sheriff, Dr. P. R. O’Connell, J.P.,

was able to speak with effect from his wide experience
as a hospital surgeon in Belfast of the ravages of
tuberculosis among the working classes of the city ;
and Dr. King-Kerr, J.P., the Chairman of the Public
Health Committee, also spoke with local knowledge.
A long and most successful meeting was brought to a
conclusion by a vote of thanks to the Lord Mayor,
moved by the Lord Lieutenant, and seconded by Sir
John Byers, M.D. On Thursday afternoon Lady
Aberdeen addressed a meeting of the Ulster Branch of
the Irish Nurses’ Association, which was presided oveT
by Lady Hermione Blackwood, herself a trained nurse.
Her Excellency appealed to the nurses to help in every
way in their power towards the success of the Women’s
National Health Association, and pointed out to them
how much benefit such an Association might confer
on the community by dealing with such subjects as the
provision of consumptive sanatoria and the regulation
of food and milk supplies. In regard to the com¬
pulsory notification of consumption, she said that there
were some things in the Act which would bear hardly
on patients unless great care were exercised by the
local authorities who put it in force, and it was
thought better to have a short measure dealing with
that class of case alone. The last visit paid by their
Excellencies before leaving Belfast on Thursday was
also one in the interests of public health, as it was
to the Model Dairy established by Mr. Alec Wilson at
Belvoir Park. The precautions taken to ensure the
purity of the milk are as follows:—(1) The employees
are inspected by a medical man, to ensure their being
free from infectious disease; (2) The cows are

systematically inspected by a veterinary surgeon, are
properly housed, and are milked in the cleanest pos¬
sible way; (3) The milk is at once chilled, to stop
the growth of bacteria, then filtered through prepared
cotton wool, bottled and sealed ; (4) All utensils are
properly washed and scalded with high-pressure steam
immediately after use. Mr. Wilson contemplates the
further step of testing all cows by the tuberculin test,
if the public is willing to pay the higher price which
this would render necessary, but at present the matter
has not been settled.

Notification of Births.— At a meeting of the
Public Health Committee held last week, the Medical
Superintendent Officer of Health recommended
bringing into operation the “Act to provide for the
Early Notification of Births,” and the Committee
agreed to recommend the Corporation to do so. This
will entail on all doctors and midwives who have seen
a woman within six hours of her confinement the duty
of sending information of the same to the Public
Health authorities within 36 hours. For this work no
remuneration will be given, though a supply of
stamped postcards will be generously given to those
who apply for them! No doubt the medical members
of the Coiporation will have something to say before
the Act is finally adopted.

LETTERS TO THE EDITOR.

SOUTHEND AND CHELTENHAM.

To the Editor of The Medical Press and Circular.

Sir, —Southend and Cheltenham do not stand alone.
The administration of sanitary laws throughout the
country is everywhere more or less defective; in many
places the laws are virtually almost completely
ignored. This fact was illustrated within the past few
weeks in the Local Government Board’s report on 30
Lancashire boroughs and urban districts. In many
of these places no medical officer is employed, and
where a sanitary inspector is engaged he is often paid
to devote only an insufficient part of his time to the
work. Although overcrowded slum-dwellings are
common, and outbreaks of infectious diseases frequent,
no isolation accommodation is, as a rule, provided;
whilst although the councils are largely made up of
tradesmen, the Adulteration of Food Acts are mostly
ignored. The offences of the Southend and Chelten¬
ham authorities, in merely treating in the most
scurvy fashion possible their medical officers, must
be, in comparison, looked upon as quite venial. For

Nov. 6, 1907.

CORRESPONDENCE.

The Medical Press. 5°3

all such offences the councils are held solely
responsible. Over and over again, and as late as
Tuesday, October 22nd, The Times (which, whatever
its faults, remains still the great leading paper) has
denounced local authorities in scathing terms. It
charges them with “ placidly obstructing, while the poor,
■who are unable to protect themselves, die of small¬
pox, of enteric fever, or of diphtheria; and while the
children, whom it would be the first duty of a patriot,
or of a statesman to protect, are left to waste their
strength in struggles against preventible diseases which
effective administration would speedily banish from
the country.” The main object of my letter now is to
oint out and emphasise the fact that if the direct
lame may be fairly cast upon these inferior
authorities the real blame and the greater shame rest
upon the great body of citizens and ratepayers who
put them in office or allow them to continue there
when proved incompetent. No effective remedy for
existing evils can be found unless the spirit of local
and imperial patriotism can be roused. One would
think this should be possible at least in a place like
Cheltenham, a wealthy residential town, the seat of a
great public school, and numbering among its citizens
probably more capable men of leisure than are to be
found in any other similar city of the same size. Even
at places like Southend, which seem to exist mainly
as cheap holiday resorts for Cockney trippers, it might
be thought that the inhabitants would recognise their
duty towards their town and their country. It might
be thought they would recognise that the greater part
of the misery due to sanitary maladministration falls
upon the poor; that high infantile mortality is only
a measure of the injury inflicted upon the survivors
who struggle through, and that without an exuberant
population, physically, mentally, and morally of the
highest quality, the nation cannot prosper, the
Empire cannot be maintained. Lastly, it is amazing
to see the apathy of the responsible classes in face of
a tremendously active socialistic propaganda that
finds ample means at hand to stir the popular dis¬
content in merely pointing to the evils which, owing
to the selfish indifference of the wealthy, leisured, and
cultivated classes, the poor are condemned, unheeded,
to endure.

I am, Sir, yours truly,

Sanitarian.

October 25th, 1907.

ADMINISTRATION OF ANESTHETICS FOR UN¬
QUALIFIED DENTISTS.

To the Editor of The Medical Press and Circular.

Sir,—A ll who believe in protecting qualified prac¬
titioners in the exercise of their profession, and in pro¬
tecting the public from the unqualified, must cordially
approve of the exertions of the Irish Branch of the
British Dental Association, to which you refer in an
editorial note in your last issue. As you say, how¬
ever, the practice is hardly of such important
dimensions as the Association seems to imagine, and
offenders can be easily dealt with by the General
Medical Council or by die licensing bodies which have
granted their qualifications. There seems, on the
other hand, to be no protection either for the public or
the medical profession against a practice more detri¬
mental to the common good, and much more wide¬
spread. I mean the practice adopted by dentists,
most of whom are not medical men, of themselves
administering anaesthetics. Still worse is the custom,
also stated to be widespread, of a mechanical assistant
administering the anaesthetic, while his principal
operates. Nowadays it is very rightly pointed out
that even medical men are hardly sufficiently trained
in the administration of anaesthetics; nevertheless,
dentists and their unqualified assistants, without any
training whatever, are willing to take the responsibility
from which some qualified medical men will shrink.
The large number of deaths which take place in the
dentist’s chairs is sufficient justification from the
public point of view for calling attention forcibly to
the matter. It should be penal by law for anyone but
a qualified medical man to administer an anaesthetic.

The British Dental Association might make a start by
forbidding it to any of their members who are not
medical men.

I am, Sir, yours truly,

Critictjs.

VIVISECTION COMMISSION DIFFICULTY.—
“KILKENNY CATS.”

To the Editor of The Medical Press and Circular.

Sir,—I am interested to read your opinion that a
committee composed of “ Mr. Coleridge, Miss Lind-
af-Hageby, Miss Beatrice Kidd, and Dr. Hadwei”'
would, after sitting a month, end in a tragedy similar
to that of the Kilkenny cats. If your assumption
were true, it might be in the best interests of the
vivisectors to appoint such a committee, as it would -
furnish a short and easy method of getting rid of us.
However, why the three last named should be ground¬
lessly accused of mutual animosity absolutely passes
my comprehension. May I explain that in the anti¬
vivisection world there is but one division—that -
between the abolitionists and the restrictionists, the
latter party being represented by Mr. Coleridge. As
this gentleman has informed the Royal Commissioners
that he “wishes to secure the continuance of research,”
and “trusts that nothing will be done to hamper the
legitimate employment of the method,” he can hardly
be called an anti-vivisectionist at all, therefore we-
have, on the side of the anti-vivisectionists, a happy
family party remaining; and if the methods of the
Kilkenny cats be adopted by those outside our circle,
we are not concerned. Real anti-vivisectionists, I need
hardly say, would not consider an increase of th&
inspectorate as any safeguard to vivisected animals.
They remember the late Professor Lawson Tait’s
earnest warning, which history has so amply justified
—“Combine to abolish the medical inspector.” The-
vivisectors and Mr. Coleridge might welcome such a
change; anti-vivisectionists would not, or would they
regard it in the light of a “concession” to their
demands.

Yours, etc.,

Beatrice E. Kidd,

Secretary British Union for Abolition of
Vivisection.

November 2nd, 1907.

A QUESTION OF PROFESSIONAL ETIQUETTE.
To the Editor of The Medical Press and Circular.

Sir,—I should be glad to have your opinion on the-
ethical aspect of the following announcement which
appeared under the heading of “ Court News ” in the-
Times of October 24th, 1907 -.—

“ Dr. J. Leon Williams, who has recently been made
a Membre Honoraire of the Soci6t6 Odontologique de-
France, ‘ en reconnaissance des 4 minents services
rendus par lui k la Science Odontologique,’ has re¬
turned to 30, George Street, Hanover Square, after
several months’ absence, in greatly improved health.”'

According to the latest Dentists' Register , this gentle¬
man is an L.D.S.I.

Yours, etc.,

Enquirer.

[In reply to the inquiry of our correspondent as to-
the ethical aspect of this announcement, our opinion-
would depend on the way the announcement was
brought about. The gentleman referred to may be the-
victim of journalistic officiousness. If, however, done-
with his knowledge, it is unquestionably a form of
advertisement to be deprecated.—E d. M. P. and C.]

We are asked to announce that a Conference of
Representatives of Sanitary Authorities will be held'
in the Council Chamber, Caxton Hall, Westminster,
at ix a.m. on Friday, Nov. 15th, for the purpose of
considering the question of the establishment of a
Supreme National Health Authority. Already the-
responses to the invitation to the Conference have been
numerous and cordial, and the meeting promises to be-
a great success.

zed by G00gle

Digiti:

504 The Medical Press. _SPECIAL ARTICLES.

SPECIAL ARTICLE.

ANNUAL REPORT OF THE ROYAL COLLEGE
OF SURGEONS, ENGLAND.

The annual report of the Council has been sent to
those Fellows and Members whose names are enrolled
on the list of those to whom the report is sent
annually. Any Fellow or Member may have the re¬
port sent each year from the College by applying to
the Secretary. The report will be laid before the
annual meeting of Fellows and Members at the
College on Thursday, November 21st, at three
•o’clock p.m.

Direct Representation. — The question of direct
representation of Members on the College
Council is fully dealt with in the report,
and includes the memorial of the Society of
Members to the Prime Minister, together with the
observations thereon by the Council of the College.
The rejoinder to these observations by the
memorialists is also published, and a statement by
the deputation of Members of the College Council,
together with some additional remarks made by the
deputation when it was received by the Lord Presi¬
dent of the Privy Council.

The question of admitting women is also dealt
with, and the petition, having 2,792 signatures in
reference thereto, is included. Counsel’s opinion has
been obtained on the points raised by the petitioners,
and it has been ascertained, (a) that the Council have
no power under the charters of the College to admit
women to examination for the diplomas of the Col¬
lege, but that they have that power under the Medical
Act of 1876; (b) that the Council can, if they think
fit, admit women tc examination for the diploma of
Member, and decline to admit them to examination
for the diploma of Fellow; (c) that a woman, ad¬
mitted a Fellow or Member under the Act of 1876,
would not be able to take any part in the govern¬
ment, management, or proceedings of the College by
reason of obtaining a registrable qualification under
the terms of the Act. Having satisfied themselves
upon these points, the Council adopted the following
resolution: “That, in the opinion of the Council, it
is desirable that women be admitted to examination
for the diploma of member.” It was decided that,
before taking a poll of the Fellows and Members upon
the question, the Royal College of Physicians should
be approached, in order that it might be ascertained
whether that College would be willing to admit
women to the Conjoint Examinations. Communica¬
tions upon the subject have accordingly been ad¬
dressed to the Royal College of Physicians, but thcr
final reply has not at present been received.

Appointment of Assessors. —The Royal Colleges
recently expressed their willingness to appoint
assessors to the examinations conducted by
the London School of Tropical Medicine,
c£ students who have followed there or elsewhere a
course of instruction approved by the two Colleges,
and to grant to such candidates as may hold the
diplomas of the Royal Colleges, and who are ap¬
proved by the examiners, certificates endorsed by the
aforesaid assessors. In pursuance of this scheme.
Dr. H. H. Tooth, C.M.G., and Mr. A. G. R. Fouler-
ton have been appointed assessors for the year ending
June, 1908.

Vivisection. —The College having been offered the
opportunity of giving evidence before the Royal Com¬
mission on Vivisection, the president, Mr. Henry
Morris, was appointed by the Council to appear be¬
fore the Commissioners as the College representative.
The president gave his evidence in May last. The
Council at the same time expressed the opinion that
the Act of 1876 was sufficient protection against any
abuse of vivisection, and “earnestly hoped that the
progress of surgical science would not be hindered by
further restrictive legislation.”

Miscellaneous Items. — The number of diplomas
issued during the period with which the re¬
port deals is as follows: Membership, 435 ;
fellowship, 4Q; licence in dental surgery,
76; and the diploma in public health, 25. The at¬
tendance of members of the Council at the various

Nov. 6, 1907.

committees held at the College during the past year
is included, and it is interesting to notice that the
president and vice-presidents were summoned to no
fewer than 69 meetings, besides the usual monthly
Council meetings. Extensive and valuable additions
to the series of tumours of the brain have been pre¬
sented to the college museum by Mr. C. F. Beadles,
and a series of specimens from the same donor illus¬
trating aberrations in the distribution of the cerebral
arteries. Many valuable preparations of the viscera
of the Port Jackson shark have been made from
material presented by the Government of New South
Wales and by Professor J. P. Hill. During the
past collegiate year the supply of books and journals
in the library has been well kept up, and the number
for this period has been 11,090. The College
obituary list includes 3 honorary fellows, 25 fellows,
and 292 members.

THE PROPOSED MEDICAL SERVICE FOR THE
TERRITORIAL FORCE.

Sir Alfred Keogh, Director-General of the Royal
Army Medical Corps, addressed a meeting of the
medical profession in Manchester during the past
week, and explained at length the nature of the War
Office’s proposals for the medical arrangement of the
Territorial Force. He said that the scheme which he
was to explain was not by any means new, seeing that
it was drawn up about at the time when he became
Director-General, but had been held in abeyance till
Mr. Haldane had considered the general arrangements
for the organisation of the Volunteers. The medical
service of the Volunteers, he remarked, was utterly
inadequate either under the territorial army system or
under the Volunteer system to perform the duties
which are required of it in time of war. He knew
that a great many people say, “ Oh, when war breaks
out you will get lots of doctors ” but “ lots of doctors ”
won’t do. There is a differentiated function for the
Army medical officer. He has not only to see to the
curing of disease and the healing of wounds, but ho
is an administrator and organiser, and the better
business man he is the better officer he is. All these
things are compatible with a very definite love for
and pride in his profession. He explained that when
war broke out, what Mr. Haldane described as the
expeditionary force would be able to leave the
country, taking the regular medical service with it.
The defence of England would then rest with the
territorial force, and the medical equipment of this
defence would fall on the medical profession. The
duty of the medical profession in connection with an
army was to maintain the strength of the fighting force
in the field. That was the primary, almost the only,
duty, because it included all the minor duties. In
one year the strength of an army in the field diminshed
by 80 per cent. A large part of that diminution was
due to disease, and it was the business of the medical
service to see that disease was prevented and to see
that no one was allowed to leave the force unless
there was the strongest possible reason for his going.
If the medical service determined that 3,000 or 4,000
or 5,000 men must leave the fighting area no one
could say “Nay,” so that such decisions entailed an
enormous responsibility. In the field ambulances
there was something entirely new in the British Army,
but something that had proved a great success in the
Russo-Japanese war. From the time that wounded
men were picked up and taken to the field ambulance
they would remain in charge of the medical staff;
they were received, clothed, fed, paid, and where neces¬
sary sent home to England by tne medical staff. This
meant that an enormous work fell upon the medical
profession. In an army of 100,000 men there would
be always about 10,000 in the custody of the medical
department. These 10,000 would have to be
rigorously scrutinised as to the absolute necessity of
their being transported home. One of »he failures of
the South African war was that many men came home
to England who never should have come. In every
one of the hospitals under the new scheme each
patient would be watched carefully and sent back to
his battalion if possible. Another new feature of the
scheme was the provision of a sanitary service for

Nov. 6, 1907.

REVIEWS OF BOOKS.

The Medical Press. 5°5

army in the field. Bach division would have ita
special sanitary department under the charge of an
•officer with special knowledge of sanitation—a man
whose whole time was given to sanitation in peace
and in war, and whose business it was to see that the
health of the troops was guarded. A school of sani¬
tation had been established at Aldershot where men
were being carefully 1 aught for every battalion. At
the manoeuvres these men had had further experience
of the work expected of them, and he was glad that
reports received from the manoeuvre areas were very
satisfactory; in time of war he would like to flood
the Army with military and civil sanitarians, and
endeavour to prevent the decimation of battalions by
disease. Turning next to the Volunteer army, he said
the territorial scheme was a scientific scheme, and
would, he hoped, effectually grapple with the
•deficiencies and anomalies of the now defunct
■volunteer medical system. We must, remarked the
Director-General, have some arrangement by which
the medical profession can devise a system of disease
prevention, hospital organisation, and so on. He
recognised that die medical profession is in a position
of special difficulty with regard to volunteering.
Under the old system the medical man had to go into
camp every year, had to go through a certain course
■of instruction, and so forth. He held that it is only
necessary for people to go into camp to undergo any
training in peace who do not in civil life perform
.those duties which they would be required to perform
in connection with the volunteer army. Surely the
medical officer of health of a county or great town
can learn nothing from us in time of peace concerning
-sanitation. These men should not have been ex¬
cluded from the volunteer army; there should have
ibeen a place for them, some method by which the
country could have the great benefit of their service
-and experience, without putting any burden upon
them in time of peace. That is one of the principles
lie desired to lay down. But, of course, there are
certain duties to be performed by medical men who
join certain branches of the medical corps in connec¬
tion with ambulances and hospitals which must be
learned. Sir Alfred went on to explain that he pro¬
posed two medical officers for each volunteer battalion
and that each officer should go into camp every two
years. Even there, he said, I do not wish to impose
difficult conditions. I say that even if the officer
cannot go into camp in the year when it comes to his
turn he need not. The conditions are such that his
explanation of inability to attend would be accepted;
T>ut he would be asked to do something else—to assist
in some way in furthering the volunteer movement in
his own time during the year that would be left to his
own good faith. In further explanation, he said that
he proposed a consolidated medical corps for the
territorial force, which meant that the medical pro¬
fession would combine in one great organisation for the
two classes of work which he had outlined—viz., hos¬
pital work and sanitary work—that the organisation
should be an exact reflection of the medical corps of
±he regular Araiy, with a principal medical officer in
each area derived from the volunteer medical service,
dhat a staff officer should be selected from the Royal
Army Medical Corps to assist the principal medical
officer, and that at the headquarters of each “ area ” a
military medical school should be established with a
specially appointed adjutant and staff of instructors.
At these schools officers could gain their certificates
and be saved the time and trouble of journeys to
Aldershot. We have, he said, no hospitals of any
kind in the Volunteers, and I wish, in accordance with
the principles I have enumerated, to raise the staffs of
those hospitals in time of peace. I ask that the great
physicians and surgeons in centres like Manchester
and Liverpool should join the territorial force, not
to undertake any duties whatever in time of peace,
but to undertake specific duties in time of war. I
do not ask them to leave their own towns. The
principle here would be of sending sick and wounded
to the hospitals. I propose to establish in connection
with Manchester a large general hospital—a military
territorial army hospital—which in time of war would
work in conjunction with the troops in the neighbour¬

hood. They could do this work without interfering
with their private work or their work in hospitals.
Sir Alfred added in conclusion, that the appeal which
he made to the surgeons and physicians he extended
also to the sanitarians of the country—the medical
officers of towns and counties. He wanted a sanitary
officer for each division in time of war. He was also
hoping to raise a nursing service, and had already
received much encouragement from the matrons of
hospitals. .

A cordial vote of thanks to the Director-General
concluded the proceedings. __

REVIEWS OF BOOKS.

POST-GRADUATE STUDIES, (a)

This collection consists mainly of papers read by
the author at various medical meetings. He has been
led to publish them in book form because he believes
the subjects dealt with may prove of interest and
service to a wider circle. The volume contains
altogether nine clinical dissertations. Most of these
deal with questions of diagnosis such as that of sub-
phrenic abscess, pleural effusion, disseminated
sclerosis, cerebral htemorrhage, and acute endo¬
carditis. One very interesting and instructive paper is
that dealing with the naked eye examination of the
faeces as an aid in the diagnosis of disease. It is, as
the author remarks, too often neglected by the medical
attendant. He tells of two cases, one a club patient
who has run to earth by having his stools examined
when they were found to be normal; and the other
who was found to be suffering from malignant disease
of the rectum. The author treats the subject under
four distinct headings, viz., the amount, the colour,
the consistence and general characters, and lastly the
presence of abnormal constituents.

The last paper in the book is on the subject of
syphilis in the Army. This gives a very exhaustive
account of the matter, and is fully illustrated by
means of several carefully compiled charts. Incident¬
ally, however, we do not think so many charts should
have been included as they tend to swell out the
volume to almost one half the size covered by the text
proper. The treatment of syphilis as it occurs amongst
soldiers is very fully given, and is largely based on
Mr. Alfred Cooper’s ideas as set forth in the latter s
work on this disease. The tables given will be found
very useful for reference and comparison.

With regard to the other papers we need not enter
into details. They have all of them reference to
subjects of every-day practical importance, and will
be of the greatest help to the busy practitioner who
is on the outlook for fresh knowledge regarding the
diseases of which they treat. Such a volume as this
forms an excellent supplement to the ordinary text¬
books of medicine, and for this reason we congratulate
the author on its publication. The style is distinctly
interesting and free from technical phraseology, so
that the volume forms quite pleasant as well as
instructive reading. It will doubtless find a place
among the ever-increasing works and monographs on
medical subjects. It is certainly well worthy of careful
perusal by all who are seekers after knowledge.

WHAT TO DO IN CASES OF POISONING, (£)
No words of ours are required to commend this
well-known pocket guide. It has been thoroughly
revised, restored, and renovated, to use the author’s
own facetious language. A great deal of new matter
has been introduced into this, the tenth edition.
Dr. Murrell’s name has become known to every
student and practitioner of medicine through this
excellent litfle treatise, without which we doubt if
we should be able to cope with poisoning cases so
well as we do. The author is witty and sarcastic at

(•1 "Poet-Graduate Clinical Studies for the General Practitioner;
Flrat Series.” By H. Harold Soott, M.D.Lond., M.H.CX, L.R.C.P.
Fellow of the Royal Institute of Publlo Health, late Medical Officer In
charge of Hospital for Women and Children, ete. London: H. K.
Lewis. 1907. Demy 8 to. Price 8s.

(6) “What to do in Cases of Poisoning.” By William Morrell,
M.D., F.R.O.P.. Physician to the Westminster Hospital, Tenth
edition. London: H. K. Lewis.

^oogle

506 The Medical Press.

MEDICAL NEWS IN BRIEF.

Nov. 6, 1907.

the same time, and his ready wit makes his remarks
strike home in a way which few writers can achieve.

The various poisons are arranged alphabetically so
that reference is quite an easy matter. It is quite
interesting to find antipyrin and many other drugs,
all of which can now be readily got in tablet form,
referred to as being distinctly dangerous and very
often giving rise to symptoms of poisoning when taken
indiscriminately by the ignorant public. Thus
sulphonal, veronal, and substances of a similar nature,
in these days frequently used by laymen without
medical advice, are mentioned as being poisons. The
perusal of Dr. Murrell’s book would doubtless terrify
the drug-taker, while it should teach the general
practitioners the dangers of administering drugs in
tablet form. This edition is sure to be as popular as
its predecessors. It is certainly very comprehensive
and accurate in detail.

ON DIAGNOSIS IN URINARY SURGERY, (a)

“This little book describes the principal modern
methods of localising and distinguishing those diseases
of the urinary organs which are usually assigned to
the surgeon.” Perhaps the author will forgive us if we
suggest that this sentence does not exactly convey his
meaning, and that if the word “patient” was sub¬
stituted for “surgeon” the sentence would be more
gramatically correct.

The little work consists of four chapters. The first
deals with the interpretation of urinary symptoms;
the second with abnormal conditions of the urine;
the third with the physical examination of the patient
and of the urinary organs; and the fourth with the
differential collection of specimens of urine. A curious
point about the last chapter is that, though Nitze’s
inspection cystoscope is described fully in the pre¬
vious chapter, in this one, which deals with the differ¬
ential collection of urine, there is no mention made
of Nitze’s combined cystoscope and ureteral catheter.
This instrument is, however, very much the easiest
means of obtaining specimens of the urine from each
kidney separately, and is far more exact than is Luy’s
segregator.

The book, however, gives, on the whole, an excellent
introductory description of several methods of diag¬
nosis in urinary surgery.

ON PRESCRIPTION WRITING. (J)

This is a most concise little work on prescription
writing, and fully justifies its existence. Although it is
short, it is most complete, and will be found in¬
valuable to the student—in America. Unfortunately
for the English student, the book is based on the
American Pharmacopoeia, and so, as far as dosage is
concerned, would lead to confusion.

There is a handy list of mis-pronunciations of com¬
mon occurrence, and also a list showing the pronun¬
ciation of pharmacopoeial terms. So far as we have
examined it, we have only noticed one mistake. Surely
the pronunciation of cochleare is as we have marked
it, and not as Dr. Mann would have it—cochleare.

THE LAWS OF HEALTH, (r)

Hygiene as it affects the school child is a very
complex subject, including, as it does, so many sciences
of diverse characters. It is now universally recognised
that the school teacher should be acquainted with the
rudiments of the subject, and for the purposes of a
text-book for such the volume under consideration is
to be commended. The author is extremely well ac¬
quainted with his subject, and has shown excellent
judgment in his selection of the matter incorporated,
so that the teacher is provided with essential informa¬
tion. Particular mention must be made of the chapter
on Physical Exercises, which includes a short disser¬

ts) “ Modern Methods ol Diagnosis In Urinary Surgery." By Edvard
Deanes)ey, M.D., B.So.Lood., F.B.CA, Hon. Surgeon Wolverhampton
and Staffordshire General Hospital. Pp. ri. and 87. London: H. K.
Levis. 1807.

(b) “A Manual of Prescription Writing.” By Mathew Mann, AM..
MJ>., Professor of Obstetrics In the University 'of Bnffalo. Be vised
by Edvard Cox Mann, M.D. Sixth edition. Pp. 232. Putnam's, The
Knickerbocker Press. 1807.

(c) “ A Handbook on School Hygiene." By Carstairs O. Douglas,
M.D., D-Sc (Public Health), F.BJB.E. Pp. 240 and vii, vith 72 illus¬
trations. London: Blaokle and Sons, Ltd. 1907. Price 3s. net.

tation on the anatomical principles underlying them,
while that on Corporal Punishment is by no means the
least important. We agree with the author that
chastisement should only be administered for the
graver faults, and for this purpose the instruments,
least likely to injure the offender are stated to be the
birch and the tawse. Altogether the book is admirable,
and can with propriety be commended not only to
teachers but also to medical practitioners, who will
find in these pages much useful matter.

NEW SURGICAL
APPLIANCE.

NEW CUPPING INSTRUMENT FOR
CERVIX UTERI.

The illustration represents a simple in¬
strument designed by me, and neatly made,
by Messrs. Hewlett and Son, Charlotte
Street, E.C. I find it useful for dry
or wet cupping of the uterus, and by
the latter proceeding I have been able to
give speedy relief to the vertical headache
so often complained of by women during
the menopause. It will also remove un¬
healthy secretions from cervical canal in
conjunction with the use of my wire
curette, and thus prepare the part for the
usual application of liquid escharotics or
astringents, hastening the cure consider¬
ably in cases of chronic endometritis, etc.
It will also be found useful during the
operation for supra-vaginal amputation by
drawing down the cervix, where the parts
may be too soft and friable to be held by
volsella. The cup is simply pressed well
up on cervix, the central rod drawn down,
and a half-turn of ring at base will
throw projecting pin into angle of slot,
and procure the vacuum in cup. This
can be left on as long as required. The
simplicity and handiness of the cervical
cupper should, I think, recommend it for
the purposes named, but no doubt many
others will be suggested to the gynaeco¬
logist. Alexander Duke.

Medical News in Brief

Engineer's Death.—Conflict of Medical Evidence,

On the 10th ult., at the North Shields County Court,
Elizabeth Davison claimed from Richard Irvin, steam:
trawler owner, /300 compensation for the loss of her
husband, John Davison, an engineer on board the-
steam trawler Mercia, who died at sea on July 14th.
Davison, counsel explained, was 34 years of age, and
left five children, the oldest of whom was n. While
the vessel was off St. Abb’s Head on July 14th he was
found at the foot of the engine-room ladder in a
dying condition. He had previously suffered from
epilepsy, and had been operated on for that, but Mr.
Morgan claimed that death was the result of an acci¬
dent. Dr. Mears, who had known Davison for seven
or eight years, spoke to pierforming the operation of
trepanning for epilepsy on May 20th last, and to certi¬
fying him as fit to follow his employment on July 6th.
He also described the post-mortem examination, say¬
ing that there was a large bruise about the size of a
saucer on the top of the head, the scalp being knocked
into a pulp. He gave his opinion that death was due
to concussion of the brain ocr shock to the nervous
system, caused by a fall down the ladder. There was,
however, he admitted, no visible injury to the brain or
skull, and no haemorrhage.—Dr. J. H. Hunter,
assistant surgeon at the Ingham Infirmary, South
Shields, also agreed that concussion might have been
caused without any visible injury to the brain, and
this view was supported by Dr. Gowans, South

itized by G00gk

Nov. 6, 1907.

MEDICAL NEWS IN BRIEF.

The Medical Press. 507

Shields. For the respondent, however, Dr. Lochland
Frazer, of North Shields, who conducted the post-
portem examination, said death was obviously due to
natural causes. There was no fracture of the skull,
no haemorrhage of the brain, and no laceration of the
base of the skull, but the aortic valve was incompetent
owing to the heart being dilated. Death was either
due to epilepsy or heart failure.—Dr. Morrison, senior
surgeon at the Royal Infirmary, Newcastle, expressed
the opinion from hearing the evidence that death had
resulted from nothing but natural causes. If death
was due to concussion there would be a bruise on the
train.—Summing up, the judge commented on the
difficulty of arriving at any facts at all. The only
undoubted fact was that Dr. Frazer found in the post¬
mortem examination what he said was amply sufficient
to cause death. There was-no evidence that the heart
affection was accelerated by the fall, and he gave his
award for the respondent.

Unregistered Dentists Pined.

At Old Street, prosecutions by the London and
County Medical Protection Society (Limited) brought
before the Court three persons—H. M. Hanreek,
Bethnal Green Road; Joseph Lechan, Whitechapel
Hoad; and Joseph Weinberg, Whitechapel Road—for
-contravening the Medical Act, 1878, by using styles
and titles implying that they were registered dental
practitioners under the Act. Mr. G. H. Young prose¬
cuted ; and evidence was given by Mr. Hugh Woods,
M.D., Secretary of the prosecuting society, Craven
Street, Strand, as to visiting the business premises of
the respective defendants. Mr. Hanreek exhibited at
his shop, which was also a hairdresser’s shop, the
name “H. Hanreek, surgeon dentist,” above the door,
and inside “G. Hanreek, practical dentist.” The de¬
fendant Lechan, who is also a chemist, exhibited the
words “surgeon dentist”; but Weinberg only ex¬
hibited a frame with the word “ dentist ” and a mass
of teeth in the window. Mr. Percy Robinson, defend¬
ing Hanreek, said the signs were put in in the time of
his client’s father, who was a registered dentist, and
they had been left since his death in 1889. He had
no idea he was infringing the Act. The defendant
lechan, defending himself, said he was qualified in
"Vienna and Berlin, and thought the qualifications
were sufficient in England. Mr. A. J. David, defend¬
ing Weinberg, submitted that the use of the word
“ dentist ” alone was not any claim to be a registered
dentist. Mr. Cluer overruled the point. He fined the
defendants Hanreek and Lechan each the full penalty
of ,£20 under the Act, and further to pay each three
guineas costs. In consideration of the defendant
Weinberg’s having been carrying on his business since
1872, before the passing of the Medical Act, the magis¬
trate imposed half the fine, £ 10, with three guineas
costs.

•Bogus Dentists in Ireland.

The campaign started by the Irish Dental Associa¬
tion against bogus “dentists ” has resulted in the case
of the Attorney-General, at the relation of Kevin E.
O’Duffy v. Henry J. Bradlaw, surgeon dentist,
Limited, and eight other defendants, which was con¬
cluded during the past week in the Dublin Courts.
The relator asked for an injunction restraining the
defendant company, who carried on business in
Dublin, from advertising for custom under the
description of “surgeon dentist” or any other
description calculated to induce the public to believe
that such business was carried on by duly registered
dentists. The defendants denied any conspiracy to
deceive the public in the formation of the company,
and stated that seven of the defendants, who signed
the articles of association, were all, at the date of
registration, registered as dentists under the Dentists’
Act, 1898. They also denied that any wrong had been
committed on the public. Since the action was insti¬
tuted the defendant company had changed their trade
name to that of “ Henry J. Bradlaw, Limited.” The
Master of the Rolls, in giving judgment, said that all
the time the action was instituted the directors and
shareholders of the defendant company were, as
stated by an eminent judge in another case, an
-audacious fraud upon the public. The names and

style and title of the company was a false represen¬
tation, and was scattered broadcast through the land.
It was not necessary for the relator to prove that
anyone incurred loss. Mr. Bradlaw might be an
excellent worker—as good, perhaps, as any medical

E ractioner, who had not been instructed in dentistry—
ut the Act of Parliament was clear on the point as
to his right to describe himself as a surgeon dentist.
He granted the injunction asked for, restraining the
defendant company from describing their business in
such a way as to lead the public to believe that their
business was carried on by a person, or persons,
registered under the Dentists’ Act, 1898. He also
granted an injunction, restraining the defendant com¬
pany and its members from using the title dentist,
either alone or in combination with any other word
or words in the memorandum of association, or any
returns or documents filed pursuant to the Companies
Acts, with the Registrar 01 Joint Stock Companies.
Royal College of Physicians of London.

At the ordinary quarterly Comitia of the College,
held on Thursday last, Daniel Colquhoun, M.D.Lond.,
of Dunedin, New Zealand, and Edward Rennie,
M.D.Lond., of Sydney, Australia, were admitted, in
absentia, to the Fellowship. Dr. F. W. Andrewes was
elected a member of the executive committee of the
Imperial Cancer Research Fund, viee Sir William
Broadbent, deceased. Dr. Frederick Taylor was re¬
elected a member of the Committee of Management of
the Examining Board in England. W. H. Price
Saunders, late a student of Epsom College, was, on
the recommendation of the Presidents of the two
colleges, appointed Jenks Memorial Scholar.

Medical Mao Accidentally Shot.

We regret to announce that Dr. Vining Paul, a
young Harwich medical man, was the victim of a
curious fatal shooting accident at Ramsey, near Har¬
wich, recently. He had been rabbit shooting with
some friends, and, the sport having finished, the guns
were placed in a motor car in readiness for the return
journey. By some mischance one of them was left
loaded and cocked, and, just as Mr. Paul was stepping
into the motor-car, a dog jumped and touched the
trigger. The charge entered Dr. Paul’s body, passing
through the left lung, and he died on Friday evening.
Dr. Paul, who was only 28 years old, came to Harwich
in January of the present year, and had previously
held an appointment at Taunton Hospital.

Royal Army Medical Corps.

Major H. S. Peeke has been granted six months’
leave out of India on medical certificate.—Captain
F. A. Stephens has assumed medical charge of Staff
and Departments, Scottish Command, vice Captain
V. J. Crawford, transferred to the Southern Command.
—Lieut. J. A. B. Sim assumed charge of the Military
Hospital, Berwick-on-Tweed, on the 1st in9t., vice
Captain F. M'Lennan, who takes charge of the Mili¬
tary Hospital, Aberdeen, during the absence on leave
of Major A. O. C. Watson.

The Royal University of Ireland.

At a meeting of the Senate of this University held
on Thursday, October 31st, the following resolution
was passed by a majority:—“ That it is expedient for
many reasons that the conferring of degrees in this
University should be confined to the purely Acade¬
mical Ceremonial, as it is in the University of Dublin
and elsewhere.” Presumably as a result of this resolu¬
tion, the National Anthem was omitted from its usual
place at the termination of the Degree-giving Cere¬
monial, which was held the following day.

Trinity College, Dublin.

The following candidates passed the Final Medical
Examination (Part I.), Michaelmas, 1907 :—David J.
Miller, Edward J. H. Garstin, Alex. K. Cosgrave
(Passed on High Marks), William A. Nicholson,
Richard J. Attridge, William H. Sutcliffe, Harold S.
Sugars, Edwin B. Bate, James E. M’Causland, James
D. Murphy, Richard D. FitzGerald, Howard S. Millar,
Frederick R. Sayers. Intermediate Medical Examina¬
tion (Part II.).—Henry H. James, Walter E. Adam,
Victor W. T. M’Gusty, Hans Fleming, William H.
Hart, Denis J. Stokes.

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508 The Medical Press. WEEKLY SUMMA RY. _ Nov. 6, 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT MEDICAL LITERATURE.

The Habitual Vomiting of Naming Infants.—

Peiser ( Berlin Klin. Woch., July, 1907) recognises
three forms of habitual vomiting in infants. The
first occurs in healthy appearing babies, who receive
too much food at one feeding, or are fed too often, or
the milk is too rich in fat. These cases are easily
controlled by regulating the amount and the number
of the feedings, or by cutting down the fats. A
second form occurs in children who, though ap¬
parently well nourished, are of nervous temperament,
awake easily, cry much, and are easily irritated.
Here the vomiting occurs from two to four hours
after feeding, when normally the stomach should be
empty. Often in this class of cases laryngismus
stridulus or tetany occurs. In certain families, with
marked neurasthenic tendency, all the children are
subject to this form of habitual vomiting, which is
extremely resistant to treatment, and finally dis¬
appears spontaneously. The author considers this
form to be due to a pyloric spasm, more easily excited
in such highly-strung children. The third form
occurs in badly nourished, weak infants, and is more
a regurgitation than an actual vomiting. In obser¬
vations on such children with the X-ray, the stomach
was dilated, and the period of gastric digestion pro¬
longed. The vomiting in this latter class of cases
takes place three or four hours after feeding. The
cause is probably a weakness of the musculature of
the stomach, and particularly of the cardiac orifice,
which allows of a regurgitation of food. The treat¬
ment of this third form is general, and not until the
general condition of the child is normal will the re¬
gurgitation disappear. D.

Nncleinate of Soda In Peritoneal Infections.—

Chantemesse and Kahn {Bull, de I’Acad. de Mid.
Paris, July, 1907) have found that nucleinate of soda,

1 to 100, injected hypodermically, at once arouses a
rather lasting increased phagocytic action in peri¬
toneal infections. In two cases they have even seen
the classic symptoms of typhoid perforations
ameliorated to such an extent as to render operation
hopeful, by the two or three injections given from
fifteen to eighteen hours after the first signs of the
perforation. The patients refused operation, dying
twelve days later of slow peritonitis, and the autopsy
revealed a very marked defensive leucocytic and con¬
nective tissue process in the abdomen, the large per¬
forations being almost thoroughly obliterated. They
see a decided utility in the action of the drug in such
conditions, and one not limited altogether to peri¬
toneal inflammations, as they have seen it of value
also in erysipelas and pneumonia. The reaction is
moderately severe, which is to some extent a draw¬
back. D.

The Gastric Secretion In Nephritis and Dechlorlda*
tlon. —Enriquez and Ambard (Semaine Mldicale Paris,
August, 1907) have found that deprivation of salt in
diet seems to have a levelling effect on the gastric
secretion. In both hyperchlorhydria and hypo-
chlorhydria the absence of salt from the diet brought
the gastric secretion to practically a uniform level,
very close to normal. Their tests further demon¬
strated that every nephritis, even the latent form, has
a marked influence on the gastric secretion. When
there are merely traces of albumin or even simple
arterial hypertension in the kidney, hyperchlorhydria
is observed. It is probably, they state, the result of
the excess of salt in the organism, salt being the
general stimulant par excellence of the gastric secre¬
tion. Retention exaggerates the gastnc secretion,
while deprivation of salt reduces it. On the other
h.ind. in nephritis with albuminuria, the retention of

! t seems to irritate the stomach mucosa just as it

irritates the kidney lesion. In this case the stimu¬
lating action of the salt is overcome by its irritating,
and therefore depressing action, with hyperchlor¬
hydria as the result. But for the same reason that
deprivation of salt has a beneficial action on the ex¬
cessive secretion, it also has a beneficial action on the
deficient secretion. Deprivation erf salt allows the
stomach mucosa to recover its tone even before the
general salt balance throughout the organism is re¬
stored, and thus dechloridation is liable to be fol¬
lowed by a brief, transient hyperchlorhydria. The
effect of salt starvation on perverted secretions opens,,
they state, a new field for the study of the pathology
of the stomach, while at the same time it suggests a
rational mode of treatment for many forms of gastric
affections which at first glance seem to have no con¬
nection with each other. D.

Acute Yellow Atrophy of the Liver In consequence
ol Chloroform Anaesthesia.— {Arch. f. Klin Chir.,
Berlin, 1907). Galeke’s patient was a robust young
woman, on whom a herniotomy, lasting half-an-hour,
was performed, under 25 c.c. of chloroform. The
anesthesia was unusually smooth; hernial sac con¬
tained only omentum. Jaundice and cholemia de¬
veloped in less than 24 hours, and at the end of 92
the patient died in coma, after delirium and convul¬
sions. The microscope revealed extreme destruction
and fatty degeneration of the cells in the liver and in
the convoluted tubules in the kidneys. The chloro¬
form was evidently responsible for the trouble, as
infection and thrombosis could be excluded. The
same chloroform, used for other patients the same
day, caused no by-effects in other cases. All the
similar cases of yellow atrophy of the liver on record,
following administration of chloroform, terminated
fatally in from three to six days. The patients were
generally young and robust. It is noticeable that the
operations had always been abdominal, and that the
patients were moderately or extremely fat. Other
facts are cited which suggest that an unusually fat
liver is less resistant to chloroform than one less so.

D.

Examination of the Faces for Occalt Blood.—

Goodman (Amer. Journ. Med. Sciences, Oct., 1907) dis¬
cusses the value of the various tests for recognising
the presence of blood in the fasces that is not evident
to the naked eye. The test which Goodman has found
most valuable is a modification of the benzidin test
of O. and R. Adler. It is performed as follows: A
concentrated solution of benzidin is made by using as
much benzidin as will go on the end of a knife in
about 2cc. of glacial acetic acid. A small piece of
faces about the size of a pea is suspended by stirring
in a test tube, one-fifth full of water; the test tube
is closed with cotton wool and the contents boiled.
Ten to 12 drops of the benzidin solution are poured
into a test tube, and from 2.5 to 30c. of a 3 per cent.
HjO added. To this then are added from 1 to 3 drops
of the boiled faces, and in the presence of blood the
colour becomes green, blue-green or blue, according
to the amount of blood present. Even with very small
amounts of blood the colour change is completed in
about two minutes. If there is no blood present the
colour is unchanged. Goodman has used this test
extensively, and finds it very reliable under certain
restrictions. If the test is negative one can be quite
sure that no blood is present, but if it is positive the
result should be confirmed by some other test. It is
of great importance that all disturbing factors should
be removed before the test is applied. Goodman
advises that if the faces show a positive reaction for
blood, another stool should not be examined until the-
diet and medication have been regulated. K.

Digitized by GoOgle

Nov. 6, 1907-

WEEKLY SUMMARY.

The Medical Press 5°9

Early Diagnosis of Cancer of tbe Stomach. —Stone
( Amer. Journ of Med. Sciences, Oct., 1907) analyses the
various forms of evidence on which an early diagnosis
of cancer of the stomach can be made. He dwells on
the importance of remembering that cancer of the
stomach can no longer be looked on as a rare disease
in patients under 35 years of age. The earliest
symptoms are those of simple dyspepsia coming on
some hours after a meal and during the height of
digestion, and he agrees with Boas that these
symptoms are usually vague and indefinite in their
onset. The ultimate diagnosis, of course, rests on the

f hysical examination of the stomach and its contents.

ree HC 1 . is absent in from 90 to 92 per cent, of the
cases, and this, combined with the presence of the
Oppler-Boas bacilli, is of the greatest importance in
the diagnosis. The detection of what is called occult
blood in the stools and stomach contents is also of
very great importance. Such haemorrhages are never
found in healthy individuals. The blood is detected
by the benzidin test, and it is said that it is present in
practically every case of cancer of the stomach. In
applying this test it is important that no meat or raw
vegetables should be eaten for two or three days before
the stomach contents and faeces are examined. Stone
urges the adoption of Mayo’s maxim that “a suspicion
of cancer of the stomach, which cannot be disproved
by known methods within a short time, should lead
to exploration. ” K.

Bier’s Hyperemia. —MacLennan ( Practitioner , Oct.,
1907) describes this method of treating microbic in¬
vasions. In treating lesions of the limbs all that is
necessary is the application of an elastic bandage
round the limb on the proximal side. The degree of
tightness of application is of considerable importance.
One should remember that the object is to impede the
return flow of the blood only, and that the pulse in
the limb must not be affected. The skin of the part
on the distal side of the limb should be of a uniform
brilliant red colour, the limb should become warmer,
and the patient should not experience any pain. The
pain in the diseased part is at once relieved by the
application of a bandage if the treatment is to do good
and is being carried out properly. In acute cases this
action is continued for 22 hours, and then there is an
interval employed in reducing the oedema by elevating
the part, and, if necessary, by massage. In parts of
the body where an application of the bandage is not
possible, the treatment may be carried out by reducing
the atmospheric pressure on the part by suction. This
method is particularly suitable to localised inflamma¬
tions. In the treatment of abscesses only a small
puncture is made, and when the bleeding has stopped,
the suction is applied, end by this means the pus is
withdrawn from the cavity. In such a case the
suction may be continued for an hour, with intervals
of three minutes every five. The usual dressing is
then applied, and next day a similar procedure is re¬
peated. If the puncture has closed, it should be
picked open before the suction is reapplied. In the
treatment of tubercular joints Bier recommends that
the congestion be maintained only for an hour a day,
as against the 22 hours recommended for acute in¬
fections. K.

Blood Changes Subsequent to Excision of Spleen.—

Matthew and Miles report the result of a systematic
examination of the blood of a patient whose spleen
had been excised for traumatic rupture. The excised
spleen was healthy, and consequently the case was a
most favourable one for observations, and as observa¬
tions were carried on over a period of two years and
three months, both the immediate and remote blood
changes were noted. They sum up their results as
follows:—(1) After extirpation of the spleen, an en¬
largement of various groups of lymphatic glands
occurs. The increase in size sets in early after the
operation, is not of any great degree, is probably
genera], and is not permanent. (2) Corresponding to
the lymphatic hyperplasia, there appears in the blood
an absolute increase of lymphocytes. This increase
persists in man for years after removal of the spleen.
(3) A moderate eosinophilia appears soon after extir¬
pation, and after persisting for some weeks again sub¬

sides. During the period of eosinophilia the blood'
plates are very numerous. (4) After recovery from the
loss of blood, the red cells and haemoglobin follow a
normal course. (5) After excision of the spleen, indi¬
viduals who recover suffer no inconvenience.

M.

Addison's Disease in Children. —Felbebaum and
Furstthandler point out (New York Med. Journal,.
Aug. 10th, 1907) that Addison’s disease is very rare in
children. The number of reported cases is about equal
in the two sexes, and the most usual recorded age is
between 10 and 13 years. TJie typical form is charac¬
terised by its very prolonged course, accompanied by
increasing weakness and gastric symptoms. In the
rarer atypical forms the disease runs an acute course,
and as the skin symptoms' are often absent, the diag¬
nosis is seldom made before the autopsy. Pigmenta¬
tion, when present, is of a dusty bronze colour, most
marked about the face, axillae, knees, abdomen, and
genitilia. The gastro-intestinal symptoms consist of
loss of appetite and constipation, with occasionally
diarrhoea. The pulse is small and feeble, and as a
rule the temperature and urine are normal. The dis¬
ease may last years, and may be characterised by occa¬
sional periods of intermission, death finally occurring
with delirium and convulsions. The most common
pathological change found is tuberculosis of the supra-
renals, but cystic fibrous degeneration, and more
rarely carcinomatous growths, have been recorded.

The Value o! Forma mint in Septic Affections of tbe
Oro-Pharynx.— M. de Santi has given an extensive trial
to formamint in septic throat conditions, and now
reports his opinion concerning its value in such cases

1 Medical Magazine, March, 1907). The drug is a com-
nnation of formic aldehyde and lactose, and when
the latter becomes dissolved in the saliva, the for¬
maldehyde is set free, and is able to exert a strong
antiseptic action. De Santi has used it in the follow¬
ing conditions :—(1) Acute suppurative tonsillitis ; (2)
In the post-operative treatment of tonsillotomy and
removal of adenoids; (3) Septic ulcerations of the
pharynx; (4) In scarlet fever; (5) In acute septic in¬
fection of the pharynx and larynx; and reports very
favourably of its value in all of them. He sums up its
advantages as follows: (1) It is a proved antiseptic
and bactericide, and is non-toxic in action; (2) It is-
far more efficient in its action than gargles or mouth
washes; (3) Its pleasant taste makes it particularly
suitable for children 5 and (4) Its portability is often
a matter of considerable convenience. M.

The Excretion of Creatinin and Uric Acid in Some
Diseases Involving the Muscles. —Spriggs writes an
elaborate report of some investigations made into the
excretion of creatinin and uric acid in various mus¬
cular diseases. He summarises his results as
follows ( Quarterly Journal of Medicine , Vol. I.,
No. 1, page 63):—(1) In two cases of primary muscular
dystrophy the amount of creatinin in the urine v/as
small, and the diminution was proportional to the
muscular wasting; (2) In a case of myotonia con¬
genita the excretion of creatinin was also low, in one
of myasthenia gravis it was diminished in lesser
degree, and in one of locomotor ataxia not at all}
(3) In two cases of tetanus and one of spastic hemi¬
plegia in a general paralytic there appeared to be
only a slight increase; in a case of spastic paraplegia
the excretion was normal; {4) In all these cases the
excretion of uric acid deviated but little from the
normal, being highest in the cases of tetanus and of
spastic hemiplegia. From the above facts it is con¬
cluded : (a) that by far the greater part of the endo¬
genous creatinin of the urine is derived from muscular
tissue, but that it is a product of its internal structural
metabolism, and not of its contraction; (£) the source
of by far the greater part of the endogenous uric acid
in the urine is to be looked for in the non-muscular
tissues.

510 The Medical Press. NOTICES TO CORRESPONDENTS,

Nov. 6, 1907

NOTICES TO
CORRESPONDENTS, ffc.

am " Corbxbfondxkte requiring a reply in this column are par¬
ticularly requested to make use of a Diitinctiv* Signotnn or
Initial, ana to avoid the praotioe of eigning themselves
" Reader,” “ Subscriber,” ” Old Subscriber,” etc. Muoh oon-
fuslon will be spared by attention to this rule.

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8t. John’s Hospital bob Disxasxs or m Sznr (Leicester
Square, W.O.).-« p.m.: Chesterfield Lecture:—Dr. M. Dookrell:
The Solution of the Confusion between Pityriasis Rubra Pilaris
and Liohen, and the Treatment of each.

Hospital fob Sic* Children (Great Ormond Street, W.C.).—
4 p.m.: Lecture:—Mr. Waugh: Appendicitis.

Fbidat, Note mb kb Sth.

Rotal Society or Medicine (Clinical Section) (80 Hanover
Square, -W.).—8.30 p.m.: Exhibition of Cases. Short Paper: —
Dr. J. Fawcett: Pneumothorax treated by Aspiration under X-
Rays. The Patients will be in attendance at 8 p.m.

Medical Graduates’ Collxob and Policlinic (88 Cfaenies
Street, W.C.).—4 p.m.: Mr. H. L. Eason.- Clinique. (Eye.)

Nobth-Bast London Pobt-Gbaduatb College (Prince of
Wales’s General Hospital, Tottenham, N.).—10 a.m.: Clinique: —
Surgical Out-patient (Mr. H. Evans). 8.30 p.m.: Surgioal Opera¬
tions (Mr. Edmunds). Cliniques: — Medloal Out-patient (Dr.
Auld); Eye (Mr. Brooks). 3 p.m.: Medloal In-patient (Dr. M.
Leslie).

JlppomtmeMB.

Burke, Gerald T., M.B., B.S.Lond., Senior House Physician at
the Prinoe of Wales' General Hospital, Tottenham, N.

Harris, Henry E., L.D.8., Dental 8urgeon to the Royal
National Orthopedic Hospital of London.’

Jaoo, W. J., M.R.C.S., L.R.C.P., Assistant House Surgeon to the
Taunton and Somerset Hospital.

Lzwthwaite, Alfred, M.B.Lond., L.R.O.P.Lond., M.R.C.S.,
Resident Medioal Offloer at the Winsley Sanatorium.

Rees, Edward Davies, L.R.O.P.Lond., M.R.O.8., L.8.A., Medical
Officer of Health by the Newtown and Llanidloes Rural Dis¬
trict (Montgomeryshire) Council.

8tidston, C. A., M.B., B.S.Lond., M.R.C.8.Eng., L.R.CJ’.Lond.,
Resident Medioal Offloer and Secretary to the General In¬
firmary, Hertford, Herts.

Paul.—T he question of priority in ths discovery of the infeo-
tion of Malta fever is definitely settled by Colonel David Bruoe,
■C.B., R.A.M.O., who states that the actual observation which led
up to this disoovery was made by Dr. T. Zammit, the Maltese
member ef the commission whioh was despatched by the Royal
Sooiety. Colonel Brace's own words are:—“ I went out to Malta
as Chairman of the Commission in May, 1905, and discussed
results of the work of those members of the Commission who
remained In the island during the previous winter. I saw Dr.
Zammit's notes ae to two experiments on the effect of feeding

S tats on material containing Micrococcal Militmtii. I urged
r. Zammit to continue his investigations, and he accordingly
bought a small herd of goats. Before proceeding to repeat the
-feeding experiments on these new goats he examined their blood,
ae a matter of routine, and, mnch to his surprise, found that five
oat of six gave a Malta fever reaction. He then took speoimens
of the blood to Maior Horrocks, another member of the Com¬
mission, and asked him to oonflrm bis observations. This Hor-
rooks did; and at once Dr. Zammit and he proceeded to examine,
-the former the blood and the latter the milk of the goats, for
the Micrococcal Militmiii, with the result, aa is well known,
that this micro-organism is found in the blood, and excreted in
the milk, to the extent of 10 per cent, of the goats of Malta."
AN UNLUCKY NAME.

Dr. O. B. Gravestone, a Chicago physioian, who informed
Ids creditors that he had been rained by his name, had simply
missed his vocation. He should have been a monumental mason.
— Star.

Dr. H. 8. T.—The " method of M. Boeri " is what is oalled
Respiratory Anto-Massage of the Abdomen, and ie prescribed
in n&bitual oonstipatton. The patient lies on his back (for
-preference) and makes deep inspirations and expirations, hollow¬
ing ont the abdomen as much as possible daring the latter. It
is claimed, and reasonably so, that the intestinal contents are
thus naturally acted upon.

^Rteihrgg of the Sctielies, Hectares, &c.

Wednesday, November 6th.

Medical Graduates’ College and Policlinic (28 Chenies
8treet, W.C.).—-4 p.m.: Mr. M. Collier: Clinique. (Surgioal.)
5.15 p.m.: Leoture: Dr. O. R. Box: Bacterial Invasion of tho
Urinary Tract in Childhood.

North-East London Post-Graduate College (Prince of
Wales’s General Hospital, Tottenham, N.).—Cliniques:—2.80 p.m.:
Medical Out-patient (Dr. Whipham): Dermatological (Dr. G. N.
Meaohen); Ophthalraologioal (Mr. R. P. Brooks).

Thursday, November 7th.

Rontgen Society (30 Hanover Square, W.).—8.15 p.m.: Pre¬
sidential Address:—Mr. W. Duddeli.- The Production of High
Frequency Oscillations (with demonstrations).

North-East London Clinical Society (Prinoe of Wales’s
Hospital, Tottenham, N.).—4.15 p.m.: Clinical Cases.

Medical GbaduaTes’ College and Polyclinic (22 Chenies
Street, W.C.).-r4 p.m.: Mr. Hutchinson: Clinique. (Snrgioal.)
5.15 p.m.: Lecture:—Dr. T. G. Stewart: The Diagnosis of Cere¬
bellar Tumours.

North-Easi London Post-Graduate College (Prinoe of
Wales’s General Hospital. Tottenham, N.).—2.30 p.m.: Gynteoo-
iogical Operations (Dr. Giles). Cliniques:—Medical Out-patient
(Dr. Whiting); 8urgical Out-patient (Mr. Carson); X-Ray (Dr.
Pirie). 3 p.m.: Medical In-patient (Dr. G. P. Chappel).

ftontoM.

King Edward VII. Sanatorium, Midhurst, Snssex.—Pathologist.
Salary, £250 per annum, with board, lodging, and attendance.
Applications to the Hon. Secretary, 19 Devonshire Street,
Portland Plaoe, W.

Weet Riding Asylum, Wakefield.—Assistant Medical Officer.
Salary, £150 per annum, with apartments, board, washing,
and attendance. Applications to the Medioal Director.
Leicestershire and Rutland Asylum.—Junior Medical Offloer.
Salary, £130 per annnm, with board, lodging, and washing.
Applications to W. J. Freer, Esq., 10 New 8treet, Leicester.
The North Riding Lnnatio Asylum, Clifton, York.—Junior Assis¬
tant Medioal Officer. Salary, £150 per annum, with furnished
apartments, board, washing, and attendance. Applications to
the Medioal Superintendent.

Warrington Infirmary and Dispensary.—Senior House Surgeon.
Salary, £180 per annum, with furnished residence and
board. Applications to J. H. J. Hampson, Secretary.

Down District Lunatic Asylum, Downpatrick.—Junior Assistant
Medical Offloer. Salary, £130 per annnm, with furnished
apartments, board, washing, fuel, light, and attendance.
Applications to the Resident Medioal Superintendent. (See
Advt.).

Castlebar Distriot Lunatic Asylum.—Assistant Medical Officer.
Salary, £100 per annum, together with annual allowances,
including £50 in cash. Applications to Joseph T. Kelly,
Clerk of Asylum. (See Advt.)

girths.

Cablyon.— On Nov. 1st, at Yeoville, Johannesburg, the wife of
F. Harold Oarlyon, M.D., O.M., of a daughter.

Hunter.— On Oct. 29th, at Lynher House, High Street, Claphsm.
London, the wife of 8. R. Hunter, M.D., M.Oh., of a eon.

Michell.—O n Oot. 26th, at 3, Trinity Street, Cambridge, the
wife of Robert Williams Michell, M.D., F.R.C.S., of a eon.

Mistin. —On Oct. 31st, at Lonsdale House, Court Road. Eltham.
the wife of Ernest Miskin, M.B.Lond., of a daughter, who
survived his birth five hours.

Carriage*.

Fairlie - Clarke—Ltell.— On Oot. 31st, at St. Stephen’s, Glou¬
cester Road, London, Allan Johnston Fairiie Clarke, M.O.,
F.R.O.S., of Horsham, Sussex, youngest son of the late W.
Fairlie-Clarke, M.D., F.R.O.8., to Violet, elder daughter of
Captain F. H. Lvell, of Oakwood Hill, Surrey.

J9ta ths.

oll.— On Oot. 28th, at 1, Elm Grove Road, Ealing Common.
Boyd Burnett Joll, M.B., M.B.O.S., formerly of Woolton.
Liverpool, and Bedford Square, London. , „ _ _ _

aul. —On Nov. 1st, from a gun aooident, Vining Paul, M.R.C.S..
M.R.O.P., only son of the late J. M. Paul, of Upper Assam,
India, and of Mrs. Paul, of Doveroourt, Easex.
coT-r.— On Nov. 3rd, William John 8oott, L.R.C.S., L.R.Q.F L.
of Hnrstpierpoint, 8ussex, aged 46, second son of Bicnara
Soott, solicitor, of Dublin.

Digitized by G00gle

The Medical Press and Circular.

“SALUS POPUU SUPREMA LEX."

Vol. CXXXV. WEDNESDAY, NOV. 13, 1907. No. 20

Notes and Comments.

The anti-juvenile smokers are already
on the alert for next session, for they
Juvenile succeeded last week in bearding the
Smoking. Under-Secretary at the Home Office
and drawing from him official bene¬
dictions and platitudes. The fact of the matter is
that the Home Secretary has his hands so full of
pressing reforms and departmental Bills that he is
not likely to give up mucn time to a petty matter of
this kind. While of course no one approves of
juvenile smokers, to hear the language on the
subject used by some good folk, it might be ima¬
gined that the fate of the Empire depended on
news- and errand-boys abjuring the “ fag.” It
might not be objectionable in itself to make the
retailing of tobacco to youths under sixteen an

• offence, especially as the cigarettes put up to catch
youngsters are usually of the worst possible quality,
but it would be nothing less than an outrage on
common sense to make it a police court offence for
lads to smoke in the streets. The amount of harm
•they would get from being treated by the law as
(prisoners, and from the associations of the police-

• court and the dock, would be infinitely greater than
.any physical deterioration they would be likely to
suffer from puffing a little tobacco. So long as
men smoke boys will imitate them, and we could
-only wish it was the worst habit they picked up
..•from their elders.

The A curious gathering took place at
Trinnph Rotherham last week, namely, a
of the combined tea-fight for midwives and
Midwife. prize-show for infants. The Mayor
was in the chair, and Dr. Robinson,
'the Medical Officer of Health, addressed the com¬
pany. In his speech, Dr. Robinson spoke of the
■waste of infant life that was going on in the
-country, and of the methods by which it might be
averted. Foremost among these he placed the
"influence of educated midwives and the early notifi¬
cation of births. Figures were given showing that
whereas the infant death-rate for England and
Wales was 133 per 1,000, that of Rotherham was,
on the average of the last ten years, 160 per 1,000.
Since the introduction of early notification to
Rotherham there had been 923 births, with 94
-deaths, among infants whose mothers had been
attended by midwives, against 910 births, with 177
■deaths, amo/ig those not so attended. “ He re¬
garded this difference in favour of Rotherham
midwives as extraordinary.” So, indeed, do we, for
the obvious inference is that infants do about twice
as well when the mothers are attended by mid¬
wives as when they are attended by medical men.
Prizes of sovereigns and shawls were then distri¬
buted to the midwives who had been most successful,
and the mothers of the lustiest infants were made
fiappy by similar presentations. While we have

the greatest sympathy with all efforts made to
check “ tfie massacre of the innocents,” we cannot
think that figures that show so much are not
capable of some other interpretation.

People with a partiality for tomato
pur^e may be interested to hear the
Tomato opinion of the Medical Officer for the
Putriflee. p ort Manchester on that delicacy.

Two hundred and fifty-four tins of
this stuff were recently seized by him, and the con¬
tents were found to be in a very revolting condition.
We leam from the medical officer some of the
tricks of trade with regard to tomato pur6e and
other kindred goods. It is well known that when
such articles of food putrify they give off gas which
bulges out the side of the receptacle. Such tins
are said to be “blown,” and, being easily detected
by their external appearance, are pounced on by the
inspector. The owners are now as wily as their
natural foe, and when tins are blown they puncture
them, let out the gas, and solder up the hole, the
chances being that the putrid stuff will be eaten
before enough gas has been formed to bulge the tin
again. Another trade dodge is what is known as
the “ sneaking " method, the removal of the lid of
the tin to let out the gas, and the resoldenng of
it. Revelations of this kind are simply nausea¬
ting, and we feel at a loss for suitable comment.
The only fit punishment we can think of is to sit
the perpetrators of these tricks in a prison cell with
no other food to eat but their own dainties, and the
only effective one under modern humane conditions
to advertise the names of the makers and their
stuffs all over the kingdom, so that all may know
what not to buy. Perhaps it was from deal¬
ings of this kind that tomatoes gained their
legendary property of causing cancer.

The election of a new member of the
London London University Senate by the
University Faculty of Medicine re-opens the
Election. controversies which were supposed

to be settled by the recent election of
Dr. Caley and Mr. Leonard Hill; it may be hoped
that the electors will clearly realise the alternatives
before them. Dr. Norman Moore and Mr. Wallis
are asking for votes to help them oppose the scheme
for a central institute for preliminary medical
study, while Professor Starling appeals for votes
in its favour. After all the crises London medical
education has been through, no crisis, perhaps is
more profound than that in which the 9mall schools
find tnemselves at present, and after all the hitter
lessons of the past, it might be hoped that the
present University graduates would be prepared to
sink their own particular wishes in a desire to com¬
bine for the common good of the London student.
At present this unfortunate individual is placed

Digitized by Google

LEADING ARTICLES

Nov. 13, 1907'

512 The Medical Press

in the position of having the largest variety
of clinical material in the world, and teachers
whose names are often household words,. and
yet he is denied the routine advantage enjoyed
for centuries by every Scotch lad who _ studies
at a metropolitan or provincial university,
namely, that of acquiring a university degree as
the natural crown of his studies. All the re¬
construction and re-fashionings of the London
University will fail until the graduates who govern
the University are prepared to make it a University
for London. This policy they seem still opposed
to, and people wonder why London is waning in
popularity as a medical centre. As a matter of
fact, for some of the famous, but smaller, schools
the position is only just short of an impasse.

Last week we commented on the
Medical Men state of sanitary administration at
and Sanitary Manchester, and the insolent way in
Officials. which the sanitary inspectors in¬
vaded the privacy of the homes of the
poor and hectored them. We have since had the
opportunity of reading an article in the Manchester
Evening Chronicle, contributed by a medical man,
in which the subject of medical notification is dealt
with. The writer, in common with the members
of the Manchester Medical Guild, protests strongly
against the conduct of the inspectors, and he
proceeds to discuss the general questions of notifi¬
cation as regards medical practitioners. He shows
how distasteful to medical men it is for them to be
turned into spies and informants as regards their
patients, and he shows how the feelings of many
medical men against notification of the ordinary
infectious diseases having been overcome, the State
has proceeded to extend the principle to voluntary
notification of consumption, and norw to com¬
pulsory notification of births. This method of
getting from practitioners Information obtained in
the confidential relation of doctor and patient can
only be justified on the ground of the greatest
necessity, and it cannot but tend to erect certain
barriers which should not exist between medical men
and the patients, especially when the latter are poor.
When, as in the case in Manchester, notification
brings in its train a sanitary official, breathing out
pains and penalties, it certainly is time to protest.
The poor have their rights even when they are ill*
and doctors, though wishing to co-operate in every
way with health administration, do not wish to be
made catspaws of a high-handed beaurocracy.

The In our last issue we published a letter
“ Kilkenny from Miss Beatrice Kidd, in which,

Cit ” with a certain lack of gratitude, she

Position. said that the Hon. Stephen Coleridge,
who has borne the burden of the
“ cause ” in the heat of the day, “ can hardly be
called an anti-vivisection ist at all.” We admit to
having frequently been at a loss to define the exact
views of that gentleman, but are we really to admit
Saul to a seat among the prophets? That prospect
does not seem likely to materialise in the imme¬
diate future, but Miss Kidd, having thus thrown
Mr. Coleridge to the vivisecting wolves, proceeds
to announce that, “ on the side of the anti-vivisec-
tionists we have a happy family party remaining.”
The happiness that animates this tamily party must,
we fancy, be more the joy of combat than the
domestic felicity of the fireside. For, apart from
Mr. Coleridge’s National Anti-vivisection Society,
we have heard of the London Anti-vivisection
Society, the British Union for the Abolition of
Vivisection, the Parliamentary Union for the Sup¬
pression (or Abolition) of Vivisection, and the
World’s Union (or League) for the same, to
say nothing of the Canine Defence League.
'V<> dare not trust our memory further, but

we believe there are yet others. The worst,
of the “ happy family ” is that each member
of it seems to want something different from,
the others, and if anyone approves of anything
the rest show their zeal by promptly expressing
discontent with their brother’s conclusion. So
far as we understand Mass Kidd’s wishes,_ as ex¬
pressed in her letter to us, they lie in the direction
of abolishing medical inspection of experiments-
Supposlng the Commissioners recommended that
.this change should be brought about, and experi¬
menters were able to work without the tutelage of
the Home Office, how could one be sure that all
the other societies and unions and Leagues would-
be satisfied too?

LEAPING ARTICLES.

MEDICAL OFFICER’S REPORT TO THE
LOCAL GOVERNMENT BOARD.

The report of the Medical Officer to the Local
Government Board is always a volume of the
highest importance to the nation, and thought
nothing of a sensational nature is recorded in it
this year, the standard of general interest is well
maintained. As indicating the growing feeling in-
favour of sanitary matters all over the civilised
world may be taken the fact that each year the-
international and imperial service rendered by the-
medical departments grows in size and importance.
In 1905, for instance, the Government, on the in»-
vitation of France, appointed two delegates, Dr-
Theodore Williams and Dr. Timbrell Bulstrode, to
attend the International Congress on Tuberculosis,,
and though their report was technically presented
to Parliament, probably nobody in Parliament
looked at it; but on the other hand the medical!
department of the Local Government Board have-
abstracted from it all that is likely to be of help in*
the solution of tuberculosis problems in this,
country. Specially interesting are the efforts being
made in France to catch individuals, especially
children, in the “pre-tuberculous ” stage, and to
provide institutions in favourable spots and under
favourable conditions for their reception. Again,
the French “anti-tuberculous dispensaries ” provide
an experiment in medico-social work that should
be carefully watched with a view to its imitation
over here if necessary. These dispensaries act as a
buffer between the sanatorium and other charitable
agencies for the sick poor, and by meeting the
wants of the latter in good time—even to the
socialistic extent of supplying food and clothing
when necessary—their supporters seek to ward off
the conditions that predispose to tuberculous
disease. From the less utilitarian standpoint,
much interest also attaches to the views on “ latent ,r
tuberculosis expressed at the Congress, the idea
being expressed that tubercle bacilli are frequently
received into the tissues of children from one
source of infection or another, and these lie
dormant till some concatenation of circumstances
in the altered condition of child-life render the sub¬
ject vulnerable to their attack. Useful “imperial”'
sendee was rendered to the country by Dr. Theodore
Thomson, who was sent to report on the advisa¬
bility of establishing a sanitary station on the
Persian Gulf in accordance with the proposals of
the International Sanitary Convention of Paris in
1903. Dr. Thomson from his practical knowledge
was able to point out that not only was there smalt

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Nov. 13, 1907.

LEADING ARTICLES.

The Medical Press. 5*$

danger of cholera and plague proceeding from the
Persian Gulf, but that the sanitary station, if
established, would not do much towards coping
with it if it did arise. Moreover, the Gulf is so
unhealthy and the expense of the station would be
so large, that he advised that such an establish¬
ment would certainly be a mistake, and that an
organisation should be prepared at Basra and
Mohammerah to deal with the inland incursions of
epidemic diseases.

In domestic affairs the department have been
busy too. Freed from the necessity of looking
after outbreaks of small-pox, the staff was employed
in a more generous manner than is often possible
in inspections and examinations. A rather dis¬
appointing account is given by Dr. Parsons of the
^150 cottages on the Letchworth estate. From
what we heard and read of these cottages, we were
inclined to believe that there was no reason why a
thoroughly satisfactory cottage should not be
erected for that sum; but Dr. Parsons was not
satisfied with a good many features they presented.
We are inclined, however, to think that he was in
a rather pessimistic frame of mind when he wrote
hi j report, for one of the points he deplores about
the houses is that the staircases of some are so
winding that it would be “practically impossible
to remove a full-sized coffin from the first floor by
the staircase! ” It might be hoped that in model
cottages on a model estate, the necessity for such
an event would be comparatively infrequent; at
any rate if the melancholy need were to occur,
special arrangements might be made, according as
the wit or ingenuity of the undertaker suggested.
An important report is made by Dr. Bruce Low on
the vaccine establishments in Germany. The
principle adopted in that country is to decentralise
the manufacture of lymph; but as this entails great
multiplication of machinery and buildings, and
certainly the risk of lack of uniformity in results,
we do not see that such a system is called for in
this country. As a lesson in German systemati¬
sation and exactitude, however, the report is
instructive.

One new and decided step forward has been
taken by the Board, namely, that of setting up a
special sub-department under Mr. Power’s general
guidance for the supervision of the administra¬
tion of the Food and Drugs Act, Dr. Buchanan
being appointed its provisional chief with the title
of Inspector of Foods. An extensive enquiry has
already been made by him into the danger of meat
from tuberculous pigs in London; but unfortun¬
ately its length precludes its being reproduced in
the medical officer’s report. The usual inspections
took place during the year under notice, some,
especially the inspections of Basingstoke, Lincoln,
and Fulbourne Asylum being of more than ordinary
significance and importance. In appendix B we
find reports from the researchers employed by the
Board, Dr. Klein having three papers, Dr. Sydney
Martin, Dr. John Wade, and Dr. Gordon one
paper each, and Drs. Andrewes and Gordon a joint
paper. It is not possible here to give any adequate
idea of the scope of these contributions, but the
most pretentious, undoubtedly, is the first one of
Dr. Klein’s, namely “On a New Plague Prophy¬
lactic.” Let us hope it may prove so.

It is a matter for reflection that while the work

of the medical departments of the Local Govern¬
ment Board is some of the most important and
responsible in the country, and while, moreover, it
is exceedingly well done, the amount of interest-
taken in it by the general public is practically nil.
Perhaps after their vaccination experience of the
lime-light of publicity, the department is not
unduly cast-down after all.

A BLOW TO QUACKERY.

The issue of the recent article for libel brought'
against Mr. Labouchere, of Truth, registered a
notable advance in the campaign against quackery.
A verdict has been given and judgment returned
in favour of the defendant. This result shows that
it is still possible in the United Kingdom with
impunity to call gross quackery by its proper name,
and to expose the malpractices of charlatans who
prey upon the public by professing to cure their,
maladies. The medical profession must admit-
their indebtedness to Truth in this matter, although-
at the same time we must repeat our contention
that the journal in question admits to its columns
quack advertisements of an obviously objectionable
character. The fact that Truth accepts money for
the insertion of advertisements of that class clearly
weakens its position as a censor morum. Apart
from this criticism, the editor of that incisive
journal may be congratulated on the ending of the-
long-drawn-out and costly legal proceedings in the
case of Dakhyl v. Truth. The plaintiff, who 00m*
plained of being libelled, is a Doctor of Medicine
of Paris. He came to England and assumed the
direction of the notorious Drouet Institute for the
treatment of deafness. The methods of that
organisation have long been the subject of-
unsparing attack in the columns of Truth. They,
afford a scathing indictment of the laxity of British
law in the protection of the public against the
machinations of gross and unblushing quackery.
The history of the Drouet Institute, properly
unfolded, would be sufficient in itself to warrant the
demand for new and stringent Medical Acts. Of:
what use is it to secure a proper education of
qualified medical men and to label them so that
they may be recognised by the community, if
on the other hand any ignorant and unquali¬
fied person is permitted to advertise his claims
as a curer of all and every ill that flesh is
heir to by means of potions, charms, appliances,
manipulations, and a host of special methods of
every conceivable kind? The evil is immeasur¬
ably great, and it must one day be rooted out when,
society attains a higher general level of intelligence.
Meanwhile, the nation pays the toll of its folly in.
the ruined health and the lives of the victims of
patent medicine vendors and charlatans. As a*
practical outcome of the case under consideration,
there has emerged a sort of judicial recognition of
the definition of the word “quack,” as one who
professes to cure many diseases with one remedy.
Mr. Justice Darling added the pronouncement that
quackery might be practised by the holders of the
highest medical qualifications. We imagine that
the truism laid down by the learned judge has
an application to professions other than that of
medicine. At the same time he may be thanked
by all honest citizens for having bestowed a good,,
hearty buffet upon that evil thing, quackery.

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5*4 The Medical Press. _ CURRENT TOPICS. _ Nov. 13, 1907-

CURRENT TOPICS-

The Pollution of Rivers.

In many ways the legislation of the United
Kingdom, even in matters that are apparently of an
urgent nature, is curiously slow and deliberate in
its inception. Take the question of the pollution
of rivers, about which there can hardly be at the
present time any serious difference of opinion.
The subject has been under the consideration of the
Royal Commission on Sewage Disposal for the last
nine years. It has been once again brought into
prominence by a deputation from the British
Science Guild which was last week received by
Mr. John Burns at the Local Government Board.
Sir William Ramsay pointed out that some
permanent arrangements should be made to carry
■on certain aspects of the work of the Royal Com¬
mission on Sewage Disposal. It was true that a
’few local river boards existed, and were doing good
work, but many more were wanted. A central
body with authority to deal not only with the
question of river pollution but with the whole
question of water supply, was absolutely essential
in order to map out catchment areas for districts
and to keep them free from pollution. Unless
something of the kind were done, twenty-five years
hence it would be too late, and things would be in
an extremely bad condition. Unless such a central
■board were created litigation could not be avoided
in all these matters, and he instanced one case
where .£12,000 had been spent needlessly under pre¬
sent conditions. The cost of the present Royal Com¬
mission was roughly about ^4,000 a year; but this
expense would cease if a central board were created.
The Commission, indeed, wanted to resign, but
could not do so on account of the necessity of con¬
tinuing the work. He did not think that the cost
of the working of a central body, equipped properly
'for both chemical and biological work, would
be greater than £6,000 or £7,000 a year.
Mr. Burns received the deputation in a sympa¬
thetic speech, and expressed an opinion that the
lx>cal Government Board should be the central and
joint authority in the matter of river pollution.
The Bill he hoped to bring forward in the spring
of next year would have to be warmly endorsed by
jpublic opinion in order to become a success.

A Model Sanitary Committee.

'Gratitude for long and faithful medical public
service is not often so conspicuously shown as by
the townsfolk of Swansea in the case of their
retiring borough and port Medical Officer of
Health. After forty-two years in the service of
ithe 'Corporation, Dr. Ebenezer Davies felt com¬
pelled to send in his resignation owing to his
•ever-increasing duties. Thereupon, an influential
deputation from the Swansea Medical Association
waited upon the Sanitary Committee of the town,
:and urged that Dr. Davies should be appointed Con¬
sulting Medical Officer, and that his successor be
a well-trained bacteriologist in addition to the other
necessary qualifications. The committee decided
to advise the appointment of Dr. Davies as Con¬
sulting Medical Officer of Health at ^100 per
annum, and to appoint a successor at a salary of
jC 7 °° or j£8oo a year. This graceful recognition
mus. be gratifying to Dr. Davies, accompanied as

it was with many expressions of esteem and respect.
In introducing the deputation, Dr. Griffiths spoke
of his work as always of an unostentatious
character, and said that in the profession they
looked upon him as a model of courtesy, consis¬
tency, conscientousness, and, he might say, honour.
The relations between the Swansea Council and
the Medical Officer of Health might well be taken
as an example by many local authorities in other
parts of the kingdom.

Plague in Glasgow.

A local outbreak of bubonic plague is announced
in the Glasgow newspapers in a small district on
the South Side. The nature of the disease has been
confirmed by a medical officer specially despatched
from the Local Government Board, Edinburgh.
Patients have been promptly removed to the
Belvedere Hospital, and “contacts” subjected to
a fortnight’s quarantine in the reception house.
The invasion of a large town by plague is serious
under any circumstances, but happily nowadays
there is no need of a panic in our own comparatively
well-ordered centres of population. Past experience,
moreover, in this very locality is reassuring, for in
1900 plague appeared there, but was restricted to
36 oases, with 16 deaths. The following year it
recurred in milder form. Its re-appearance in the
same spot in 1907 renders it possible that the in¬
fection has persisted, and that it would have been
wise to demolish the building where the disease
formerly obtain a foothold.

Strait Jackets in Poor-Law Infirmaries.

From a medical point of view the use of the strait
jacket, under any circumstances, is questionable, but
most of all is it to be deprecated when left in the
hands of laymen to administer. The Local Govern¬
ment Board appear to think the application of that
antiquated appliance demands supervision, for they
have intimated to the Hampstead Board of
Guardians that an inquiry will be held with refer¬
ence to the recent inquest on the body of an inmate
of the workhouse. The peculiar circumstances of
the case were that the man in question died in the
observation ward of that institution after having
been there seventeen hours, seven of which were
spent in a strait jacket. From the newspaper report
it is uncertain whether deceased was seen at all by a
medical man, but it clearly intimates that he was
placed in the jacket in the absence of medical orders.
There is apparently no padded room in the work-
house, a fact that met with the Vice-Chairman’s
approval, if we may judge from the remark that
such rooms were antiquated and undesirable. Of
all things in the world we should have thought that
that mild condemnation would have applied with a
hundredfold force to the strait jacket. The whole
question of, in our opinion, the Poor Law accommo¬
dation for refractory and delirious patients generally
requires searching inquiry and stringent remedy in
the interests of common humanity.

Birthday Honours.

All medical men will have found peculiar pleasure
in seeing the name of Professor Clifford Allbutt in
the Birthday Honours list. The honourable style of
K.C.B. will sit on no worthier member of the pro¬
fession ; the only criticism we feel inclined to offer
is that it has been long overdue. Dr. Allchin,
another well-known physician and medical sys-

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Nov. 13, 1907.

PERSONAL.

The Medical Press

tematiser, has been made a knight, and Dr. Beat-
son, C.B., of Glasgow, long a devoted volunteer,
has been promoted to the knighthood of his order.
Both distinctions are well earned. Although not
strictly medical, the knighthood of Mr. A. C.
Scovell, who has been so long associated with the
profession and with health administration in
London, calls for special mention. It may be true
that the world knows little of its greatest men ; it
certainly is true that London is totally ignorant of
the enormous debt it owes to Sir Augustin Scovell
for his steady and fearless administration during
the late small-pox outbreak. Two names are of-
special interest to Irishmen. Knighthoods have
been conferred upon Mr. Robert Matheson, LL.D.,
who fills the important post of Registrar-General,
and Dr. YV. J. Thompson. Dr. Thompson, who is
senior physician on the staff of Jervis Street Hos¬
pital, is one of the physicians to the Lord Lieu¬
tenant. He has been largely concerned in the work¬
ing of the recent Tuberculosis Exhibition in Dublin.
Mr. Robert Matheson is well known as a very able
statistician. He, also, was deeply interested in the
working of the anti-tuberculosis movement in Ire¬
land, and contributed to the exhibition a large series
of statistical tables relating to the same subject.

The Closing of the Tuberculosis Exhibition.

The closing of the Tuberculosis Exhibition in
Dublin on Friday last was marked by lectures
delivered in the theatre of the Royal Dublin
Society by Sir Shirley Murphy and Dr. A. K.
Chalmers on “The Control of Milk and Food
Supplies and other Conditions affecting Tuber¬
culosis,” under the presidency of His Excellency
the Lord Lieutenant. The subject of the lecture
was well chosen, for up to the present Irish sani¬
tary authorities have practically done nothing
towards controlling the milk and food supplies with
a view of preventing tuberculosis. It is, of course,
too soon to judge of the effect of the exhibition as
a whole. It is, however, safe to say that a degree
of public interest in the question has been roused
such as never would have existed before. It
remains to be seen whether the public will insist,
through the sanitary authorities, on making their
opinions effective. We confess we have not much
faith in the professions of the Local Government
Board or of the various sanitary authorities. The
former boasts of its energy and activity in pressing
reforms on the local bodies, but this energy and
activity began only a year or two ago, and little
was heard of it until Lady Aberdeen brought the
question to the front. The value placed by the
Board on sanitary work may be judged by noting
that the usual salary of a medical officer of health
as sanctioned by them is ^15 to £20 a year, and in
some cases ^5 a year. The local authorities, too,
will always be obstructive until there is a strong
public opinion to drive them on. If the exhibition
has done any good, it is in the formation of this
opinion.

Infantile Mortality in Durham.

The Archdeacon of Durham has made his
triennial visitation at Durham notable by calling
the attention of the clergy to the overcrowded
population and the terrible infantile death-rate in
the county. Speaking of the importance of the
question of housing in Durham, he found that,

while the population of Durham and Essex were
practically the same, in Durham the percentage of
overcrowding was 28.4 per cent., while in Essex it
was 2.7 per cent. The deaths in Durham were
21,962, and in Essex 14,913. The rate of infant
mortality in Durham was 156 per thousand births,
and in Essex 115 per thousand, or three deaths in
Durham to every two in Essex. They were better
now in respect of overcrowding than they were
twenty-five years ago, but they must be far better
than they were that day before the clergy and laity
could come to the conclusion that they had done
their duty. Dr. Eustace Hill, Medical Officer of
Health for the Durham County Council, pointed
out that their county had the highest infantile
mortality in England and Wales, with the
exception of Glamorgan. One-third of the total
number of deaths were infants under one year old,
two-fifths of infants under two years, and nearly
one-half under five years of age. Half of the total
number of infants’ deaths were preventable, and
the total number of avoidable infant deaths were
100,000 yearly. In this matter the Archdeacon has
set a worthy example to his fellow Churchmen, who
will find in social reforms a field of altruistic labour
worthy of the highest ideals and traditions of
Christianity.

PERSONAL.

The King has bestowed another mark of his favour
upon Sir Frederick Treves in granting him as a
residence Thatched House Lodge, Richmond Park,,
a charming house standing in three or four acres oft

beautiful grounds. -

The County Council of Bedford have appointed Dr.
G. F. McCleapr, Medical Officer of Health for Hamp¬
stead, as Medical Officer for Bedfordshire.

Professor Clifford Allbutt has been appointed a : <
K.C.B. {Civil Division).

Dr. W. H. Allchin and Dr. W. T. Thompson have •
been made Knights Bachelor.

Lieut.-Colonel and Hon. Colonel G. T. Beatson,
C.B., R.A.M.C. (Volunteers), cf Glasgow, has been 1
promoted to be K.C.B.

Dr. R. M. Coulter, Deputy Postmaster-General of
Canada, has been appointed C.M.G.

Dr. Preston King has been elected to the Town-
Council at Bath; Dr. H. A. Latimer at Newport.:
and Mr. Paul Swain at Plymouth.

There is a vacancy for a medical member on the-
Senate of the University of London, caused by the.-
resignation of Dr. Launston E. Shaw.

Dr. James Pearson, J.P., has been elected Mayor
of Bootle for the present year.

Mr. W. H. Power, C.B., F.R.S., medical officer
to the Local Government Board, has been awarded
the Buchanan medal of the Royal Society.

Dr. Ronnaux, surgeon of the St. Julian Hospital
at Cambrai, has contracted tetanus from an opera¬
tion, and though his arm has been amputated hi9

life is despaired of. --

Dr. Louis C. Parkes, Medical Officer of Health
for Chelsea, will introduce a discussion at the Royal
Sanitary Institute to-morrow (Thursday) night on the
“ Smoke Problem Abatement Society.”

The Public Health Committee of the Corporation
of Dublin has presented a beautifully illuminated
address to Sir Charles Cameron, C.B., Medical Officer
of Health for Dublin City, in which the Committee
congratulates him on the success of his efforts to
improve the state of public health in Dublin.

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51 6 The Medical Press. _ CLINICAL LECTURE. _ Nov. 13, 1907.

A Clinical Lecture

ON

DEFORMITIES OF THE FOOT ASSOCIATED WITH ABDUCTION.

B r EDRED M. CORNER. RScXond^ RLCCanUb, F.R.C&,

Surgeon in Charge oE Out Patients. St Thomas’s Hospital} Senior Assistant-Surgeon. Hospital for

Sick Children.

Gentlemen, —To-day I want to talk about the
reverse of what we were speaking about on Monday.
I then showed you a number of slides illustrative of
the deformities associated with the adducted position,
which the foot assumes during activity. This after¬
noon I wish to show you a number of slides setting
out the positions and deformities of the abducted
foot, which position of abduction the foot assumes
during rest. In this slide the arch of the foot is not
much marked, although it is not entirely obliterated.
And it is very useful in practice if you can remember
that the foot can become abducted, and therefore
present all the symptoms which you naturally
associate with flat foot, and yet have a slight arch.
The next slide shows the position of the bones of the
foot in abduction or rest. The toes are turned out¬
wards opposite the mid-tarsal joint. In contrast with
that, I show you a slide of a foot in adduction or
activity. In activity there is a raised heel and
increased arch, the person standing on the toes. In
the movement of adduction the toes are turned
inwards and the movement has taken place about the
mid-tarsal joint.

I now want to show you how this abducted position
of the foot can be recognised in early life. Inactive,
young, or weakly people turn their toes out; as
people grow older their tendency is to assume the
abducted position. This is caricatured in the shuffling
gait of the aged. People who turn their toes out and
have abducted feet do not lift their feet well from the
ground, so that their gait is never as clean and neat
as that of people having adducted feet. In people
who maintain their feet naturally in the abducted
position one finds long narrow feet, with smooth
uppers of their boots. In the abducted foot the heel
of the boot is always worn on the outer side. I
remember one case where that point was brought
prettily into the Law Courts. A man had sustained
a Potts’ fracture of his leg, and the result of the
reduction of the deformity was to leave his foot in the
flat or abducted position, a position which I fear is
fairly common after Potts’ fracture of any severity.
The "employer’s insurance company, which was dealing
with this man, refused compensation, and the case
came to the Courts. A number of surgeons from the
West End went to give evidence. The first surgeon-
witness, an important and well-known man, had this
pointed out to him; the patient’s boot was produced
to him. He explained very carefully to the judge and
jury that the man now, as the result of the accident,
was walking on the inside of his foot. The counsel
on the other side produced the boot and asked this
very important surgeon why it was, if the man walked
on the inner side of his foot, he wore away the outer
side of the heel!

The next slide shows the sole of an abducted foot;
and you will notice a callosity occurs beneath the
third toe. Sometimes instead of one callosity you
find there are two. The callosity in the active foot
is partly under the ball of the big toe. Abduction is
the position of the slow, the heavy, the inert. It is
associated with a number of deformities, which
we can classify as (a) those taking place at
the ankle joint, like talipes calcaneus; ( b) those taking
place at the mid-tarsal joint; and (r) those_ taking
place at the metatarso-phalangeal joint. We have
not time, nor would it be profitable, to go into alt

(a) Delivered at the Medical Graduate*’ College and Polyclinic,
EindoD. 1907.

these deformities to any extent. We will speak of
only a few.

First, there are deformities of the ankle joint.
There may be a combination of talipes calcaneus ,
valgus , and -flat foot. These factors are always
present, and are quite inseparable in the acquired
deformity. The acquisition of this deformity is
largely dependent on the integrity of one muscle,
namely, the tibialis posticus. That is a muscle in the
calf of the leg whose function is the raising of the
arch of the foot. Whenever the foot is active, as in
springing and jumping, the heel is raised from the
ground and the arch of the foot is increased, so that
nobody can have an active foot unless the tibialis
posticus is well developed. The peronei muscles are
its great antagonists, and if those muscles have the
mechanical advantage, the foot will flatten, and will
enter into a position which you might call talipes
equino-valgus, but which I prefer to call pes abductus.

Everybody is conversant with the ordinary condition
known as flat foot, but I would impress upon you
that people may come complaining of all the
symptoms of flat foot, yet may not have a flat foot.
It is not flatness of the foot which leads to the
complaint, but the abducted position of the foot.
There is a point here in regard to the treatment. The
time-honoured treatment of cases of flat foot has been
to teach them exercises; but if you have had the
opportunity of watching a person who has been,
having his flat foot treated by exercises, you will
have found that the exercises have certainly made him
better, but they have not given an arch to the instep ;
the foot remains flat. The teaching of exercises has
only recently come from Sweden into the hands of
the more intelligent instructors. In connection with
these exercises I would remind you that we are really
considering only two muscles: the tibialis posticus
and the peronei group. The first of these raises the
arch of the foot, so that it is absolutely necessary to
every person whose foot is to assume the position
of activity. The peronei flatten the arch. The
function of the peronei in ordinary people is to evert
the foot. But if the foot is already flat it is already
turned out, so the peronei cea9e to be everters of the
foot and become flexors, like the other calf muscles.
So if people whose feet are flat and therefore already
abducted are taught tip-toe exercises in the ordinary
way, those exercises will strengthen the tibialis
posticus, and at the same time strengthen the
antagonising peronei. But the exercise, while
strengthening the muscle which raises the arch, also
strengthens the muscle which flattens is, so the arch
remains flat, although the patient is better. In this
connection I would mention another condition which
is associated with the abducted position of the foot,
namely, ingrowing ankle. Unfortunately, these people
are often put into strong boots with stiff uppers. That
is a great mistake, comparable to putting a stiff
jacket on to a case of lateral curvature of the spine,
instead of by exercises and other measures im¬
proving the musculature of the back. In ingrowing
ankles also the musculature must be improved,
especially the tibialis posticus. This should not be
done as the superannuated soldier teaches boys, with
the toes turned out; but with them pointing straight
forward, or even turned a little inwards.

The next deformity associated with the resting
oosition of the foot occurs at the metatarso-phalangeal
joint; is that very common deformity hallux valgus.

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Nov. 13. 1907.

CLINICAL LECTURE.

The Medical Press. 5*7

Here I show you a slide of hallux varus, which is
associated with the active position of the foot.
Hallux valgus is usually attributed to badly-shaped
boots; but this is not always so. If you examine such
a foot whilst inside the boot you will often find quite
an interval between the toe and the inner portion of
the boot. Hallux valgus is a part of the abducted
position of the foot, and as a result of that, the inner
side of the head of the first metatarsal is pressed
against the boot upper; and whenever a bony point is
pressed or rubbed against a firm thing like the upper
of a boot, it develops a bony boss on that surface, and
so the toe will be pushed into a position of hallux
valgus. The operation usually done consists in
removing this bony boss, and passing a tenotome
through to divide the contracted ligament, (a) It is
common for people to forget to divide that ligament,
but if that is not divided, the toe will not go into
place. After doing that operation, warn the patient
■that the toe will not stay in the position in which it has
been placed, but with the removal of the piece of bone
and bursa it will probably be painless. In every case
•of hallux valgus a certain amount of attention should
always be given to the boots worn. The usual idea
is that these people should wear broad-toed ugly-
looking boots; but that is quite unnecessary. As a
sort of rough-and-ready test you can estimate whether
a boot is right or not by drawing a line parallel with
‘the inner margin of the boot. If it is a well-made
boot this line will pass through the middle of the
heel.

Now I want to say a word about hallux rigidus,
-particularly in association with the inactive or
abducted position of the foot. This is the form
-usually described in the text books and shown in the
out-patient room. In this condition, as you know,
the big toe stands out, and is stiff and painful.
Hallux rigidus, as ordinarily described, can be bent
towards the sole of the foot, but not in the contrary
direction. That is the distinction between hallux
-rigidus associated with the active as compared with
that of the inactive foot. The proximal phalanx of
the big toe moves round the head of the metatarsal
bone in an arc of a circle, the radius of which is the
lateral ligament of the joint. If on the dorsum of the
head of the metatarsal a bony boss forms, it will slowly
push the phalanx, so that the toe gets bent upwards.
In the inactive foot, pressure is not borne there. The
-callosities of the sole of the abducted foot are under
the third toe, not under the big toe. But in the
Inactive foot it is the upper part of the head of this
metatarsal which is driven against the boot upper. As
the upper part of the bone enlarges, the ligament will
T>e tight, and the toe will be more and more bent in
towards the sole of the foot. Xliis slide shows hallux
rigidus not as ordinarily described; the bony boss is
on the lower surface of the metatarsal, not the upper;
and as the deformity grows, the phalanx will become
dorsally flexed, so that it curls up backwards. This
Is hallux rigidus of the active position of the foot.
As the bony boss on the upper part of the metatarsal
continues to grow, and the big toe becomes more and
more flexed into the sole of the foot, there arises the
condition described as hallux flexus. If it requires
any treatment it is almost invariably amputation at
that joint. The next slide shows hallux extensus,
and it is associated with the active position of the
foot. The bony boss is developed on the under¬
surface, so leading to the dorsiflexion or extension
of the toe. Such a condition will lead to a transverse
crease developing in the upper of the boot. The first
line of treatment of this is by means of exercises,
which may be combined with passive manipulation of
the toe. In teaching such exercises, as tip-toe exercises
in hallux rigidus, it is well that they should be begun
with the toes turned outwards; then the toes should,
every day or every two or three days, be turned a
little more in, until finally, if the exercises are going
to cure it, the patient should be able to perform them
with the toes turned in. With regard to operative
treatment in such a case, when it is associated with an

(a) “Operation* of General Practice.” Pp. 245-246.

inactive foot, with the bony boss on the head of the
metatarsal bone at the “top, you need have no scruple
in taking away the head of the first metatarsal. That
seems a severe piece of advice, when it is remembered
that the great stress falls on the first metatarsal; but
that is untrue of the inactive or abducted foot, and
it is in this that the ordinary hallux rigidus of the
textbooks occurs; and in those cases the under¬
surface of the head of the metatarsal bears np pressure
during walking, therefore its loss will not be much
felt by the patient. The next slide shows that the
bony boss on the head of the first phalanx formed
at the lower part, and a bursa, and then a corn, and
the distal phalanx is extended or flexed towards the
dorsum of the foot. In that case you find a com
under the head of the proximal phalanx. It is not
uncommon to see in the out-patient room a corn not
under the ball of the big toe, but under that toe more
distally. When that is the case one can be certain
that the foot is habitually in the inactive position.
For this deformity I suggest the name digitus
extensus.

This slide shows hallux valgus, and in that the
valgus takes place partly in the metatarso-phalangeal
joint, and partly in the interphalangeal joint. In
the next slide the phalanx is affected at the inter-
phalangeal joint solely. So it is a case of digitus
valgus of the great toe.

The next slide shows ordinary hammer toe, and the
deformity there is the same as that which I showed
under the name digitus flexus of the great toe. The
general operative treatment consists in making a
lateral incision through the skin, dividing the lateral
ligament at the interphalangeal joint, and removing
the head of this proximal phalanx. If it ever was
necessary, as it very uncommonly is, to operate on a
case of digitus flexus of the great toe, then a similar
lateral incision is made, and the head of the proximal
phalanx will be removed.

And now I want to say a word about ingrowing toe¬
nail. It is a very common condition, and I want to
point out the many reasons why it is commonly
associated with the abduction or the inactive position
of the foot. The ingrowing toe-nail, especially early
cases, can be cured by ordinary local cleanly treat¬
ment, and the treatment for the abducted position of
the foot, by which I mean tip-toe exercises, with the
toes turned out, but with the foot directed straight
forward. In very few of these cases is it necessary
to proceed to operation, but where that is required,
these slides show what should be done. Half the
nail and the matrix are removed, and the wound
sewn up (ah

It ha!d been my intention also to speak about
deformities of the leg and elsewhere which one finds
associated with the abducted position of the foot.

People whose feet are in the inactive position, if
they fall on their feet, are far more liable to injure
them, and to break a bone, particularly the second or
third metatarsals, than are people with adducted feet.
In these cases one is apt to find pain and tenderness
persisting for a long time about the base of the third
metatarsal bone. It is very difficult to know why this
pain persists; one is apt to think some more severe
injury has been overlooked. Skiagrams do not help
us much in this matter, because they do not show us
distinctly the parts in the region of the base of the
third metatarsal. In an abducted foot, it is difficult
to state whether the lesion about the base of the third
metatarsal bone is fracture, or a partial dislocation,
or an injury only, of the soft parts, which is called a
sprain. If one starts massage and exercises as soon
as it can be done, one knows that that injury will get
well in two or three months. Still, the patient usually
suffers from some disability all his life. If he be a
labouring man, he is not able to stand so long as he
formerly could, or he is not able to go up a ladder as
well. Thus there is something taken off his wage-
earning capacity. These cases should be borne in
mind and understood, because they often figure in
legal actions against employers.

(a) “Operation* of General Practice.” Pp. 246-247

518 The Medical Press.

ORIGINAL PAPERS.

Nov. 13, 1907.

Note.— A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture for
neat week will be by R. L. Swan, F.R.C.S.I., Surgeon to
Dr. Stesvensl Hospital and to the Orthopssdic Hospital,
Dublin. Subject: “A Reference to Some Tubercular
Diseases of the Knee-Joint, and to the Treatment of the
Synovial Cavities .”

ORIGINAL PAPERS.

DEATH FROM HAEMORRHAGE
FROM A MEDICO-LEGAL POINT OF
VIEW.

Past II.

Bv PROFESSOR HENDRICK, M.D.,

Of Hamburg.

(Specially reported by our German Correspondent.)

Continued from page 494..

II.— Death from Haemorrhage in Consequence of
Solution of Continuity of the Great Blood
Vessels.

Death from solution of continuity of the great blood
vessels, aorta, innominate artery, pulmonary artery,
inferior and superior vena cava, is not frequent, as
they lie in a position specially protected by the
sternum.

When they are wounded, death, as a rule, follows
very quickly—more quickly than when the heart is
wounded (as Richter showed in his experiments on
animals), as the blood finds less resistance in the
adjoining tissues, and in consequence of the impos-
sibility of assistance it flows uninterruptedly.

The bleeding takes place into the mediastinum, and
after bursting into the pleura, into the pleural cavity,
or when the abdominal aorta is injurea, into the ab¬
dominal cavity. By compression of the lungs, as shown
by Richter’s experiments on rabbits, the bleeding is
somewhat checked, but it has never been observed that
this has ever had any influence on the rapidity of the
course. Pneumothorax may be associated with the
hsematothorax that is set up. As regards the causes,
besides the traumatic, spontaneous rupture may take
place, or rupture from very slight force, especially in
the case of the aorta (rupture of the aorta). These are
caused by morbid changes of the arterial walls,
arteriosclerosis, fatty degeneration, endarteritis,
aneurysm, the extension of ulcerative processes from
adjoining parts (cancer of the oesophagus, caries of
the vertebrae, foreign bodies that have stuck fast in
the oesophagus).

If the rupture affects the whole three coats of the
vessel, the bleeding is more rapid. The favourite place
for rupture is just over its commencement. Generally
the rupture is transverse. If only the intima and
media are affected, a dissecting aneurysm may form,
and the bleeding may be interrupted by it, but only
for a short time generally—a few hours to a few days.
The adventitia at last yields to the pressure of blood,
and death from haemorrhage takes place. If the vessels
are healthy, only extraordinary violence can cause
them to rupture. A case described by Langenbeck of
rupture of the aorta without disease of the vessel is
an exception, where a perfectly healthy person at a
trial in court suddenly collapsed from rupture of the
aorta (quoted from Drenckheim). Proof or a causal
relationship between rupture of an aneurysm of the
aorta and an earlier violence that has been followed
by an aneurysm is extremely difficult to establish.
Thus Pantzer describes a case where the question for
decision was : Had the aneurysm that caused the death
any causal relationship with an accident that happened
seven years before? The three opinions that were
given by three different experts did not agree as to the
cause. As most aneurysms develop without any
demonstrable cause, an aneurysm that leads to fatal
haemorrhage may at most, with some degree of proba¬
bility, but not sufficient for a judicial decision, be
traced back to a former injury.

Bleeding to death from solution of continuity of the
sub-clavian vessels is, according to Israel, extremely

rare, and this is attributable to their protected posi¬
tion. It is distinguished from that before described,
in so far that it may be either internal or external, and
assistance may possibly be rendered. The internal
haemorrhage runs the same course as that of the great
cardiac vessels before described. When it is external
its course may be retarded by the blood making its
way under the muscles, and the formation of a clot.
Death takes place from the haemorrhage alone, or asso¬
ciated with air embolism with its resulting suffocation
(complicated death from haemorrhage). The course of
the bleeding may be interrupted by the formation of a
spurious or varicose aneurysm, that ruptures suddenly
and leads to death. If, after professional assistance
has been rendered, death takes place from late haemor¬
rhage, it is, according to Maschka, the business of the
medico-legal expert to decide how far the injury itself
caused the death, and to mark how far improper be¬
haviour on the part of the wounded man himself, how
far the professional treatment or any accidental
wound contributed to the late onset of haemorrhage.
Here it may be a question of neglect on the part of
the surgeon; but as Sachs specially notes, it is to be
borne in mind that, in spite of the omission of a sur¬
gical operation, which must have been a considerable
one, the patient would not be saved. Cases of this
kind are given by Seydel (Kasuist. Mitteilungen aus
der forens. Praxis, Vierteljahrsch. f. gerichtl. Med.,
Bd. XLIII.), and by Nussbaum (Friedrich s. Blatter f-
gerichtl. Med., 1876, S. 146).

Bleeding to death plays a great role, from a medico¬
legal point of view, in the frequently occurring death s-
from the throat being cut in cases of murder and-
suicide. If the carotid is wounded, death takes place
in a short time, as the blood can flow outwardly with¬
out check. If, as happens in most cases, the trachea
is opened, the blood flows from the superficial vess-ls
(the external jugular and the superior thyroid artery
and: their branches), as well las from the deeper ones, into
the respiratory passages, and suffocation ensues before
the patient bleeds to death. The great veins of the
neck being opened also, air may enter, and death be
caused by air embolism. The case is therefore one of
complicated death from haemorrhage from blocking of
the air passages or from air embolism. The quantity
of blood which continues pouring out from the body
until death cannot be measured; in any case of death
with this complication a much smaller loss of blood
leads to death than in ordinary cases. The decision of
the question as to the deed, whether murder or suicide,
frequently presents difficulties. The following may be
taken as general criteria: The suicide stabs from above
on the left downwards towards the right or from
above on the right downwards to the left, according
as he is right or left-handed. Often from repeating
the stabs, or from the skin falling into folds from in¬
voluntarily bending his head, he will show several in¬
cised wounds; whilst in murder, often committed
whilst the victim is asleep, there is more generally one
deep and more horizontal wound. The suicide will
sometimes show secondary incisions on other parts of
the body from unsuccessful attempts; he will have the
weapon in his hand, and this will be bloody. On
closer consideration of these criteria, we must concede
that Puppe is right when he says:—“ The differential
diagnosis in cases of death from cut throat between
murder and suicide offers a remarkable uncertainty,
whatever the circumstances may be. A series of dis¬
tinguishing signs are usually present in murder cases,
but there is not one that has not been observed in
suicide cases also, and vice vend.”

Bleeding to death from wounds of the large vessels
of the lower extremities occurs the most frequently of
any of the kinds hitherto described; it is especially
the subject of medico-legal inquiry, as suicide from
wounds of the arteries. It is distinguished from death
from haemorrhage from injury of the subclavian
artery in being more accessible to assistance either by
the injured party himself or by others; its course may
therefore be interrupted, but if the aid is not speedily
on the spot, the end comes quickly. Moreover, in spite
of professional assistance, death often takes place
from secondary haefnorrhage.

Bleeding to death may also occur from injury of
superficial veins. Thus Caspar-Liman mention a ca»e

Digitized by GoOgle

^Nov. 13, 1907. ORIGINAL

(Kasuistik, No. 128), in which a person rising from a
broken night commode injured the saphena vein and
•bled to death. Schlag also reports a case of a person
who bled to death from an opening in the saphena
'vein of the right leg, which had been made with the
intention of committing suicide. Bleeding to death was
-rendered possible here by the vein being varicose and
adherent to the periosteum.

Leonpacher (Aerztl. Sachverst.-Zeit., 1898, No. 5,
S. 99) cites a further case of the kind, where a woman
in a railway carriage bled to death in 13 minutes from
a vein that had burst without knowing herself that she
was bleeding.

Bleeding to death may also occur from smaller
wessels than those mentioned, but unfavourable con¬
ditions are usually necessary, especially a morbidly
•diminished power of coagulation of the blood
(haemophilia). In the latter cases even a slight injury
may cause fatal haemorrhage (extraction of teeth, epis-
■taxis, etc.).

Fatal haemorrhage may take place from parenchy¬
matous bleeding from injuries of the corpora caver¬
nosa, the tongue, and the spongy bones. Injuries of
•.the corpora cavernosa occur principally from attempted
rapes and injuries of the female genital organs which
will be described later. In fatal haemorrhages from
■the tongue, the fatal termination is mostly complicated
by the blood finding its way into the lungs and
■causing suffocation, but the fatal result may follow
tfrom external haemorrhage only (Colley) (32).

Fatal haemorrhage from parenchymatous bleeding is
•almost always internal. In diseased organs it may be
spontaneous or from only slight violence, but in
healthy organs onlv from the effects of considerable
force. The following have been observed: being run
over, falls from a height, crushing between fixed or
moving objects, a blow, a push, or a fall. The diag¬
nosis can only be determined on opening the body,
•especially in the not rare cases in which the body
•shows no external marks of violence. For determining
the diagnosis—whether of spontaneous or traumatic
origin—the situation and direction of the opening are
•of value; if spontaneous it will be found at the spot
where experience teaches the disease is by preference
localised, whilst in traumatic ruptures certain physical
laws will be followed as to size, consistency, position
•^whether protected, etc.), the form of consolidation,
the condition of the hollow viscera as to fulness, and
the form of rupture. In the meantime the points of
predilection for rupture of organs as determined by
•experiment are more important from a scientific than
from a practical point of view (see Geill) (35).

More in detail to be discussed are fatal haemorrhages
from ruptures of the brain, liver, lungs, spleen,
kidneys, pancreas, stomach, intestines and bladder.
Ruptures of the heart and aorta have already been
■treated of. Ruptures of the female genital organs will
t>e treated by themselves.

Fatal haemorrhage from bleeding into the cranial
-cavities from the venous blood vessels, the meningeal
•artery and its branches, the basilar artery and its rami¬
fications (intra-cranial haemorrhage), may appear under
-very varied aspects from a medico-legal point of view.
The simplest cases to determine are those in which
there has been fracture of the skull, laceration of
vessels, cerebral haemorrhage, or rupture of the brain,
fracture of the skull being a certain sign of trau¬
matism. Death takes place from paralysis from blood
pressure, and generally not immediately after the
injury, but after a certain time—hours, sometimes even
days—have elapsed, during which the signs of pressure
gradually increase; or also directly from breaking up
.of brain substance, in which latter cases there are
-transitions in the mode of death from crushing of
important organs. It is important here to observe that
signs of external violence may be altogether absent,
and that the part injured does not always correspond
to the part where the violence has fallen, but fre¬
quently lies quite opposite to it (contre coup). Those
cases are more difficult to determine, but also more
rare, in which vessels are torn or even the brain
lacerated without any fracture of the skull being pre¬
sent. Zaajer describes such a case (36), where a woman
.aged 38 died from laceration of the brain without any
fracture of the skull, probably after being abused by

PAPERS._ The Medical Peess.. 5*9

her husband; the man, however, in the absence of
legal proof, got off. Defraneschi (38) (Aerz. Sachverst.
Ztg., 1902, No. 7), mentions a case where a countryman
received a blow on the head. The next day he became
unconscious and died in 24 hours. The autopsy showed
laceration of the middle cerebral artery and effusion
of blood without any fracture of the skull.

The mechanism of these injuries, according to the
experiments of Bruns, Baum, Messers and Treub (7),
is as follows: The elastic skull is compressed by the
violence by which the cerebral fluid is forced back
into the cavity of the spinal cord; after the cessation
of the violence the skull springs back quickly, the
fluid cannot move so quickly, and a negative pressure
arises within the skull, whence the rupture. The place
of rupture may be in any part.

Those cases are most difficult to determine in which
there is disease of the walls of the vessels—arterio¬
sclerosis, small miliary aneurysms (Hofmann), vas¬
cular internal pachymeningitis, which may have caused
spontaneous rupture, but in which there has been a
possibility of a traumatic origin.

These cases are frequently the subject of legal pro¬
ceedings when property is in question (Schilling) (37),
where violence may be asserted when there has been
none, or of so trivial a nature (a box on the ear) that
for the first moment one doubts the deadly effect. The
number of possible origins in these cases is great. A
box on the ear may be fatal when the skull is thin, a
blow of the fist, if there is an aneurysm, a fall from
slipping may be fatal because the man is a drinker
with arterio-sclerosis. The decision will be still more
difficult when death does not follow the suspected in¬
criminating event immediately, but later, as the fol¬
lowing example from a collection of medico-legal
opinions from Vienna shows : A woman was struck on
the head with the fist, possibly also with a closed
knife; she fell down, and remained several hours on
the ground, got up again and walked away; possibly
also she again received blows on the head. The morn¬
ing after she was found dead in bed. Post-mortem
examination: superficies of the brain covered with
blood. The question was : did she die from violence,
a blow, a fall, a push, or was she thrown, or was it
in consequence of lying on the cold ground in a
drunken condition, or after the excitement of a fit of
rage? In a similar case, where a blow on the head,
brandy, and struggling had caused extradural haemor¬
rhage and bleeding between the cerebral hemispheres,
a ruling opinion was given to the effect that the brandy
and the struggle were secondary causes. Another case
in which apoplexy had taken place in consequence of
leucaemia, shows how easily an inconspicuous trauma
may be taken as the cause of the haemorrhage in such
cases.

The differential diagnosis between spontaneous and
traumatic haemorrhage may be determined according
to the following criteria (Schilling) (37):—

(1) Spontaneous haemorrhages are mostly central,
and spread from within outwards, and have a known
seat which, according to Andral (quoted in Schilling),
was out of 386 cases 61 times the corpora striata, 35
times the optic thalamus, 27 times the centrum ovale,
and the ganglia 202 times. They mostly proceed from
the branches of the artery of the fissure of Sylvius,
and pathological changes of the vascular system are
found in other parts.

(2) In traumatic haemorrhages without fracture of
the skull there are dural, sub-dural, or arachnoideal
haemorrhages in one large or several small collections.
If central extravasations are present, they are always
accompanied by bleeding from the meninges. V.
Bergmonn decided in a case where a drunken man
was struck to the ground, that_ the absence of menin¬
geal extravasations with a central one in the interior
was in favour of a spontaneous origin.

Fatal rupture of the liver always takes place when
the lesion is of a certain extent. Death after the
injury may not be rapid, as might be expected where
the blood has free exit into the peritoneal cavity. In
a case observed in v. Nussbaum’s klinik (quoted from
Drenckhahn) (26), a man who had been crushed
between wagons, and after this injury walked to the
hospital six hours afterwards, died from a large rent in
the right lobe of his liver. According to Puppe (26),

Digitized byGoOQlC

520 The Medical Peess.

ORIGINAL PAPERS.

Nov. 13, 1907.

rents are distinguished according to their situation,
in the convexity, at the base, ana sub-capsular. The
liver tears from contusions most readily of all the
organs of the body in consequence of its size and its
method of fixation, its dependence in firm ligaments,
The blunt injuries that cause the liver to give way are,
according to their frequency, the following (Heinzel-
mann) (13) : the most frequent is being run over ; next
a push; thirdly, falls from a great height, from a
horse, a wagon, and such contusions. It is indu¬
bitable that pathological processes make the liver more
likely to tear under the influence of slight degrees of
violence (Geill) (35). In a case mentioned by Chiari
(1 x), a carcinomatous liver ruptured from turning in
bed. Heinzelmann (9) reports a case of rupture of
the liver that could have arisen from turning in bed
or from a forced inspiration. In two other cases one
was from a fall on the right side (tuberculous omen¬
tum), the other from a fall on the ice (tuberculous
diathesis). Fischer (11) states that ruptures of the
liver are seen from slight blows over echinococcus
cysts; Taylor (n) is of opinion that a liver with fatty
degeneration may rupture from contraction of the
abdominal muscles. Lidell, Strassmann, and Hof¬
mann express themselves to the same effect. Accord¬
ing to the Handbuch der Chirurgie, by v. Bergmann,
tuberculosis, syphilis, and amyloid predispose to rup¬
tures. Experiments made on dead livers with regard
to friability or firmness (Caspar-Liman, Ogston,
Strassmann) have not led to any uniform Jesuits of
practical value. In the same way no special direction
of rupture after contusions, as compared with spon¬
taneous rupture, has been determined. It can perhaps
only be said that amongst the kinds of rupture the
sagittal in the middle part preponderate.

Ruptures of the lungs come in the second line as
regards frequency of occurrence. Fatal haemorrhage
from rupture of the lungs takes place from every
moderately severe injury of them. It is mostly com¬
plicated by bleeding into the opened air passages and
consequent suffocation, which when the force is great
follows immediately with formation of haemato or
haemato-pneumothorax and subsequent compression of
the lungs. The lungs being so well protected against
injury by the chest walls, for rupture to take place
the larynx must be closed through fear at the moment
of compression, when the lungs burst like a bladder
filled with air, naturally at some locus minoris re-
sistentiae, caused by disease. As to the direction of
the rent morbid conditions of the lungs have less
influence than pleuritic adhesions (Altmann) (41). The
principal line of rupture is longitudinal along the
posterior inner margin of the lungs, the next hilus
rupture, rupture between the lobes. It is also to be
noted that ruptures may affect the inner parts of the
lungs only, without being visible externally, and these
may arise from purely internal causes, so that from
the condition found there may be nothing to indicate
external violence (Caspar-Liman).

In injuries and ruptures of the spleen, which in
regard to frequency occupy the third place, the
haemorrhage is generally fatal, either immediately or
from an intervening cause (peritonitis), as is shown in
statistics collected by Heidenhain (42). From statis¬
tics by Edler (quoted from Handbuch by v. Bergmann)
of 44 ruptures, 42 were fatal, 39 from haemorrhage,

3 from peritonitis. Death does not always take place
rapidly, but in a case of Schwing’s, for example, half
an hour after the rupture in a pregnant woman, in a
case reported by Tomkins (Lancet, Jan. 4th, 1881), three
weeks after. Rupture of the healthy spleen are very
rare on account of its protracted situation, provided
the force acting on the abdomen is not actually a
crushing one. Sometimes they occur in new-born in¬
fants from manipulations during birth. The patho¬
logical conditions that cause the spleen to give way
easily are infarctions, acute swellings from infective
diseases, particularly typhoid, chronic enlargements of
it from venous stasis, disease of the heart, cirrhosis
of the liver, and especially malaria (important in
malaria districts). Playfair (7), in the cou-rse of
two and a half years in the East Indies, saw more
than 20 cases of rupture of the spleen ; he states that
in those parts one-third of the whole population suffer
from enlargement of the spleen. As causes that bring
about rupture of the unhealthy spleen, violent mus¬

cular contractions of the abdominal muscles and of
the diaphragm are mentioned (v. Bergmann’s Hand¬
buch der Chirurgie), for example, violent sneezing
(Silberstein), vomiting (Kering). Even palpation of a
splenic tumour in a cachectic individual may cause
rupture of it (Colin). In order to explain the
mechanism of rupture of the spleen, one must look
upon it as a hollow organ filled with fluid and sus¬
pended by ligaments (Geill). Rupture from violence
is usually transverse, and in the neighbourhood of the
hilus. This direction is dependent on the manner in
which the spleen is suspended by its ligaments.

Ruptures of the kidney take rank as regards fre¬
quency in the fourth place; as isolated injuries they
are rare, as the kidneys are well protected by muscles,,
connective tissue, and fat, and also by the vertebral
column (Geill). They occur most frequently along,
with other injuries from being run over. Hofmann (1)
mentions a case in which a medical man, going
quickly, ran up against a wooden barrier, which
caused fatal haemorrhage from the kidney. Mit-
tenzweig (Zeitsch. f. Med. Beamte, 1893, S. 616) re¬
ports a case of traumatic bleeding from the right
suprarenal capsule, 24 hours after the patient had got
caught between the buffers of railway wagons; the
bleeding was internal, and was caused by rupture of
the vessels of the right suprarenal capsule; there were
also fractures of Tibs, of a clavicle and thrombi of
the middle intercostal arteries.

In injuries of the kidneys ending fatally, according
to statistics collected by Kuster (Kuster, Die chirur-
gischen Krankheiten der Nieren, Deutsche Chirurgie,.
Liefg. 52b), death takes place from hemorrhige in
almost half the cases (in 30 out of 67 cases), and mostly
from secondary haemorrhage during the first four
weeks, or from rupture of an aneurysm that has-
formed. From a medico-legal point of view it is
important to know this.

Ruptures of the pancreas are less frequently trau¬
matic than spontaneous from disease—mostly fatty
degeneration—and may cause death from the bleeding
that takes place (pancreatic apoplexy). Various views-

£ revail as to the nature of pancreatic haemorrhage.

enker (11) looks on it as the cause of sudden death;
Reubold (ii)^is a symptom of circulatory disturbances-
that have themselves caused death (Sachs). Kratter
(45) investigated 33 cases, and came to the conclusion:

“ Pancreatic haemorrhage is not the cause but the con¬
sequence of sudden death, and is not very rare when
death is sudden. It has a diagnostic significance, in¬
asmuch as it indicates a cause of death in which an
agonal trauma occurs (spasm of the diaphragm), which
affects the abdominal salivary glands.” Further obser¬
vations are necessary for the clearing-up of this
question.

Injuries and ruptures of the hollow organs lying in
the abdominal cavitv, the stomach, intestines, the
bladder, as well as all other organs carrying vessels—
the mesentery and omentum—may all lead to death
from haemorrhage. Tuberculosis, ulcers of the mucous-
surfaces (round ulcer of the stomach, typhoid ulcer
of the intestines, dysenteric ulcerations), all predispose
to ruptures. For their occurrence it is necessary that
a part of the gastro-intestinal canal shall be over-full
of liquid, semi-liquid, or gaseous contents, and be
forced against a solid body—the vertebral column—
and kinked at the side so that the contents cannot
escape. According to the laws of hydrostatics, rupture
must then take place, and must alwavs be at the
weakest or diseased part. The following have been
observed to cause fatal intestinal haemorrhages: The
lifting of a cask (Hankel) (48), a blow of the first
against the abdomen (Bodgan) (49), manipulations
during labour (Ciechanowsky) (50), and others. Fried-
berg (14) mentions a case of fatal haemorrhage from
the stomach from the improper use of an emetic.
Dr. Graetz-Sobbowitz (52) (Aerztl. Sachverst.-Zeit.,.
1900, No. 5, S. 95) reports a case of fatal intestinal
haemorrhage from an accident in which a workman
was engaged in lifting an iron rail with a lever, when
the lever slipped, and he received a blow on the
abdomen with it; he fell forwards, and by the evening
was dead. At the autopsy a good deal of hemorrhage
was found between the layers of the mesentery, and the-
small intestines were also filled with partly fluid blood.
Digitized byV^jOOQle

Nov. 13, 1907.

ORIGINAL PAPERS.

The Medical Press. 521

LITERATURE.

(1) E. v. Hofmann, Lehrbuch der gerichtlicnen
Medizin, herausgegeben von Kollisko, 1902.

(2) Strassmann, Lehrbuch der gerichtl. Medizin, 1895.

(3) Caspar-Liman, Prachtisches Handbuch der
gerichtlichen Medizin., 6 Auflage.

(4) Maschka, Handbuch der gerichtl. Medizin,
1881 ; Oesterlen, Tod duich Veiblutung.

(5) Schroeder, Lehrbuch der Geburtshilfe, 12 Auflage,
herausgegeben von Olshausen und Veit.

(6) K6nig, Lehrbuch der speziellen Chirurgie, 1881.

(7) Handbuch der Chirurgie von v. Bergmann,
Bruns, und Mikulicz, 2 Auflage, 1902-1903.

(8) Eichhorst, Handbuch der speziellen Pathologie
und Therapie, 5 Auflage, 1895.

(9) Juergeusen, Antiphlogistische Heilmethoden,
Blutentziehang; in Ziemssen, s Handbuch der allge-
meinen Therapie, 1880.

(10) Bflrntrager und Berg, Die Diagnosis des Ver-
blutungstodes aus dem Leichenbefunde. Viertel-
jahrsschrift fiir gerichtliche Medizin und Oeflentliches
Sanitatswesen, 1904, Heft 1.

(n) Sachs, Die Blutungen, besonders die Verblutung
in ihren gerichtsarztlichen Beziehungen. Fried-
reichsblatter fiir gerichtliche Medizin und Sani-
tatspolizei, 1899, Heft 4, 1900, Heft 1.

(12) Seydel, Einiges ilber den Verblutungstod.
Aerztliche Sachverst andigen Zeitung, 1900, Heft 1.

(13) Puppe, Rapmu.id, Dittrich, Der beamtete Arzt.

(14) Friedberg, Gerichtsarztliche Gutachten, 1875,
Seite 144.

(15) Riith, Herzverletzungen mit nicht sofort tfitlichen
Ausgang. Friedreichsblatter fiir gerichtliche Medizin,
1896, S. 87.

(16) Picht, Stichwunden des rechten Vorhofs. Tod
nach sechs Tagen. Zeitschrift fiir Medizinal Beamte,
1898, No. 16

(17) Bartikowsky, Ein Fall von anscheinender
Neuritis und Tod (lurch Herzruptur. Aerztliche Sach¬
verstandigen Zeitung, 1896, S. 264

(18) Richter, Ueber den Eintritt des Todes nach
Stichverletzungen des Herzens. Vierteljahrsschrift fiir
gerichtliche Medizin, 1896, Bd. XI., S. 264.

(19) Peisach, Zur Kasuistik der Herzverletzungen.
Inaugr. Dissertation. Miinchen, 1895. Zeitschrift fflr
Medizinal-Beamte, 1902, S. 183.

(20) Placzek, Experimentelle Herzverletzungen und
Hamato-pericard. Vierteljahrsschrift fflr gerichtliche
Medizin, 1902.

(21) Richter, Zur Kenntniss der Herzbeuteltampo-
nade. Vierteljahrsschrift fQr gerichtliche Medizin,
1902, Bd. XXIV., S. 109.

(22) Placzek, Zur Kenntniss der Herzbeuteltampo-
nade. Vierteljahrsschrift fiir gerichtliche Medizin,
Bd. XXIV., S. 264.

(23) Elten, Ueber die Wunden des Herzens. Vier¬
teljahrsschrift fflr gerichtliche Medizin, 1893, Bd. 5,
S. 41.

(24) Leonpacher, Kurze Mitteilungsn aus der foren-
sischen Praxis, Stich in das Herz, Tod nach 3 Tagen.
Freidreich, s Blatter fur gerichtliche Medizin, 1897,
No. 6.

(25) Fischer, Die Wunden des Herzens und” des Herz-
beutels. Archiv. fttr klinische Chirurgie, Bd. IX.,
1898.

(26) Drenckhahn, Ueber den Tod nach Quetschung
des Thorax, vom gerichtsarztlichen Standpunkt.
Friedreich, s Blatter fiir gerichtliche Medizin, 1899,
S. 31, 161, 241.

(27) Fall von traumatischer Herzruptur ohne Verzet-
zung des Brustkorbs. Zeitschrift fdr Medizinal-
Beamte, 1899, No. 16.

(28) Pantzer, Quetschung des Oberkflrpers bei einem
Unfall. Vierteljahrsschrift fur gerichtliche Medizin,
.898, Bd. XV., S. 313-.

(29) Israel, Die Stichverletzungen der Schlflssel-
beingefasse in gerichtsirztlicher Beziehung. Viertel¬
jahrsschrift fflr gerichtliche Medizin, 1896, S. 247.

(30) Puppe, Ueber Selbstmord durch Halsschnitt.
Zeitschrift fiir Medizinal-Beamte, 1897.

(31) Schlag, Selbstmord durch Erfiffnung der Vena
saphena magna. Zeitschrift fur Medizinal-Beamte, 1902.

(32) Colley, Ueber Zungenverletzungen in gericht-
lich-medizinischer Beziehung. Vierteljahrsschr. fiir
gerichtliche Medizin, 1897, Bd. XIV.

(33) Langenbuch, Ueber Aortenrupturen mit Bezug
auf einen Fall von totaler Querruptur der Aorta. 4
Kiel, 1869.

(34) Leonpacher, Kurze Mitteilungen aus der
forensischen Praxis. Verblutung aus der Krampfader.
Friedreich, s Blatter fiir gerichtliche Medizin, 1897,
No. 6.

( 35 ) Geill, Die Ruptur innerer Organe durch
stumpfe Gewalt. Vierteljahrsschrift fiir gerichtliche
Medizin, 1899, Bd. 48, S. 205.

(36) Zaajer, Ausgedehnte Gehirnruptur ohne Schadel-
knochenfractur. Vierteljahrsschrift fiir gerichtliche
Medizin, 1893, Bd. II., S. 239.

(37) Schilling, Die differentialdiagnose tfltlicher
traumatischer und spontaner Hirnblutung. Aerztliche
Sachverstandigen-Zeitung, 1899, No. 4, S. 73.

(38) Defraneschi, Traumatische Hirnblutung ohne
Schadelverletzung. Aerztliche Sachverstandigen-Zei¬
tung, 1902, No. 7.

(39) Henzelmann, Ein seltener Fall von tOtlicher
Leberruptur. Friedrich, s Blatter, 1886, S. 216.

(40) Schukowsky, Ueber einen Fall von Lebeizer-
reissung bei einem neugeborenen Kinde. Aerztliche
Sachverstandigen-Zeitung, 1902, S. at.

(41) Altmann, Die gerichtsarztliche Beurteilung der
Lungenverletzungen Vierteljahrsschrift fur gerichtliche
Medizin, Bd. 14, S. 71.

(42) Heidenhahn, Ueber, Rupturen und Verletzungen
der Milz und den dadurch bedingten Verblutungstod.
Vierteljahrsschrift fiir gerichtliche Medizin, 1888,
S. 87.

(43) Mittenzweig, Fall von traumatischer Verblutung
der rechten Nebenniere. Zeitschrift fiir Medizinal-
Beamte, 1893, S. 616.

(44) Kiister, Die chirurgischen Krankheiten der
Nieren. Deutsche Chirurgie. Lief. 52b.

(45) Kratter, Ueber Pankreasblutungen und ihre
Beziehungen zum plOtzlichen Tode. Vierteljahrsschrift
fiir gerichtliche Medizin, 1902.

(46) Raude, Ueber die Verletzungen der Nieren in

S richtlich-medizinischer Beziehung. Vierteljahrsschrift
r gerichtliche Medizin, 1900, Bd. XX.

(47) Dittrich, Ueber einen Fall von genuiner, akuter
Pankreasenzundung nebst Bemerkung fiber die anato-
mische und forensische Bedeutung der Pankreas¬
blutungen.

(48) Hankel, Tfltliche Magen-und Darmblutung nach
Aufheben eines Fasses. Vierteljahrsschrift fiir gericht¬
liche Medizin, 1853.

(49) Georges Bagdan, Morte subite par haemorrhagie
intra-abdominale suite d'un coup de poing dans le
ventre sans besoin apparante (sic). Annales d’hygiene
publ. et de Medicine legale, 1898, Tome XI., No. 6,
p. 561. Aerztliche Sachverstandigen Zeitung, 1899,
No. 5, S. 99.

(50) Ciechanowsky, Ueber Darmrupturen bei Neuge¬
borenen. Vierteljahrsschrift fur gerichtliche Medizin,
1898, S. 221.

(51) Key-Aberg, Zur Lehre von der spontanen Magcn-
ruptur. Vierteljahrsschrift fiir gerichtliche Medizin,
1891.

(52) Graetz-Sobbowitz, Tfldliche Darmblutung nach
einem Unfall. Aerztliche Sachverstandigen Zeitung,
1900, No. 5, S. 95.

(To be continued.)

A GENERATION'S OBSERVATION OF
DISEASE, (a)

By JAS. ORMISTON AFFLECK, M.D.Ed.,
F.R.C.P.,

Consulting Physician to the Edinburgh Royal Infirmary, etc.

Dr. Affleck remarked that since he first studied
medicine great changes had occurred. The science
of bacteriology had arisen, and had shown us the
cause of many diseases, while in the more recent
researches into immunity we were discovering the
exact nature of many mortiid processes. The
chemistry of digestion had also thrown fresh light
upon many of the most important diseases the
physician encountered, while the introduction of

(a) Abstract of President’s Valedictory Address, delivered before
the Edinburgh Medico Chlrurgical Society, November 6th, 1907,

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522 The Medical Press.

Rontgen rays was an instance of the fruitful appli¬
cation of physics to medicine, and the same science
had given us means of investigating the blood
pressure, and the various methods of applying
.electricity in diagnosis and treatment. The study
of the blood, top, had resulted in many valuable
.additions to our power of diagnosing morbid pro¬
cesses. He believed, however, that the older
amongst his hearers, in particular, would bear him
out as to the valuable information that could be
derived by simple observation of patients. He did
not mean only the facies of disease, but used the
word physiognomy with a wider meaning, to in¬
clude all the signs which were visible to the unaided
senses

Take, for instance, cough. We could distinguish
the short, suppressed cough of pneumonia, the
dry, irritable cough of early phthisis, the hysterical
cough, the barking cough of puberty, whooping
cough, the clanging cough of ultra-thoracic pres¬
sure, the cougn of chronic bronchitis, and he
believed also that the cough of pyopneumothorax
had a character of its own. Simple observation of
the phenomena of disease, such as these, gave in¬
formation of great value, ,and out of many instances
which rose to his mind he might cite the case of a
young clergyman who entered the consulting-room
with the complaint of chronic indigestion, vomiting,
lassitude and headache. Watching him as he
spoke, the pearly glistening of the conjunctiva
attracted attention, and led to an immediate exa¬
mination of the urine, which showed that Bright’s
disease was the cause of his symptoms. Again,
a business man who had always enjoyed the best
of health presented himself for life assurance. It
was noticed that his hair was rather dry and
scanty, and there was a dull, pinkish, malar flush.
These aroused the suspicion that he had diabetes,
and this was found to be the case.

In typhoid fever, again, the patient’s expression
was often characteristic. In the Fever Hospital
he noticed that the first note that his friend Dr. Ker
made on the case of a newly-admitted patient was
whether he “ looked like ” typhoid fever or not.
As a result of experience, a physician gradually
acquired what, for want of a better word, he would
term “clinical impressions.” Some possessed the
faculty much more than others, and it was one of
the most valuable assets it was possible to acquire.
By clinical impressions he meant something which
was quite uncommunicable to others ; the pnysician
himself could not tell why or how they came—they
were the unconscious result of comparisons and
recollections. Such impressions had often been of
the greatest service to him both in suggesting to
him fresh lines of treatment which had often proved
successful, and sometimes in encouraging him to
offer hope where the circumstances seemed des¬
perate. Such impressions sometimes led one astray,
but they were, nevertheless, of the greatest value,
and the faculty of acquiring them ought to be de¬
veloped as far as possible.

Next he wished to speak of the psychical aspect
of disease, and of the importance of trying to dis¬
cover what was in the patient’s mind. It was
hardly too much to say that there was no disease
but had its effect on the patient’s temperament.
In some we found illness causing irritability and
fretfulness, while in others the reverse change
occurred, and the busy, restless, energetic man
became an example of patient fortitude. Mental
processes had a profound effect on the body; he
instanced, as a case in point, a young girl in his
ward whose constant high temperature aroused
great anxiety until her appearance of well-being
had suggested its hysterical origin. Subsequent
events showed that it was one of those rare cases of
hysterical hyperpyrexia.

The importance of mental effect in therapeutics

Nov. 13, 1907.

was shown by the well-known story told of Syden¬
ham. Having a patient whom no efforts of his
could cure, he told him that there was only one
physician who had made a study of his complaint,
br. Robertson, of Inverness. The patient decided
to seize this hope of cure, and posted the distance
of six hundred miles, armed with a history of his
symptoms, and an introduction to Dr. Robertson.
When he arrived at Inverness he learned, with dis¬
may, that not only did no Dr. Robertson live at
Inverness, but that no practitioner of that name
had existed there within the memory of the eldest
inhabitant. As enraged at the deception which had
been practised on him as he had been hasty in
setting off on his journey, he hurried back to
London and upbraided Sydenham. “ But you ap¬
pear better," said the doctor. “Yes, I’m better,”
replied he, “ but no thanks to you for it, Dr. Syden¬
ham.” “You are better, thanks to Dr. Robertson,
of Inverness," answered Sydenham; “I wished to
make you travel with a definite interest, and I made
you go to Inverness with the object of consulting
Dr. Robertson, and travel back to London in order
to abuse me.” He could only see what was passing
in a patient’s mind by the exercise of the gift of
sympathy, so that the cultivation of this should be
one of our objects. If it were important to study
the patient’s thoughts, it should equally be remem¬
bered that the patient would study the doctor’s face,
and many were quick to perceive what was in his
thoughts. It was onlv when he could detect sym¬
pathy and comprehension that he gave the physician
his entire confidence, and without the patient’s con¬
fidence it was difficult, or impossible, to do him
good.

A PRELIMINARY NOTE ON A

SIMPLE OPERATION FOR UNCOMPLICATED
OBLIQUE INGUINAL [HERNIA IN YOUNG
ADULTS (a).

By GEO. LYALL CHIENE, M.B., C.M.,
F.R.C.S. Ed.,

Senior Demonstrator of Surgery, University of Edinburgh; Assistant
Surgeon Edinburgh Royal Infirmary

Oblique inguinal hernias in children being
admittedly of congenital origin, and due to the
existence of a preformed sac, partial or complete,
and ligation of the neck of the sac at the internal
ring having been proved to be an efficient line of
treatment, it is justifiable to suppose that if in
young adults oblique inguinal hernia is also of
congenital origin— i.e., due to the existence of a
preformed sac, a similar operation will prove satis¬
factory. The operation devised for the purpose
consisted in an incision over the internal abdominal
ring about half an inch above Poupart’s ligament,
with successive division of the muscular layers,
exposing the neck of the sac, which was then
divided and ligated. The second stage in the
operation consisted in union of the wound, without
an attempt to close the inguinal canal, or to remove
the sac, and without interference with the integrity
of the normal function of the internal oblique and
transversalis muscles. Evidence from various
sources was put forward to show that there was no
essential difference as regards origin between
so-called acquired oblique inguinal hernia which
developes gradually, and the congenital form,
which develops suddenly. In both classes of. case
it was argued that a preformed sac existed.
Murray’s observations on cadavers showed that in
a considerable proportion of cases, where hernia
had never occurred, there yet existed a passage
large enough to admit a probe along the inguinal
canal. The internal ring was normally closed by
the valvular actio n of the internal oblique and

(a) A b* tract of paper read before the Edlnbvrjh Medina!-€%ir•'
8ocy., Nor. 8th, 1907.

Digitized by G00gk

ORIGINAL PAPERS.

■Nov. 13, 1907.

ORIGINAL PAPERS.

The Medical Press. 5 2 3

4ransversalis muscles (as could readily be appre¬
ciated wheai, during the operation, the patient came
-out of the chloroform to some extent and began to
strain), and it was held that, provided the sac was
effectively dealt with, the natural function of these
muscles would be regained and would be amply
sufficient to maintain the closure of the internal
ring. On the other hand, operations which in¬
volved suturing the internal oblique and trans¬
versals with a view to producing closure in this
way, interfered with the normal function of the
^muscles and the natural mechanism occluding the
ring. The operation was devised for young adults,
and the limit of age at which it could be performed
with,a good prospect of success depended on the
tone of the muscles of the patient. The advantages
of the operation were the absence of complications
arising from manipulation of the sac and scrotum,
.and, owing to the position of the incision, the
•diminished risk of contamination. It was not
necessary to keep patients in bed more than a fort¬
night or three weeks. As soon as the wound was
ifirmly united it was better to allow them up so as
to restore the function of the muscle closing the
•ring.. The principle was insisted on that in oblique
•inguinal hernia a preformed sac was a necessity,
-and that unless this was present the internal ring
would be kept closed by the valvular action of the
-muscles. From this it followed that the sac being
closed, the normal muscular action would reassert
itself. Operations which attempted to cure hernia
by suturing the pillars of the ring, &c., deviated
from this principle, and did not sufficiently take
-account of Nature’s method of occluding the in¬
guinal canal. Reference was made to a number of
cases in which the operation had been followed 1
by a satisfactory result. I

THE LIMITATION OF MORTALITY
FROM TUBERCULOSIS.

By W. R. MacDERMOTT, M.B.,

Medical Officer of Poynti Pats.

An experience of forty years of tuberculous
-disease may justify me in expressing views of its
nature, even though my knowledge of the litera¬
ture bearing on it is extremely defective, in part
from want of access to its vast and ever-increasing
mass. Under the condition, there may be nothing
new in what I have to say; it may be all a many-
• told tale, but, if so, it certainly is not adequately
represented in the body of opinion which consti¬
tutes current formal doctrine, that which every
medical man and every medical student is expected
to know.

If that formal doctrine was simply speculative
and academic, it might be allowed to pass; all our
judgments are more or less of the nature, even
where the necessity of action compels us to select
one judgment, discarding or ignoring others. It
Is one thing, however, to do so consciously, another
to do so at the expense of consciousness of what is
Ignored. The proposed, and far more than pro¬
posed, “ war on the white scourge ” is an instance
of this ; we form a judgment under some precon¬
ception, of the necessity for action against tuber¬
culosis, but the merit and necessity of the action
not at all make the judgment a necessary
one ; it is in reality only one with many alternatives,
which we have no right to discard or be ignorant
of because they do not give us grounds for action,
or grounds not at all sufficient to justify a vast
expenditure of public money.

The position is not new; we have had experience
of it in the past, and of the futilitv of a judgment
based on imperfect knowledge. For long enough
medical men stood helpless before small-pox. It

might satisfy the anti-vaccinationists to say that the
right thing was to have initiated a sanitary cam¬
paign against the scourge, isolation hospitals,
sanatoriums, and so on; but that would have satis¬
fied Sydenham as little as his successors nowadays.
A sanitary campaign would have been all very right
on general principles, but medical men would never
have committed themselves to the opinion that it
would have prevented or arrested epidemic small¬
pox. They would not commit themselves now to
the opinion that, in the absence of vaccination, it
would not occur, however perfect the conditions
of sanitation might be. They would hold that
isolation and isolation hospitals only met the case
of the disease as it actually occurred, and had
limited efficacy in preventing it spreading. What
was early seen was, that it was limited by its
own incidence, that experience of it was the most
effective means of controlling the mortality from
it. The adoption of inoculation rested on the
observation that the disease was not a fatal one
for the mass of persons under ordinary circum¬
stances, that its fatality depended greatly on it
selecting certain persons under certain circum¬
stances. The general conclusion arrived at was
that the fatality was a minimum in proportion as
the experience of the disease was a maximum, and
the conclusion was sound enough to base the
practice of inoculation on. Looking on vaccinia as
a modification of variola, the principle holds good
for the artificial induction of the disease as the
most effective means of controlling its mortality.

The received doctrine in respect of tuberculosis
is that it is, unlike small-pox, a persistent morbid
state, but I would suggest to the thinker on the
subject to contradict tentatively every article of his
faith; it is no sin to do so. We cannot say that
small-pox is not a persistent state; it leaves behind
a state of body which is certainly not the original
one, as evidenced by loss of susceptibility to the
disease. We do not call the new state morbid,
although there may be no essential difference be¬
tween it and the states we do apply the term to.
Again, small-pox does persist as changed states of
the skin and other organs in very gross form.
That, of course, we put in a different way, but we
cannot always draw a line between a disease as a
primary affection and what it leaves behind—dis¬
tinguish clearly between them. In the next place
we may contradict the position that tuberculosis
is a permanent morbid state in the sense small-pox
is said not to be. Its typical form may be stated,
in respect of invasion and course, as not in any
essential respect different from typical small-pox.
The form, fortunately comparatively rare in the
human subject, is best seen when induced experi¬
mentally in susceptible animals. It is in both cases
rapidly and more uniformly fatal than small-pox.
How, then, does it come that a disease of such
character is, relatively to its prevalence, under ex¬
treme limitation with respect to the mortality from
it; in what direction are we to look for the
restraints on its mortality ?

In the present state of our knowledge of it,
several answers may be given to the question
which, though not very satisfactory, are taken
together inconsistent with the doctrines at present
in fashion. If we go back to the older writers we
will find that they do not affirm, or deny, or were
ignorant of, in a general sense, an initial cause
for the disease, a contagious or infective agency
which they were unable more precisely to define
What, however, they had clearly in mind was, that
certain morbid processes, once set up, were self¬
acting—had continuous operation independent of
the exciting or contributory cause. YVhat they
said or supposed was, that a certain medium was
the first and necessary condition of zymosis, and
that the spoiling of the medium, say, the blood, or

5^4 The Medical Press.

ORIGINAL PAPERS.

Nov. 13, 1907.

an element in it, under zymosis, led, In the case
of tuberculosis, to a specific exudation from the
blood. It was, however, only natural and logical,
going back to what is now called the nutrient
germ medium, to hold that it varied of itself inde¬
pendently of any extraneous agent exciting zymo¬
sis, and that diseased states, quite apart from
zymosis, would arise from change in it. The case
was not that of an organic fluid sealed up in a tube
and found stable under the condition; the fluids in
the actual case are undergoing metabolism from
instant to instant in presence of a host of causes
which might vary or derange the operation. Thus
the old is a general position allowing the modern
one of germ action as a particular case. The par¬
ticular case meant that the medium was normal
for the zymosis, but that did not mean that it was
physiologically normal; the very state that favoured
zymosis might be the true pathological antecedent
and explain what is meant by predisposition. But
the pathological antecedent is capable of morbid
development per se; it is the essential factor, the
zymotic operation, particular itself, only gives it
some particular modification. On the other hand,
while zymosis spoils the medium it operates on,
the medium may be spoiled for the zymosis by the
pathological development or by return to its normal
physiological condition. Thus the old view that
tuberculosis was due to a diseased state of the
blood inducing a specific exudation, may be so far
correct that unless some pathological change
occurred in the nutrient media the tuberculous
infection would not develop; it might be present
indeed, or there might be exposure to it, but it
would not act as a disease or cause of death unless
as perpetuating and aggravating the prior condi¬
tion itself, per se morbid, and, for all we know,
capable of development on its own lines in the
absence of the specific infection.

From the point of view, we may be justified in
tentatively, at least, objecting to the position that
the tuberculous infection is primarily itself a
disease or cause of death, that it is so’ only as it
interacts in a prior condition. We may conceive it
as occurring in some animal system, including the
human, as a normal event, not per se disturbing
the normal state. This does not exclude the sup¬
position that it may disturb certain organic sys¬
tems on transmission from a system it does not
disturb, since the nutrient media of the receptive
system may be such as more easily gives the con¬
dition favouring development of the bacilli in
number and virulence.

For the human system the question is whether
the infection subsists, giving no pathological
effects. We are so much in the habit of associat¬
ing it with such effects that we never think of
determining it as an initial occurrence not neces¬
sarily harmful in itself. If in any case it seems to
be so, as, for instance, when transmitted from a
healthy person, we pass the fact by. The logical
conclusion would be for it, not as a rare exception,
but as the general rule. If we proceed from this
we will find that much of the obscurity enveloping
the subject clears up. As our knowledge of the
infection extends we get to see that our exposure
to it is universal, and our experience of it almost
equally so. Not only so, but the exposure is a
common one for a large group of animals in contact
with man, and the attempt to differentiate bacilli
specific for each animal has utterly failed.

The response to the exposure, or the experience
of the infection in man, is, of course, placed under
limitation by the preconception that it is neces¬
sarily a disease; it is looked for only under the
condition of some diseased manifestation or other.
Even so, however, the manifestation, varying in
degree from what is scarcely perceptible to rapid
and fatal virulence, would justify the conclusion,

or rather the judgment, conformable to our pre-
I sent knowledge, that the infection per se subsists
i essentially in a form consistent with normaL
j organic integrity. It is of the utmost importance
to take this view into consideration, since the
presence of the infection in such form, while not
disturbing normal integrity, may induce toleration
of it, limiting thereby the mortality which, under
some circumstances, it may cause. It is quite true
that, in any case, the zymotic products of the
tubercle bacillus affect the composition of the
nutrient fluids, and thereby the life of the organic
cell; but it is equally true that there is response or
adjustment to the condition which, within certain
limits, is only a case of the general physiological
adjustment of the cell to the vaiying conditions to
which it is normally subject. If for any reason the
cell is unable to make the necessary adjustment,
then the power for mischief of the tuberculous
infection arises, but that adjustment can never be
called into play in the absence of the occasion for
it. The cell has normally the power of reacting
to a host of circumstances, but the power, even
though connate, in practice depends on experience
of the circumstances. If the cell thus happens to-
have no experience of variation of temperature, its
potential capacity of accommodating to the varia¬
tion in the absence of experience of it does not save
it when suddenly exposed to change of tempera¬
ture.

As a potential cause of death, tuberculosis is to-
be judged by its typical form. Taking the form
as invariably fatal, the restraint on the fatality is to
be judged from the fact that infection invades the
infant system in the first few months of life without
causing any significant fatality. It does not in
the least matter whether the proportion of infected"
infants is taken as 30, 50, or 100 pier cent.; the
evidence is wanting in any case of a fatality
corresponding to the potential form. The extent
of incidence of the infection is taken under the
preconception of 9ome morbid sign, or of the pre¬
sence of the bacilli being necessary to determine it.
The reaction to tuberculin is a more certain test,
but, as far as I know, has not been sufficiently
extensively applied to give experience of infection
in infants in adequate numerical terms. That,
however, does not matter so long as it is left un¬
determined whether the infection is permanent or
not, whether, as occurring in a transient, im¬
perfectly developed or spieedily suppressed form, it
does not prevent recurrence, or induce toleration
or modification of itself in varying degree under
recurrence. From personal observation of many
hundred cases under the condition of non¬
discrimination between slight and severe, I venture
to say that far and away the most prevalent form
is recurrent, the recurrences being independent or
distinct in the pure pathological sense. But, as I
conceive, they are not independent in another
sense; the experience under recurrence engenders
as a sum effect and cceteris paribus toleration of
the infection. The difficulty in the way of under¬
standing this seems to me to arise from attention
being concentrated on the severe permanent and'
progressive cases. It must, however, be allowed
that these cases constitute in reality onlv a frac¬
tional part of the experience of the infection ; thev
do not at all give us a general view of the experi¬
ence. I am venturing again on expression of
personal observation in saying that in a large
proportion of the severe and fatal pulmonary cases
factors apart from the mere tuberculous infection
are more or less, clearly in evidence. A statement
which will receive so much corroboration from
others hardly needs excuse. Another point will
receive like corroboration. I have come across
cases in which life was prolonged amazingly,
although both lungs were riddled through and

Digitized by GoOgle

Nov. 13, 1907. _ OPERATING

through with disease; not a square inch sound, and
other cases rapidly succumbing although the
greater part of both lungs were, apparently, at
least, quite sound. The opinion that the difference
was in proportion to induced tolerance may stand
until we can form a better one.

A great many of our cases contradict the sup¬
position that the system is poisoned by the infection
or by the products of the bacilli and as many that
death is caused by destruction or alteration of
tissue. So far, however, as both causes exist and i
coexist in some complex relation, it seems clear 1
enough that the induction of toleration applies to
govern the course of even the most severe cases.

It would indeed be unnecessary to reason that
experience of the infection induced tolerance of it,
and that the induced tolerance was the chief
restraint on an otherwise extremely fatal disease,
if our formal doctrine and public opinion as based
on it did not propose action directed to “stamp
out ” infection. The infection of small-pox was not
stamped out; it, or a modification of it, was used
to control itself in the light of the fact that it was
so controlled.

My main position here is an expression for the
infection at limit, to use a mathematical term. At
an inferior limit the infection occurs in a transient
and quickly-suppressed form, and that is only to
give the series under which it occurs legitimate
extension.

“ Two calves ”(“ Second Interim Report of the
Royal Commission on Human and Animal Tuber¬
culosis,” p. 9) “each received in the form of an
emulsion the same estimated dose (9,000 bacilli) of
the same emulsion of virus I. One calf died of
general progressive tuberculosis, while the other,
killed in apparent health, showed only a very
limited retrogressive tuberculosis.” The report
goes on to make a more general statement to the
same effect. Now, the latter calf would have re¬
acted to tuberculin, but would it if the experience
had been a transient one, leaving no effects, or
effects completely recovered from? Or, taking the
case of insusceptibility, the dose being supposed to
be that ingested under ordinary exposure, are we to
attribute it to something we do not know or some¬
thing we do know—induced tolerance? The
Commissioners say that they excluded prior spon¬
taneous tuberculosis in the animals they experi¬
mented on as far as possible, but how could they
exclude passing intestinal infection having no
effect other than that of inducing tolerance?

Or how could we in the case of children who, for
all we know, are swallowing thousands of the
bacilli and becoming accustomed to the thing as
they would to mercury or opium, if constantly
administered in harmless doses? The Commis¬
sioners speak of a “ combat between the pathogenic
energies of the bacilli and what has been called the
resistance of the tissues.” But the reaction we call
resistance needs experience of the action resisted,
and we are cognisant enough of the experience in
general to know that, whatever other factors may
enter its operation, it is not necessarily constant, but
efficient through repetition.

Our line of inquiry, I conceive, should be directed
to ascertain the extent of the tuberculous infection
in the human subject as a normal and unavoidable
occurrence. That it develops a formidable disease
is quite compatible with the position that it is the
most efficient agency in limiting the disease and
the mortality from it. I have long ago come to
the conclusion that tuberculosis in a transient form
is almost universal among infants, often as an in¬
testinal infection. But for some reason there is
either connate or rapidly-induced tolerance of the
infection in infancy; the mortality from it is out of
all proportion less’ than it is in infected adults or
adolescents. Nevertheless, as is stated in the

THEATRES. _ The Medical Press. 525

report cited, “ the same dose of the bacilli produces-
less effect on an adult animal than on a young calf.
This result we may explain as due to the powers-
of resistance of the tissues increasing with age.”
The result, however, may be more easily explained
by saying that tolerance acquired in infancy per¬
sists to enable the adult to resist the effects of the
larger dose. But the tolerance is no doubt to be
taken in relation to the “virulence” of the bacilli,
a term expressing a variable distinct from dose.
Induced tolerance, so far as it goes, protects the
adult, but other factors arise both in the bacillus
as an operating agent and in the individual it
operates on. These factors, as prominent, obscure-
tolerance; we cannot, or do not, use that in treat¬
ment of the disease, and so incline to ignore it
when it appears as a failure to us. Nevertheless,
it may be, in reference to the potentiality of the
disease and the mortality from it, the main agency
averting a vast destruction of human life. What
tuberculosis now does is as nothing as compared'
to what it would be capable of doing if under no
restraint arising in itself.

While, of course, admitting that everything
should be done for the individual patient, I have, no¬
faith in a “campaign” against tuberculosis resting
on the notion of abolishing or diminishing the
specific infection and exposure to it. Much, indeed,
of what I see in print seems utterly absurd to me—
fit to figure in mediaeval medical lore. Treating the
individual or protecting him against infection by any
of the methods proposed is not a campaign against
tuberculosis. We must learn, as in the case of
small-pox, to use the infection itself before we can
make any impression of a permanent nature on
the mass’incidence of the disease.

OPERATING THEATRES.

NORTH WEST LONDON HOSPITAL.

Two Cases of Chronic Abscess of Maxillary
Antrum.—Mr. Mayo Collier operated with the
most satisfactory results on two cases of abscess of
the maxillary antrum of long standing. Now some six
months have elapsed, and the two cases are entirely
free from antral discharge, pain, or discomfort of any
sort. The first case was one of a woman, set. 48, who
had had a discharge from the right antrum for the last
eight years. She had to wash the cavity out daily
with lysol lotion to prevent the discharge becoming
offensive. An opening had been made in the site of
the first molar tooth, and a drain was established here
by a plug fitted to the false teeth. The case was
apparently one due to an abscess at the root of one
of the molar teeth bursting into the antrum and so
infecting it. The tooth had been removed and the
antrum washed out and drained by establishing an
I opening near the site of the first molar tooth. The
i patient now complained of the constant annoyance of
| having to wash out the cavity daily, and the offensive
condition of its contents unless the cleansing was
, regularly performed. On the date of the first visit
! Mr. Collier washed out the cavity himself through the
J opening in the alveolus, and noted that the result
1 showed flakes of green offensive pus and dibris. He
; advised an immediate radical operation, and stated
that no hope could be entertained of a cure or a
restoration to the normal of the lining membrane by
any further washing and disinfectants. The case was
accordingly admitted, and Mr. Collier proceeded to-
j operate by the following method. A long strip of flat
j sponge was packed in the inferior meatus of the nose
i from front to back with the double object of prevent-
j ing blood passing into the pharynx, and also of pre-
| venting any damage to the septum when breaking
' through the inner wall of the antrum into the lower

Digitized by GoOgle

Nov. 13, 1907.

526 The Medical Press. TRANSACTIONS

meatus. Mr. Collier pointed out that this was one of
the most important steps of the whole operation,
because it afforded not only a guide to the lower
meatus but also a buffer to the impact of the chisel or
drill that it was necessary to use in breaking through
the inner wall of the antrum. A sponge was next
packed in the buccal cavity so as to prevent any blood
entering the pharynx. This was followed by a trans¬
verse incision at the junction of the lips and gum in
the site of the canine fossa; the tissues down to the
bone having being separated with an elevator and
retracted up and down, the cavity was first found by
introducing a protected gimlet. As soon as the cavity
was made sure of, a cone-shaped burr was introduced
in the site of the puncture, and the opening gradually
enlarged until it was of sufficient size to admit the little
finger of the left hand. By this means every nook and
corner of the cavity could be carefully explored and
the diseased tissue or polypoid granulations removed
with a curette. Mr. Collier pointed out that it was
not necessary to denude the interior of its periosteal
covering; all that was necessary was to curette softly
the whole lining membrane of its thickened and
diseased covering. This being done the most important
part of the whole procedure was undertaken, namely,
that of making a large communication between the
cavity of the antrum and the floor of the nose in the
site of the lower meatus. If the outer wall of the nose,
as it frequently is, he said, is thin, an elevator or
• chisel will pass easily through it from the floor of the
antrum, but often the bone is of considerable thick¬
ness, and the gimlet has to be used at several spots
before the elevator or forceps can pass easily. When
a large opening had been established the sponge was
withdrawn and the dibris of bone and mucous mem¬
brane curetted and removed so as to establish perfect
freedom from the nose to the antrum. The bleeding
from the antrum and nose having been arrested by
packing for a short time, the opening in the canine
.fossa was closed by stitching the periosteum and
mucous membrane separately, and a pad was placed on
the cheek so as to prevent displacement of the parts.
The patient was removed to bed, and instructions were
given that no washing or interference of any sort be
adopted. Mr. Collier said this was a common-sense
procedure suggested by the ordinary principles of
: surgery, and that no lesser operation could be expected
to bring about resolution of the lining membrane of a
cavity so peculiarly situated as that of the antrum.

The second case was that of a man, ast. 50, who had
suffered from stinking discharge from the nose for
several years before being treated. The fact of an
abscess existing in the antrum was discovered by his
local medical attendant, and a tooth having been
removed the cavity was washed out in the usual way.
This was not followed by resolution, and ordinary
daily procedure had to be adopted to prevent the
patient being offensive to himself and to others. Mr.
Collier having ascertained by washing that the dis¬
charge was still persistent and offensive performed an
.almost identical operation as in the previous case with
a similar most satisfactory result.

There are no fewer than 555 scarlet fever patients
in the Birmingham city isolation hospitals. This is
an increase of nineteen in the total recorded a week
ago, when the aggregate was 536. Last week there
were 71 fresh cases of the malady reported, as com¬
pared with 74 for the previous seven days. The
type of the disease is not virulent, and consequently
the case mortality is low, only two deaths attribut¬
able to the disease having been registered during the
past fortnight. The general health of Birmingham
is not bad, judged from the death rate, which last
week was 15.5 per 1,000 of the population, the
zymotic death rate being 1.2.

OF SOCIETIES.

TRANSACTIONS OF SOCIETIES.

ROYAL SOCIETY OF MEDICINE.

Clinical Section.

Meeting held Friday, November 8th, 1907.

Sir Thomas Barlow, Bart., in the Chair.

Mr. J. Hutchinson, jun., showed a case of

TRIGEMINAL NEURALGIA.

in which the Gasserian ganglion had been excised for
recurrence of the pain after intra-cranial neurotomy of
the second and third divisions of the fifth nerve. The
patient had had characteristic trigeminal neuralgia for
seven years. Three years ago the inferior dental nerve
had been resected through the ramus of the mandible.
The pain had been relieved for a time, but 18 months
later, on account of recurrence of pain, the second and
third divisions had been cut within the skull. When
the patient came under Mr. Hutchinson’s care about a
year later the pain had come back, and there was some
return of sensation in the area of distribution of the
second division. The Gasserian ganglion with the
exception of the ophthalmic part was therefore removed.
Mr. Hutchinson showed the case to demonstrate the
comparative valuelessness of mere division of the
nerves, whether within or without the skull. He
referred to Abbey’s operation of intra-cranial neurec¬
tomy with occlusion of the foramina with indiarubber.

Mr. Charles Ballance had several times done the
operation of removal of the Gasserian ganglion with
preservation of the ophthalmic part, and had found it
satisfactory'. He had recently had an opportunity of
seeing Abbey’s operation carried out by its originator.
In some cases there had been a return of pain in five
years, and at a second operation it had been found that
a few filaments of the nerves had penetrated the
foramina and restored the continuity of the trunks in
spite of the rubber plugging. The great advantage of
the operation was that it was extradural. Mr. Ballance
had lately had to operate again upon a case in which
four and a half years earlier he had done intra-cranial
neurectomy and plugged the foramina with gold leaf.
At the second operation it appeared that union of the
nerves had occurred. In spite of such liability to
recurrence he considered the operation compared
favourably in many ways with the intra-dural methods.

Mr. Hutchinson replied.

Dr. Bertram Abrahams showed a case of

MYOPATHY.

The patient was a man of 43; he gave no family
history bearing on the case. There had been increasing
weakness of the legs for 17 years and latterly of the
arms also. There was wasting of the biceps, pectoralis
major, quadriceps, gluteus maximus, and supraspinatus
on both sides, and to a less extent of the pronators
flexors of the left forearm, right hypothenar muscles
and latissimus dorsi, together with the adductor and
abductor muscles of the thighs. There was hypertrophy
of the deltoids and serrati, and to a less extent of the
triceps, infraspinatus and rectus abdominis. The
deltoids did not respond to electric stimuli, but the
reaction of all other muscles was normal. The erect
posture was only maintained with much lordosis; the
gait was markedly straddling. Dr. Abrahams said
that the case seemed to be most nearly allied to Erb's
juvenile form of muscular atrophy.

Dr. A. M. H. Gray showed a woman of 41 with
TYPICAL SIGNS OK MYXCEDEMA.
who 16 years earlier had had exophthalmic goitre.
When seen three years ago the patient had ascites
which cleared up under treatment with thyroid extract.
It occurred slightly when the treatment was temporarily
discontinued. The thyroid gland could not be felt;
a small papillary growth the size of a pea was present
on the dorsum of the tongue just in front of the
foramen caecum. It was not thought to be of thyroidal
nature.

Digitized by GoOgle - -

Nov. 13, 1907.

TRA^^X CTlbN'S SOCIETIES. The Medical Press. 5 .

Drs. Parkes Weber, Hebrtngbam, and Garrod dis- <1
cussed the case. Dr. Gray replied.

Mr. T. H. Openshaw showed a ewe of

RECURRENT DISLOCATION OF BOTH SHOULDEBS
BY OPERATION.

The patient was a man of 27, an epileptic, aad had j
had numerous dislocations of the shoulders daring the j
fits. Many methods of treatment were tried without
success. Finally the subscapularis was detached from
its insertion into the humerus and uhited to a part of
the deltoid. Mr. Openshaw had done this operation
three times, in all cases with permanent success.

Mr. J. Hutchinson, jun., discussed the case.

Dr. Herringham showed a case of

NEURITIS OF THE BRACHIAL PLEXUS,

probably resulting from arthritis of the shoulder.
Evidence of involvement of the whole plexus had
followed within a few weeks upon an apparently rheu¬
matic affection of the joint Dr. Herringham regarded
the lesion as a perineuritis spreading to the nerve
sheaths from the capsule of the joint.

Dr. Sidney Phillips referred to the frequency with
which signs of joint affection are found in cases of
neuritis.

Dr. Herringham also showed a case of “splenic
anaemia,” in which there was widespread pigmentation
of the whole body.

Dr. Murray Leslie showed two cases of “congenital
heart disease” in adults.

Dr. J. Fawcett read a short paper on the
TREATMENT OF PNEUMOTHORAX BY ASPIRATION UNDER
THE X-RAYS.

He gave the history of a case in which the operation
was done under the X-rays so that the necessary
amount of suction could be exactly adjusted and no
undue negative pressure be produced. The lung could
be watched expanding as the air was withdrawn. He
considered such treatment would in selected cases effect
a considerable shortening in the course of the con¬
dition, and that it was therefore justifiable to incur
the slight risk entailed.

Dr. Parkes Weber and Dr. Sutherland discussed
the paper, and Dr. Fawcett replied.

EDINBURGH MEDICO-CHIRURGICAL SOCIETY.

Meeting held November 6th, 1907.

The President, Dr. Affleck, in the Chair.

Mr. Cotterill showed :—(x) Specimens from a case
of panhysterectomy for fibroids and ovarian der¬
moids ; (2) Pyosalpinx complicating appendicitis;

(3) Spindle-celled sarcoma of foot; (4) Hydatids of
liver; (5) Cerebellar tumour, successfully removed.

Mr. Cotterill also showed:—(1) A patient who,
after being thrown from a gig, developed an orbital
angioma, with marked proptosis of the right eye, and
a pulsatory swelling giving rise to a bruit which could
be heard both by the stethoscope of an observer and
by the patient himself. In such cases ligature of the
carotid had not always proved satisfactory on account
of the very free anastomosis which took place. In the
patient in question there was very considerable evi¬
dence of anastomosis, particularly with the r.asal
branches of the facial artery. He had, however, been
encouraged by the fact that pressure on the common
carotid checked the pulsation and bruit, and therefore
the common carotid had been ligatured. The result
■was entirely satisfactory, the proptosis having disap¬
peared, and the movements and aspect of the eye
having become quite normal, except from some weak¬
ness of the sixth nerve. (2) A case of sarcoma of the
chest wall. As in most cases of this kind, the growth
of the tumour had been very irregular as regards its
rapidity. It had begun in the posterior triangle of the
neck, and was probably a lympho-sarcoma. The
tumour wa 3 now very exclusive, and involved a large
area of ihe chest wall. It was proposed to treat the
case by ROntgen rays. In a previous case of similar
nature very great improvement—indeed, almost com-

ete disappearance of the sarcoma—had resulted from’
-rays. On the interruption of the treatment, how¬
ever, recurrence took place.

Mr. Alexis Thomson showed:—(1) A child with'
spontaneous fracture of the lower end of the femur,
probably the result of osteomyelitis fibrosa. The
fracture took place as the boy was standing in the'
street, without any violence having been employed. In
spontaneous fractures of this kind union took place
readily, but there was no means yet known of pre¬
venting recurrence. (2) A child with an unusual form
of greenstick fracture of the forearm. The fracture
was not, strictly speaking, greenstick at all, but a
complete break of both bones. Union had not taken
place, and there was extreme angular deformity. In
fractures of both bones of the leg in children, it was'
sometimes extremely difficult to obtain union, and'
metal supports had to be used to prevent riding. He
proposed to operate in this case, and unite ends of
the broken bones. In the arm shortening was of little
consequence; hence he would be able to remove tb«
bone pretty freely, so as to get good union.

Dr. Robertson showed (for Mr. Stiles):—(1) A
patient after extensive operation for epithelioma of
the floor of the mouth. The tongue and the glanda
had been removed previously. (2) A patient, set. 80,
after operation for malignant disease of the upper jaw.
In this case a preliminary laryngotomy had beer, per^
formed. (3) A case of renal calculus in a patient who
had suffered from Potts’ disease of the spine.

The President delivered his valedictory address.
After thanking the Society for the honour they did
him in electing him to fill the presidential chair, he
referred with gratification to the fact that during hi9
term of office a large number of communications had
been made by the younger members of the Society.
This was as it should be, for the future of the Society
depended on its younger members. In taking leave of
the Society as its President, he wished to speak, how¬
ever, not of the past, or of the future, but of the pre¬
sent, and to lay before them some results of the experi¬
ence of more than

a generation’s observation of disease.

Dr. Affleck concluded his address, which was listened
to with much appreciation, by expressing his wishes
for the continued prosperity of the Society, and the
security he felt that it would be in good hands, as he
vacated the chair to allow Dr. Ritchie to ascend it.

(A full abstract of the President’s address will be
found on page 521.)

Dr. Allan Jamieson, in moving a hearty vote of
thanks to Dr. Affleck for his conduct in the chair
during the past two years, spoke in appropriate terms
of the courtesy and tact with which he had guided
the affairs of the Society, and the charming valedictory
address he had delivered. Mr. Cotterill seconded the
motion, which was carried by acclamation.

Mr. George Chiene then read a preliminary note
on a

SIMPLE OPERATION FOR UNCOMPLICATED OBLIQUE
INGUINAL HERNIA IN YOUNG ADULTS,
which will be found in another column, page 522.

The paper was discussed by Messrs. MacGillivray,
Scott Carmichael, Dowden, Strothers, and Cotterill,
and Mr. Chiene replied.

The following were elected office-bearers for the
ensuing season:—President, Dr. James Ritchie; Vice-
Presidents : Mr. C. W. MacGillivray, Dr. Byrom
Bramwell, and Dr. Geo. Hunter; Council: Prof.
Harvey Littlejohn, Dr. Aitchison Robertson, Dr.
Keppie Paterson, Mr. W. Guy, Dr. Affleck, Mr. Berry,
Dr. Gulland, Dr. Ker ; Treasurer : Mr. J. W. Dowden;
Secretaries: Mr. David Wallace, C.M.G., and Dr.
F. D. Boyd, C.M.G. (editor of “Transactions”), and
Dr. Wm. Craig.

Royal College of Surgeons, Ireland,

We are asked to announce that, on and after
January 1st, 1910, all examinations for the Fellowship
will be conducted under the scheme now known as
Grade I. No candidate after the above date will,
under any circumstance, be admitted to examination
for the Fellowship of this College under the scheme
now known as Grade II., which will then cease to be
used.

, y Google

5 2 & The Medical Press.

ROYAL ACADEMY OF MEDICINE IN IRELAND.

Section of Pathology.

Meeting Held Friday, October 25TH, 1907.

The President, A. R. Parsons, M.D., in the Chair.

THE NITROGENOUS METABOLISM IN A CASE OF
MYELOGENOUS LEUKEMIA.

The President read a paper on the above subject.

Dr. Walter Smith said it was not usual to discuss
the Presidential Address, but he thought it would be
unbecoming to pass over without remark a paper
which marked a departure in the transactions of the
section. It was a courageous attempt to investigate
one of the darkest corners of pathology, the full in¬
vestigation of which would tax the resources of the
most skilled chemist. It wa9 no disparagement of the
paper to say that it did not lead to any definite con¬
clusion. The same might be said of the general litera¬
ture of the subject; and it might be safely asserted
that up to the present chemical investigation failed
to throw any light on the cause of leukaemia. The
subject, moreover, was only part of the much larger
subject of the general effect of diseases of the blood,
on metabolism, the metabolism generally taking the
direction of catabolic destruction. Before they could
get any general light on the subject, they must take
into consideration other affections, such as gout with
its uncertain relations to uric acid. More important
than even the serious loss of proteins which had been
observed in very acute cases of leukaemia, but not
definitely in the chronic cases, was the question
whether there was any distinction to be drawn,
chemically or otherwise, between lymphatic and
myelogenous leukaemia. There was, at any rate, one
curious difference in regard to the nature of the cells
that were found predominating in the two forms.
Generally speaking, comparing the leucocytes with the
large neutrophile cells, they were distinguished by a
lesser chemical activity, and it would almost seem as
if the chemical activity of the leucocytes in the normal
body was held in check by anti-enzymes in the blood.
They had become familiar with the doctrine that pro¬
bably every cell in the body was, as it were, capable
of eating itself. The chemical changes in the blood
were so diverse that it was almost impossible to throw
any light on the subject. All sorts of extraordinary
things had been reported a9 existing in the blood.
The xanthin bodies were well represented in the blood
of leukaemia, but there were other bodies which might
be post-mortem products. The solid exudate in acute
pneumonia underwent resolution with puzzling
rapidity; that was probably due to autolytic action,
and we might probably look in that direction for the
explanation of unresolved pneumonia. Dr. Parsons
had been unable to trace any connection between uric
acid and the leucocytes in leukaemia, and the fact that
nitrogenous bodies in contact with the blood might
furnish non-nitrogenous products showed how cautious
they should be in interpreting the results of nitro¬
genous metabolism.

Dr. Magee Finny said the subject opened up a !
great range for discussion. The practical point as to
the X-rays being one of the great causes of improve¬
ment, if not the sole cause, was very important. It
was not so long since the rays were only applied for
diagnosis; cases in which they had been used as a
means of therapeusis were not very numerous, and it
seemed very remarkable that such results had been
obtained in the case. A relationship between the
elimination of uric acid and the white cells had been
found ; that, however, was valuable negative informa¬
tion for future observations.

Dr. Parson s replied.

Dr. Teed, the City of London analyst, in his recent
quarterly report, mentions that the highest percentage
of adulterated samples was in drugs bought with pre¬
scriptions. Out of seven prescriptions purchased, six
were not made up in accordance with the demand of
the purchaser, showing 85 per cent, of the prescriptions
to be wrongfully compounded.

Nov. 13, 1907.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Pari*. Nov. 10th, 19*7.
Phlegmasia Alba Dolens.

In spite of the progress of antisepsy and of
obstetrical asepsy, which have diminished and almost
removed puerperal complications, there is one excep¬
tion, however, and that is phlegmasia. According to
Boissard this affection is more common to-day than
ten years ago, and is observed more frequently in
private practice than in hospitals, where the women
generally return to their homes before phlegmasia sets
in.

Facts, parodoxical in appearance, would seem to prove,
says Dr. Keim, that phlegmasia is not always due to
puerperal infection. If on the one hand, it is observed
in the course of convalescence of normal confinements,
it is rare in certain cases of grave genital infection.

In the production of thrombosis, says Charrin, the
resence of a germ is by no means indispensable. The
lood can coagulate under the influence of the fibrin-
ferment of the leucocytes in contact with the fibriuo-
plastic of the product. This coagulation, under the
influence of chemical elements, can take place in two
periods of puerperality; after delivery, under the
influence of the chemical elements contained in the
uterus itself; during the last weeks of pregnancy,
under the influence of chemical elements of the neigh¬
bourhood and notably the intestine.

The increase of the coagulation of the blood during
pregnancy, is due, outside the transformation of the
liver, to the composition of the blood itself, which is
rich in fibrin. This excess of fibrin persists a certain
time after delivery; a favourable adjuvant in haemor¬
rhage, it can become an element of intravascular
coagulation in retention of clots, exudation of serum
and above all, after intra-uterine injection of salt water
or corrosive sublimate. The blood of the uterine
vessels is frequently put in contact, through the
placental wound, with the products contained in the
uterus; albuminoids, fibrinous clots, and for this
reason phlegmation has been frequently observed
following placenta praevia. Various are the conditions,
consequently, outside infection, that would explain
the frequency of abdominal venous coagulations and
phlegmasia following delivery affecting either the
uterus, the liver, or the blood, which do not exist after
miscarriage.

The chemical causes have also their importance.
They act by exaggerating the physiological thrombosis
after delivery, and produce phlebitis of the uterus with
subsequent extension to the lower limbs.

Thyroid Insufficiency.

The slight symptomatic manifestations of thyroid
insufficiency should be known to the medical practi¬
tioner in order for him to be able to apply the treat¬
ment of opotherapy. Dr. Henri de Rothschild has just
published an interesting review on the stigmata of
insufficiency of the thyroid gland.

Transitory (Edema .—Without any trace of albumin
the affection is manifested by white, painless and
elastic oedema, localised chiefly on the eyelids, the
forehead, the malar region, and sometimes on the feet.
This oedema returns more or less frequently, and is
observed in the morning, after some annoyance, fatigue,
migraine, or the menses. The repetition of these little
signs have a certain diagnostic value.

Caloric Troubles .—These depend on the decrease of
the thermogenic function of the thyroid body; but
before assigning to them a symptomatic value the
urine should be examined, for in cases of albuminuria
they are also observed.

In any case they consist in a sensation of cold,
particularly in the feet, but also over the whole body
or in the back, the thighs, or in one or other of the
oxtremities. The patient complains constantly of cold,
and covers himself up in mantles or shawls and requires
several bed coverings at night with the hot water bottle.

CORRESPONDENCE.

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CORRESPONDENCE.

The Medical Press. 5 2 9

Nov. 13, 1907.

In these patients, the extremities are pale, the hands
-are cyanosed, and chilblains are frequent.

Other patients complain of shivers running through
their whole body, especially the back, at certain
moments in the day, generally towards four or five
o’clock in the evening. They feel a sensation of iced
water running down their back and limbs.

In a certain number of patients, the central tempera¬
ture falls somewhat below the normal, particularly at
night, and the slightest draught produces rheumatic
or neuralgic pains, which we call lumbago, wryneck,
migraine.

All these patients complain of fatigue in the morn*
ing; it is with reluctance they leave their bed and
only recover their normal condition about half an hour
after rising. They are also easily fatigued after walk¬
ing some distance. This symptom is also found in
neurasthenia.

Headache .—This symptom assumes two forms;
frontal or occipital. Frontal headache resembles that
of acute coryza, while in the occipital form the pain
is over the seat of the occipital nerve, and resembles
neuralgia. Generally more intense in the morning,
it disappears in the evening or after a copious repast.
In these patients are also observed muscular pains
occupying different points of the body; the thighs, the
intercostal muscles, those of the back of the neck, the
lumbar region, etc.

Physical and Mental Insufficiency are frequently met
with in these cases. A small number of internal
secreting glands regulate the physical and intellectual
development of a child, and in this the thyroid gland
plays a capital r 61 e. Consequently a default in the
function of the thyroid retards the growth and fre¬
quently the intelligence of the child. According to
M. Hertoghe such children have difficulty in learning
arithmetic and orthography, while stammering, incon¬
tinence of urine and cryptorchidia are freqeunt.

AU of the above permanent signs of thyroid in¬
sufficiency are not necessarily to be found in the same
individual, and one of them alone should not be con¬
sidered as a basis for diagnosis, but where two or three
-are observed together they should attract attention.

GERMANY.

Berlin. Nov. 10th, 1907.

At the Society for Innere Medizin, Hr. E. Barth
read an interesting paper on

The Physiology of the Tonsils and the Indica¬
tions for their Removal.

He said that at present ideas as to the functions of
the tonsils were not at all clear. Whilst one looked on
them as indifferent structures, another considered them
to be a protective apparatus against infection. From
this want of clearness arose uncertainty as to the sur¬
gical treatment of the organs—for example, as to their
removal in affections of the ear. As recent investiga¬
tions had shown, the tonsils were composed of the
same tissues histologically as the lymph glands, that
they had therefore the same office in the oiganism ;
besides this, they had some macroscopical peculiarities
that would be spoken of later. As regarded the
function of lymph glands, the lymph was freed from
foreign bodies such as micro-organisms, etc., in pass¬
ing through them; they served, therefore, as a pro¬
tective apparatus. Whether they possessed an internal
secretion was still uncertain. The lymph glands
further served for the production of lymphocytes. The
tonsils would probably fulfil similar functions, the
filtration of the lymph that poured through, and the
production of lymphocytes. They had also the pecu¬
liarity of superficial position, and the formation of
cells on their free surface. A stream of lymphocytes
flowed through their epithelium, which formed a pro¬
tection against the entrance of infectious germs into
the interior of the tonsils. As it was assumed that
the lymphocytes had no independent movement, it was
believed that they were carried outwards by a stream
of fluid. More recent researches, however, had shown
that lymphocytes had an active independent move¬
ment ; whether, however, any discharge of fluid took
place was questionable. No epithelial openings

through which the lymphocytes could pass were pre¬
sent on the surface of the tonsils. As pointed out
above, the macroscopical structure was peculiar—an
enlargement of the superficies by numerous lacunae.
Altogether, therefore, the tonsils, along with their
character of lymph glands and the stream of lympho¬
cytes, possessed a large surface and a strong secretion.
The action of this structure and of these physiological
properties of the tonsils was that of a mechanical
protection against infection, and, moreover, chemical,
fermentative, and antiseptic properties have been
ascribed to them; but these had not been proved with
certainty. The tonsils did not act phagocytarily.
There was no evidence that jthe tonsils were the sites
of blood formation.

Now as regarded the clinical properties of the blood
in hypertrophy of the tonsils, we found an increase
of the eosinophiles, a diminution of the neutrophile-
polynucleated cells; but no specific influence on the
formation of blood could be assumed at present. The
tonsils were, however, by no means indifferent
structures, as was assumed by many. They passed
through a development dependent on age. In the
youth of the individual they were in active function ;
in old age they underwent involution, as the pro¬
tection they afforded was not so necessary as in early
life. But the most dangerous general infections
affected the tonsils. How was this to be brought into
unison with the above views? The lymph glands were
certainly protective organs, and yet they became
flooded with infective material. It was further to be
noted that the affections of the tonsils were often
secondary. It had also been shown by experiment that
foreign material escaped outwardly through the
lymph glands. When miero-organisms were found in
the tonsils, therefore, it must not be said they were
the ports of entry for them, as they might have been
carried there from the interior. Pathological changes
in the tonsils did away with the protective function,
and even caused them to act in a contrary manner.

Our therapeutic measures must be based on our
knowledge of the functions of the tonsils. Healthy
tonsils must, of course, be retained ; those loaded with
foreign detritus must be cleansed. In case of relapsing
inflammations of the organs we must ascertain whether
the inflammation was secondary; hypertrophy, even
in itself, was no ground for removal of the tonsils,
as, so long as they were composed of normal adenoid
tissue, their protective power was increased. Tonsils
should only be removed when the enlargement was
accompanied by marked local disturbance, as upon
the hearing. Children with enlarged tonsils were in
greater danger in acute infective diseases, especially
in scarlatina. Here the tonsils should be removed, and
the removal should be done thoroughly. It was fre¬
quently done imperfectly, and a re-growth took place.

In removal it sometimes happened that the tonsils
were so thoroughly taken away that firm cicatricial
tissue formed to the detriment of the adjacent parts.
The proper way to do this was to remove all above the
level of the mucous membrane, so that that was re¬
tained intact.

AUSTRIA.

Vienna, Nov. 10th, 1907.

Glaxtcoma.

Chaldpecky in his lectures maintains that traumatic
glaucoma is a rare occurrence. The internal pressure
of the bulb resulting from cicatrices of the cornea,
occlusion of the pupil, luxation of lens, etc., are tem¬
porary conditions following an accident that fre¬
quently occur and can immediately be relieved.
Glaucoma is a more serious affair, and might arise as
a secondary disease.

We cannot refuse to accept that some cases of
traumatic glaucoma sometimes appear, and among these
the older authors supply us with a few published cases.
Graefe expresses himself in similar terms, and closes
by saying that you will hardly ever meet with
traumatic glaucoma in a healthy eye, but as a secondary
result you may.

Landesberg records one case of considerable interest
in this respect. A young offioer, set. 46, was engaged
in the war of 1866 when suddenly a bullet whizzed past

Digitized by GoOgle

53 ° The Medical Press.

CORRESPONDENCE.

Nov. 13, 1907.

his left eye without actually wounding it, but he
became instantly blind with it while he continued to
shoot with his right till he got his left leg smashed
and had to be taken to hospital, where Graefe con-
firmed the glaucoma. This is a case that must be
received with caution. It is possible that this eye was
glaucomatous before he entered the battlefield, and as
he shot with the right eye it is very probable that no
notice was taken of the glaucoma till the accident.

At a later date, 18S1, Ferber relates how a boiler¬
maker had his left eye injured with a splinter of iron
and was blinded. In 1887 a similar accident happened to
his right eye, which hitherto had been considered
sound. On examination four weeks after the accident
vision of left eye = able to count fingers at a metre
distant; right eye, able to count at tnetre distance;
tension, one degree harder, iris striated, opacity, retina
covered with a white exudation in which Vrak extra-
vasated blood, and excavation of the papilla.
Iridectomy was performed with resulting bleeding from
the yellow patches. Aftef nine weeks residence he was
dismissed with vision — *| 8 The glaucoma in this
case is attributed to a traumatic irritation of the
secreting ocular nerve producing a neuropathic
hypersecretion with final intra-ocular pressure.

More recently Praun recorded one from Fuch’s clinic
of a boy who got the eye injured with a piece of iron,
producing ciliary injection, opacity of the vitreous
humours, hyperemia of papilla, and veins, while the
arteries were observed to pulsate; the outer half of the
retina became detached and the tension was increased.
Pilocarpin was administered and the retina subsided,
but rose again after a short cessation worse than ever.
The glaucomatous process increased, iridectomy simply
relieving tension. This may be considered a veritable
case of traumatic glaucoma complicated with separa¬
tion of the retina, probably due to the irritation of
the tensor and intraocular pressure.

Gamier relates the case of another boy, set. 11, who
got a stroke on the eye followed by intra-ocular ten¬
sion, and within ten days the eye became so staphy-
lomatous that it had to be enucleated. The vessels
were found in a hydremic and swollen, or dilated,
condition. The cause in this case seemed to be a
blocking of the lymphatic vessels.

Sala endeavours to explain the cause of glaucoma by
telling how he commenced to operate on an eight year
child for a soft cataract, and when he had pierced the
cornea no fluid came out, but the tension was instantly
relieved. His inference is that the lens swelled and
the comeal-ins angle became mechanically closed. The
thick colloid mass that forms in the anterior chamber
of the eye is an important factor in the production of
glaucoma. Sometimes, however, the serous iris is
the cause of the tension, although it is attributed to
an increased secretion of fluid, but the real cause is
more probably the albuminous colloid substance. In
slight cases of glaucoma warm compresses, massage,
and puncturing the anterior chamber will increase the
circulation and relieve the stoppage in the comeo-iris
angle, and thus avert a calamity. Intra-ocular tension
alter contusion is relieved in a similar manner. Experi¬
ments with eyes prove that albuminous fluids do not
P"**-!? along . t ] le . Schlemm canal; thus a quantity
of albuminous fluid in the anterior chamber produces
first a congested state of the fluids of the eye, com-
E!f, s * in & ** and producing hasmatic stasis,

followed by closure of the corneo-iris angle and
increased tensor that results in glaucoma.

Tuberculosis.

At the conference Panwitz discussed the cost of

sanatoHftHfhn"^ st ™ ggle with tubercle. A good
f *5? uId v be ereclcd for £200 per bed. *
* ho “ gh , t sanatoria were like “Kirks” or

SteSio"A tali 1X5 built substanliall y without con-

whlTthe 8 ° pini ° n that the y shouId be put up

greatest economy, as public bodies were far

too extravagant. Teleky agreed with the latteTS the
institution s^* ** ««*"' of thf^g

“ n

through which it passes at the exclusion of others—
lungs, bowel, or skin are difficult to determine.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME..

SCOTLAND.

Suspected Case of Plague in Glasgow. —A sus¬
pected case of plague has occurred in the South Side
of Glasgow, a district in which there is a considerable
foreign population, and in which a limited outbreak
of the disease occurred in 1900. The patient was at
once removed to hospital, and as nearly a fortnight
has elapsed since his isolation without the occurrence
of any fresh cases, there seems no reason to fear that
the experience of seven years ago will recur.

Rowdiness at the Glasgow University Gradua¬
tion. —The ordinary degrees in Medicine and Law
were conferred at the Graduation ceremonial held in
the Bute Hall on November 7th. There was a crowded
attendance, and rowdiness on the part of the students
was a conspicuous feature of the proceedings, benches
being torn up to make an arena for a private feud
between the engineering and medical undergraduates,
which was waged, however, without the knowledge of
most of the audience, so great was the din of whistles
and singing made by the other students present. The
Principal made the usual appeal for silence prior to
offering a Latin prayer, but the appeal, like the prayer
itself, and the subsequent proceedings, was quite un¬
heard. The whole of the ceremony, which lasted for
half an hour, practically proceeded in dumb show, the
graduates coming forward, being capped, and return¬
ing to their seats, the only evidence of their identity
being that obtainable from the printed lists. For¬
tunately there were neither honorary graduates—who
might have felt that they were being treated with dis¬
courtesy—nor orators, whose feelings required to be
considered; in fact, a purely domestic row.

Edinburgh Royal Infirmary. —At their meeting on
November 4th, the managers appointed Dr. Edwin
Bramwell, F.R.C.P.Ed. and Lond., to be an Assistant
Physician to the Royal Infirmary.

BELFAST.

Ulster Medical Society. —The opening meeting
of the session was held in the Medical Institute on
Thursday evening, November 7th, when the President,
Dr. John McCaw, delivered an important .\nd
interesting address on “Tuberculosis in Childhood'
and its relation to Milk,” which will be published at a
later date. Dr. McCaw’s long experience as physician •
at the Belfast Hospital for Sick Children, and his
special attention to the diseases of childhood qualify
him to deal with this subject, and though much has
been said and written on tuberculosis of late, he.
succeeded in being fresh and interesting, as well as
practical.

Public Health and the Registration of Deaths.
—At the last meeting of the Public Health Com¬
mittee a letter was read from the Chief Secretary for.
Ireland, in answer to a request that he should receive
a deputation on the above subject. He points out
that he is aware that no arrangements exist by which
particulars of deaths occurring in the city are com¬
municated to the sanitary authority, and that while
he recognises the importance of such an arrange¬
ment, there is no way at present of bringing it into
existence. He proposes, therefore, to consider
whether it will not be possible to introduce legisla¬
tion next session to apply Section 28 of the Registra¬
tion of Births and Deaths Act, 1874, to Ireland. The
section referred to requires every registrar to furnish.-
a sanitary authority, when required by such authority,
particulars of any deaths registered by him, on forms
supplied by the sanitary authority, who shall pay
twopence for such return, and a further sum of two¬
pence for every death entered in the return.

joogle

TNov. 13, 1907.

REVIEWS OF BOOKS.

The Medical Press. 53 1

LETTERS TO THE EDITOR.

THE CANCER PROBLEM.

'.To the Editor of The Medical Press and Circular.

Sir,—A mong the various theories advanced as the

• cause of cancer, excess of nitrogenous diet seems to
be a likely one, while others suppose that the meat
from an unhealthy animal is a more probable cause.
I have a strong suspicion myself that the large con¬
sumption of frozen meat, either supplied from abroad

• or killed here and kept in cold storage, should be just
as likely a cause of cancer, if not more so. I have
been informed by those who know that carcases of
sheep are sometimes kept in a frozen condition for
three years before being sent to the various retail
shops. Could such meat be healthy to consume, even
supposing (which requires a stretch of the imagina¬
tion) that such carcases were those of healthy animals?
The cold storage system I detest, as neither vendor nor
purchaser can tell when the animal was killed. It would
be interesting in this connection if reliable statistics
could be obtained of the percentage of cancer cases in
the United Kingdom before and subsequent to the in¬
troduction of this vile method of retarding decomposi¬
tion by means of cold storage.

I am, Sir, yours truly,

Alexander Duke.

REVIEWS OF BOOKS.

BLOOD STAINS? THEIR DETECTION AND
DETERMINATION (a).

The differentiation of blood stains from other stains,
and the determination of the source of stains proved
;to be blood, is one that presents oftentimes very great
-difficulties—even to the skilled expert. To help the
expert to come to a conclusion, a large number of
tests—chemical, spectroscopic, serological, biological,
:and microscopical—have been devised. Some of these
•tests are satisfactory up to a certain point, and then
fail; others are fallacious; while one or two have for
years stood the closest investigation without our con¬
fidence in them being in any way lessened. In the
case of all of them, however, certain details of tech¬
nique must be followed, and some of our text-books on
forensic medicine admittedly do not give sufficient

• details to allow the investigator to make the most of
the tests at his disposal. For these reasons a book
devoted entirely to the subject, in which no essential
-detail is omitted to make room for other matter, and

in which practically the whole of the various tests
are considered as to their faults and limitations, can¬
not but be of the highest service to the medico-legal
•expert. A bibliography containing some 336 refer-

• ences to the tests shows the enormous amount of work
that Major Sutherland has devoted to the compilation

-of this volume, and his personal wide experience, his
perspicacity, and his thorough and conscientious study
have enabled him to produce a thoroughly trustworthy
work, which we can with all confidence recommend
to the coroner, the general practitioner, and to the
•.worker in the clinical laboratory.

ANTISEPTIC METHODS (6).

“Antiseptic Methods” lays down certain guiding
rules for the application of the general principle with
which it is concerned. But the title does not suitably

• describe the scope of this little work, as it almost

• entirely deals with what we usually understand the
“ Aseptic ” technique in operation, and during the

. dressing of surgical wounds.

The author, Mr. Upcott, draws attention to many
apparently trivial but really essential details, which

(a) “Blood Stain*: Their Detection, and the Determination ot
their Source." A Manual for the Medical and Legal Profession*. By
Major W. D. Sutherland, of His Majesty's Indian Medical Service.
Pp. 167 andxlli. With eight Illustrations and two plates of spectra.
1907. London: Ballliere, Tindall and Cox. Prioe 10s. 6d. net.

(5) “ Antiseptic Methods; for Surgical Noises and Dressers." By
Harold Upcott, F.R.CJS. Pp. rill and 51. London: Bailliere, Tindall
And Cox, 1907.

it is necessary to bear in mind to prevent wound in¬
fection. For instance, the precaution which should
be taken in the preparation of the patient, the
handling of sutures and basins during operations, and
the subsequent removal of the stitches, are con¬
sidered

“Antiseptic methods” is written for dressers and
surgical nurses. The beginner will certainly find it
a very useful little book.

INTUSSUSCEPTION (a).

Is this little book, the author, Mr. Clubbe, relates
his experiences, which extend over a period of
thirteen years, in the treatment of Intussusception.
During this time he has dealt with what appears
a very large number of cases (144).

The author is a strong advocate of a preliminary
irrigation. He says: “I think injections of warm oil
should be given in all cases, after the child is under
the anaesthetic, even in cases of long standing, when
we know that it is impossible to complete the reduc¬
tion by these means. My reasons are these. It
always reduces the intussusception to a certain ex¬
tent, and in the best and gentlest possible way; in
this way it lessens the shock of the coming opera¬
tion, because less manipulation of the intestines is
needed. It is specially useful in cases in which we
find the intussusception in the rectum, because if we
do not use it we may find some difficulty in getting
our fingers below the tumour to commence the
squeezing process.” In fourteen cases reduction was
brought about by this method alone. From his obser¬
vations in 124 laparotomies for this condition the
author asserts positively that adhesions between the
invaginated portion of the gut do not exist, even
when resection of the intestine is necessary. The
irreducibility is due to the swelling and thickening of
the intussusceptum.

This book is well worth perusal, especially by the
young practitioner. Mr. Clubbe’s style is simple and
graphic, and he draws a very vivid picture of the
symptoms of Intussusception, but his account of the
differential diagnosis is scanty.

TRANSACTIONS OF THE ROYAL ACADEMY OF
MEDICINE (a).

Is this volume the first section, that of medicine,
is the largest, and contains several papers of great
interest. It opens with a paper in which the author
explains the commonest functional heart murmur— i.e.,
pulmonary systolic murmur—as being due to dilata¬
tion of the infundibulum of the right ventricle.

A long paper, entitled “ Our Debt to Ireland in the
Study of the Circulation,” follows. In thi9 is shown
the enormous amount of work contributed to this
branch of medicine by Irish physicians from the time
of Graves and Stokes to the present day. Next are
several papers which formed the subject-matter of a
debate on the treatment of gastric ulcer. Of these,
two are contributed by physicians, and two by sur¬
geons. There is a paper, with bibliography, on the
rare condition of movable spleen, founded on a case
which simulated a movable kidney, with intermittent
hydro or pyo-nephrosis. Another paper of interest is
one on a case of myelogenous leuchsemia, in which
the white blood corpuscles were reduced after three
and a half months’ treatment by X-rays from over
900,000 to 10,000, with reduction of a greatly enlarged
spleen to normal size, and a corresponding improve¬
ment in the general symptoms.

In the surgical section the contribution on “Sphinc-
teric Control of the Male Bladder and its Relation to
Prostatectomy,” will attract attention. The author
comes to the conclusion, after performing various
experiments on dogs, that probably in man the internal
sphincter vesica is the important muscle, and not the
compressor urethrae, as generally supposed. The idea

(а) “ The Diagnosis and Treatment of Intussusception." By Charles
P. B. Clubbe, Hon. Burgeon to the Prinoe Alfred Hospital, Sydney ;
Joint Lecturer In Clinical Surgery at the 8ydney University. Pp. x
and 62. Edinburgh and London: Young J. Pentland. 1967.

(б) “ Transactions of the Royal Academy of Medicine hi Ireland
Vol. xxv. Dublin: John Falconer. 1907.

Digitized by G00gle

532 The Medical Press.

NEW INVENTIONS.

Nov. 13, 1907-

of these experiments was originated by a case under :
the author’s care, in which, after perineal prostatec- ,
tomy, the patient had voluntary control over micturi¬
tion, which took place through a fistula in the
perineum.

“Limits of Abdominal Operations” is the title of a
paper concerning movable kidney, vermiform appen¬
dix, and gastroptosis. With most of what is said we
are in accord, but we find it hard to reconcile the fol¬
lowing two statements :—“ I venture to think that one
attack of appendicitis is sufficient to justify opera¬
tion,” and “ I do not think operation advisable during
a first attack, nor, indeed, during an y attack, unless
there is present some special indication.” Surely it
is better to remove the appendix at once, provided, of
course, the case is seen sufficiently early—say, within
the first 24 hours.

Then follow papers on a comparison of the treat¬
ment of enlarged prostate witnessed in some of the
hospitals of Paris, Berlin, and London ; on chronic
pancreatitis successfully treated by draining the gall¬
bladder ; on fractures of the shaft of the femur, advo¬
cating treatment by a modified Park Hill apparatus.
The last paper in this section is one on intestinal
obstruction, based on a series of 12 cases. In this the
author speaks very strongly on the subject of high
mortality—at least 40 per cent., “which disgraceful
state of affairs,” he says, “must be largely attributed
to the pernicious habit of meddlesome medication and
delay until the unfortunate patient is so profoundly
poisoned by toxic absorption from his intestine, and
exhausted to such an extent by pain and vomiting,
that he is quite incapable of withstanding even the
simplest surgical procedure.” We fully endorse this
statement.

This section concludes with brief abstracts of
numerous cases and specimens shown at the meetings.
We are glad to note that several of the contributions
in this volume are by physicians not resident in
Dublin, showing that the Society is not merely of
local interest. Then follow the sections of obstetrics,
pathology, State medicine, anatomy, and physiology.

DISEASE IN CHILDREN, (a)

No one who is acquainted with Dr. Sutherland’s
skill as a diagnostician and teacher can fail to open
this book with eager expectancy. We look for
thoroughness in anything that he puts his name to,
and in this case we are not disappointed. This is
certainly one of the best of the Oxford medical
publications. It is written in a somewhat authorita¬
tive style, but there is throughout much that is con¬
vincing. We are pleased to observe that the author
does not recommend arsenic in the treatment of
chorea. With small doses he has never got good
results, while large doses, he says truly, are not by
any means free from risk.

In connection with congenital pyloric stenosis we
observe that the author still ventures to recommend
operation, especially in those cases where medical
treatment has failed. In this respect he follows the
teaching of most authorities at the present time. He
has a good deal to say on the subject of incontinence
of urine, and he mentions adenoids and enlarged
tonsils as associated causal conditions. This, how¬
ever, is not our experience, and we have frequently
found the condition actually rendered worse by opera¬
tion for these growths. He prefers atropine to bella¬
donna, as the former is more active. This is Holt’s
teaching, and we believe it is to be highly commended.
To be of any value, however, it must be given in full
doses.

Vulvo-vaginitis in its commonest form, he says, is
due to want of cleanliness. In other words it is
simple and not gonorrhoeal in nature. We are glad to
find that this is the opinion of a practical observer
as Dr. Sutherland undoubtedly is, for we so often
hear it taught in these days that the majority of these
cases in children are really due to the gonococcus.
In fact, it will be found that the author’s teaching is

(a) The Treatment of Disease in Children.” By G. A. Sutherland, I
M.D., F.R.C.P., Physlolan to Paddington Green Children's Hospital, I
ete. London: Henry Frowde, Oxford UnWermity Press. 1907. Price 1
5s. net. 1

uniformly sound and common-sense in principle.
The book is free from padding and unnecessary*
verbiage. All the commoner diseases of infancy and*

I childhood are included. An - appendix of useful
prescriptions completes this thoroughly practical little
! work. We heartily recommend it as a guide to junior
practitioners and to those who for some reason or*
i other have not made a special study of children’s
I diseases during their medical curriculum. A study
of this volume will afford the reader many valuable
! hints which he will find of very great service in
i practice.

THE MODERN TREATMENT OF PULMONARY
CONSUMPTION (a).

Dr. Latham’s book has now become one of the
standard works on the subject with which it treats,
and it is so well known that a brief notice is all that
is necessary of the third edition. The most important
change in the present edition is the insertion of a
section on the value of the opsonic index in diagnosis
and treatment, and the use of the new tuberculin. It
will, we are sure, be a great satisfaction to many
clinicians to learn from Dr. Latham that in his experi¬
ence the treatment by tuberculin can be quite as
readily carried out and as safely controlled by clinical
evidence as by the opsonic investigation. Were we
dependent on the opsonic investigation for the use of
tuberculin, its use would be very much limited—among
the poor, at all events, where it is most wanted. We
sincerely trust that the book will have a wide cir¬
culation among the general practitioners of this
country, where all forms of tuberculosis are so
common.

NIW MEDICAL AND SUMICAL APPLIANCES.

A NEW POST-NASAL CURETTE.

The use of a curette for the removal of adenoids,
in preference to the post-nasal forceps, has now
become an established method. It was Delstanche

A

who first invented an ingenious hinged and toothed
cage to Gottstein’s curette. The post-nasal curette
generally used has a straight shaft from the catch to
the handle, and when introduced behind the soft
palate and swept downwards and backwards, the shaft
of necessity is elevated, the result being that consider¬
able bruising of the uvula and soft palate is caused.
In the instrument devised by Mr. William Lloyd,.
F.R.C.S., and manufactured by Messrs. Allen and
Hanburys, Ltd., the shank is curved from A to B, with
the result that in the large number of cases in which,
the inventor has used it, traumatic inflammation, etc.,,
is avoided.

NEW “TABLOID” SLIPPERY ELM.

Mucilage of slippery elm is largely used as a de¬
mulcent and astringent sedative. Alone, or combined
with phenol, it is employed locally in pharyngitis an<T
other throat affections, and internally in diarrhoea and
dysentery. The mucilage is also stated to have a
nutritive value. In tabloid form slippery elm presents
a convenient means of administration. Each repre¬
sents 5 gr. (0.324 gm.) of the mucilage, and one may¬
be slowly dissolved in the mouth or swallowed whole
with water as required.

CARBOLIC ACID AND SLIPPERY ELM.

Each tabloid contains carbolic acid } gr. (0.032 gm.).
One may be slowly dissolved in Ihe mouth, or one to-
two swallowed whole with water twice or thrice daily
after food. Both the foregoing tabloids are issued in
bottles by Messrs. Burroughs, Wellcome and Co.

(a) “The Diagnosis and Modern Treatment of Pulmonary Con¬
sumption. with special reference to the Early Recognition and Per¬
manent Arrest of the Disease.” By Artfanr Latham. MJX Third.)
Edition. 8vo. Pp. Ill and 257. London: BalUlere, Tindall and Cox-
1907. Trice 5s. net.

itized by G00gk

Nov. 13, 1907.

PASS LISPS.

Medical News in Brief

Death Under Nitrous-Oxide Oas.

Mr. Walter Schroeder held an inquest at Holborn
on November 9th on Louisa Allen, 30, who died at a
dentist’s.

The husband, Alexander Allen, said his wife had
suffered from neuralgia for some time, and had been
under medical treatment for the last three months.
She went to the Welbeck Street Dispensary for
Epilepsy and Paralysis, and she was advised to con¬
sult Mr. Cox-Moore regarding her teeth. She went
to him, and he extracted four of her teeth. She left
home on Thursday seemingly in good spirits, in order
to go and have more teeth taken out. Later in the
day witness was summoned by telegram, and on
arriving at the dentist’s he found that his wife had
died under the operation.

Mr. Edward Cox-Moore said he had practised as
a dental surgeon for twenty-five years. Mrs. Allen
went to him as a Hospital Saturday Fund patient, and
had four teeth extracted under a nitrous-oxide gas
anaesthetic. When she came on the second occasion
he administered a moderate dose of gas nitious-oxide,
using a face apparatus which was regarded as perfectly
safe. The gas took effect, and he took out the teeth
that had been selected, and found the woman in a
normal state and regaining consciousness. About two
minutes later she lurched forward and died. He
believed that the patient was not under the influence
of the anaesthetic when she died, although he would
not positively state that she had recovered conscious¬
ness. He had for the last seven or eight years given
an anaesthetic to about 1,500 persons annually, without
mishap.

Witness’s statement was corroborated by John L.
Burden, who assisted him.

The evidence of Dr. W. Harper, Bloomsbury Square,
was to the effect that death was due to syncope whilst
suffering from fatty degeneration of the heart and
whilst under the influence of an anesthetic.

A verdict of “ Death from misadventure ” was
returned.

Spreading Scarlet Paver.

William Rance, a fried fish dealer, of Leyton, was
summoned at Stratford for exposing a child while
suffering from scarlet fever without proper precau¬
tions.

Dr. F. J. Taylor, Medical Officer of Health for
Leyton, prosecuted, and said that on October 16th
he examined defendant’s child, certified it to be suffer¬
ing from scarlet fever, and gave directions for isola¬
tion. On the 17th Mr. Miller, sanitary inspector,
found the child isolated, but on the 23rd the boy
was seen running about with other children. The
defendant said the child was a great trouble, and he
had no control over him. On October 25th, when the
inspector called, the boy was seen without a coat and
with wet hands. He said he had been washing
potatoes. On October 29 the boy’s mother said he
was out of doors—she could not keep him in—but the
next day isolation had again been resorted to. On
the 31st Mr. Miller saw the boy in High Road, Leyton,
wheeling his sister in a cart.

Dr. Taylor added that there was a great deal of
scarlet fever about, and the ignorance of people
created a difficulty, but when persistent obstinacy
was added to it there was more difficulty still.

The defendant said at first he did not know the
child was suffering from scarlet fever, and when he
was told his wife did her best to keep him upstairs,
but he would not stay.

The Bench said they regarded it as a serious matter,
and imposed a fine of 20s. and costs.

Dablln Hospital Sunday Fund.

The annual collection for the Dublin Hospital
Sunday Fund took place on Sunday last, and will, we
trust, result in a large addition to this most valued
fund. The fund assists no fewer than 15 institutions,
which provide 1,543 beds for the sick poor, and receive
annually 16,000 patients, in addition to the many
treated at outlying dispensaries, and about 29,000
accident cases. Since 1897 the fund has distributed
to the hospitals no less than ^126,775 15s. 9d. During

The Medical Press 533

the past two or thiee years the collections have been
smaller in comparison with previous years. The Earl
of Meath, President of the fund, has made an appeal
in its behalf which we hope will re-establish the fund
on its old basis, and thus further a most necessary
work. Additional contributions may also be sent to
the Royal Bank of Ireland, Dublin, or to the
Treasurer, Mr. Joseph T. Pim, of 22, William Street,
Dublin.

SeMlon ol the Qeneral Medical Councli-

We are requested to announce that the autumn
meeting of the General Council of Medical Education
and Registration will commence on Tuesday, the
26th inst. The President, Dr. Donald MacAlister, will
take the chair at 2 p.m.

PASS LISTS.

Conjoint Examinations In Ireland.

The following candidates have passed the First Pro¬
fessional Examination of the Royal College of
Physicians and the Royal College of Surgeons:—

U. L. Bourke, F. E. Fitzmaurice, J. M. Gilmore,
C. W. Joynt, J. Kirker, C. J. Kelly, A. G. J.
Macllwaine, B. Malaher, B. Murphy, D. McDevitt,.

B. Nearv, A. J. Neilan, J. M. K. O’Byrne, J. H. Rish-
worth, C. Roche, G. Wilson, G. Young.

The following have passed the Second Professional
Examination :—J. J. Barry, F. J. Graham, P. Grace,.
R. H. Hodges, W. H. Murray, M. O’Brien, H. C.
Smyth, T. P. Shorten.

The following have passed the Third Professional
Examination:—S. J. Barry, A. J. Bennett, G. E_
Beggs, H. F. Blood, T. C. Casey, Miss C. Daniell,.
J. C. L. Day, E. C. Deane, E. Dundon, H. Hunt,.
F. M. Harvey, S. W. Hudson, L. C. Johnston, J. O’L.
Murray, J. Menton, M. C. O’Hara, J. C. O’Connell,.
R. Power, W T . F. Russell, C. D. K. Seaver, I. Scher,
H. B. Sherlock.

The following have passed the Final Examination :—

C. W. Green (Honours), M. D. Healy, M.D., Denver
Univ. (Honours), J. McNamara (Honours), H. C.
Carden, W. J. Connolly, A. Curry, B. Foley, G. A.
Francis, E. H. F. Gilligan, G. T. M. Martin, E. Mont¬
gomery, W. St. L. Moorhead, P. J. Murray, C.
McQueen, M. H. O’Sullivan, J. T. Rearden, G. F.
Shepherd, P. D. Walsh.

The following candidates have passed the Diploma
in Public Health, November, 1907: Major J. W.
Bullen, M.D., R.U.I., R.A.M.C.; E. J. Day, M.D.,.
Univ. Durham ; F. C. Drew, M.B., Univ. Edin. ;
Capt. D. P. Johnstone, L.R.C.P. and S. Edin.; G. A..
Moorhead, F.R.C.S.I.

Apothecaries* Hall of Iralaad.

At examinations recently held, the following can¬
didates passed in the subjects indicated:—John W.
Harvey, Physics; J. Stewart, Physiology; John Clarke-
and J. Hargraves Robinson, Pathology; Alexander
Sllbermaine and John Clarke, Hygiene; Major Moody,
Alexander Silbermaine, and John Clarke, Medical'
Jurisprudence; Alexander Silbermaine, Materia
Medica (Honours); John Clarke and Alexander Sil¬
bermaine, Pharmacy; J. M. Downer, Khaja
Moinuddin, and N. Murphy, Surgery; S. V. O’Connor
and J. Hargraves Robinson, Medicine; J. M. Downer
and J. Hargraves Robinson, Midwifery (Honours).

The Diploma of the Apothecaries’ Hall was granted
to the following candidates, entitling them to practice-
Medicine, Surgery, Midwifery, and Pharmacy: J. M.
Downer, Khaja Moinuddin, and N. Murphy.

Faculty of Pbyolclaao and Sargoona of Olasgow-

At a meeting of the Fellows of the Faculty last-
week, ihe following office-bearers were appointed for
the following year, viz.:—Dr. John Glaister, President;
Mr. D. N. Knox, Visitor. Councillors: The President,
ex-officio; The Visitor, ex-officio; The Treasurer, ex-
officio; Dr. J. Lindsay Steven, as Representative to the-
General Medical Council; Dr. Robert Perry, Dr. Neil
Carmichael, Mr. H. E. Clark, Dr. Ebenezer Duncan,
Mr. J. Walker Downie, Dr. John Barlow; Dr. W. G.
Dun, Treasurer; Dr. J. Lindsay Steven, Honorary
Librarian. Board of Examiners for the Licenser
William H. Hill, LL.D., Clerk; Alexander Duncan,.
B.A., LL.D., Secretary and Librarian; Walter Hurst,.
Assistant Secretary and Librarian ; William Matthews..
Officer.

itized by Google

534 The Medical Pre^s.

WEEKLY SUMMARY.

Nov. 13, 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT SURGICAL LITERATURE.

Recurrence of Retroperitoneal Lipoma. —Johnstone
{Brit. Med. Journ., Oct. 12th, 1907) reports a case in
which he removed a retroperitoneal lipoma weighing
21 lbs. in 1905. It was situated in intimate relation
to the right kidney and ureter, and the tumour was
shelled out of its bed apparently completely. The
patient remained perfectly free from disease for about
two years, but then commenced to suffer from stomach
troubles. On re-admission to hospital the abdomen
was found to be distended and filled with lobulated
tumours. The individual masses were firm in con¬
sistence, and one in particular was so hard that malig¬
nant recurrence was feared.. On opening the abdomen
the tumour was found to consist of a number of
lobules varying in size from that of a goose egg up
to that of a Rugby football. They were more or less
pedunculated, and only united at their common site
of origin, which was in the right flank in angle
between the outer border of the kidney and the iliac
crest. All the masses were removed, the perirenal fat
being completely cleared away, leaving the quadratus
lumborum bare. The peritoneum was sutured over
the denuded muscles, and the abdomen closed. The
tumour masses weighed altogether 12J lbs., were
pinkish white in colour when fresh, and the micro¬
scope showed typical lipomatous tissue, with no trace
of malignancy. The patient had an uneventful con¬
valescence. S.

Anastomosis Between the Common Bile Duct and
the Duodenum tor Obstructive Jaundice. —Fullerton
(Brit. Med. Journ., Oct. 26th, 1907) reports the fol¬
lowing case:—The patient, a male, aet. 66, had no
history of any illness whatever since childhood. He
was quite well until three weeks before admission into
hospital, when the patient’s friends noticed that he
was jaundiced, and he commenced then to lose flesh.
There was no pain. The liver was enlarged, and the
gall-bladder was distended almost to the umbilicus.
The probable cause of the condition was thought to
be carcinoma of the head of the pancreas or of the
common bile duct near its termination. No tumour
except the distended gall-bladder could be felt. On
'opening the abdomen the gall-bladder was found to
be larger than a goose’s egg, and contained three small
stones. None were found in the cystic duct. When
?the liver was drawn up, a hugely dilated common bile
• duct, about as large as a piece of small intestine, was
ffound. On opening the duct a quantity of srlairy
■fluid with no trace of bile in it escaped. The finger
could be introduced into the duct and passed up into
the cavities in the liver, corresponding with the
hepatic ducts. With some difficulty the common bile
duct was anastomosed to the first part of the duo¬
denum with a Murphy’s button. The gall-bladder was
stitched to the peritoneum and transversalis fascia,
and drained. Three weeks after the operation the
Murphy’s button was passed, and about the same time
the gall-bladder fistula closed. On examination five
months after the operation the patient was found to
be in good health and had put on flesh. S.

Cholecystectomy: The IodicatioRs and Contra-
Indications tor its Performance. —Mayo Robson (Brit.
Med. Journ., Oct. 26th, 1907) is strongly of the opinion
that the gall-bladder should not be treated as a dan¬
gerous organ in the summary fashion in which we
now deal with the appendix. The gall-bladder adds
mucous to the bile, and thus makes the latter less
irritant. If the reservoir function of the gall-bladder
is lost, it leads to dilatation of the common bile ducts
and the hepatic ducts and back pressure on the
secreting part of the liver. Mayo Robson has also
f ound that at times this condition leads to interstitial
•'reatitis. The author has removed the gall-bladder

94 times in nearly 1,000 operations on the biliary pas¬
sages. The indications for cholecystectomy arei—fri
In cancer or other new growth of the gall-bladder.
(2) In contracted and useless gall-bladder, the result
of repeated attacks of cholecystitis. (3) In dilated and
hypertrophied gall-bladder resulting from obstruction
of the cystic duct. (4) In phlegmonous or gangrenous
cholecystitis. (5) In empyema of the gall-bladder.
(6) In mucous fistula of the gall-bladder, the result of
stricture or other obstruction of the cystic duct. (71
In gunshot or other serious injuries of the gall-bladder
or cystic duct. Cholecystectomy is contra-indicated
in all cases where the surgeon cannot be certain that
the deeper bile passages are free from obstruction
unless at the same time the cystic or common bile
duct be short-circuited into the intestine. S.

Rupture of the Liver : Operation—Death. —Haubold
(Med. Record, Oct. 26th, 1907) describes the case of a
man, jet. 29, who fell about eight feet and struck the
lower portion of the right chest against a pile of
lumber. This caused him considerable pain, but he
walked a long distance home without any assistance.
During the night he vomited the contents of the
stomach, and the pain in the side increased. On ad¬
mission to the hospital next morning a linear con¬
tusion was found extending from the anterior portion
of the seventh rib to the tenth rib at the posterior
axillary line. Temperature 99 deg. in rectum, pulse
88. Abdomen moderately distended. No broken
ribs. The face was pinched, but there was no pallor,
restlessness, or thirst. Fifty hours after injury the
temperature was 99, pulse 90. There were no symptoms
of progressive haemorrhage, and the man’s condition
was considered to be improved. Yet the history and
the anxious expression of the face, and the distended
and rigid condition of the abdomen, led to the belief
that the liver was ruptured, and justified laparotomy.
On opening the abdomen, it was found full of dark
fluid blood. An irregular rupture of the liver surface
three inches in length wa9 found, situated low down
in the right lobe, and so far posteriorly as to preclude
repair by sewing or cautery. There was some oozing
from the wound, but not so active as to cause
immediate aljuro. The abdomen was flushed out with
hot saline, a Mikulicz tampon was passed down to
and into the wound, and gauze was carefully packed
into it. This seemed to control the bleeding. The
patient went off the table in a moderate state of shock.
Pulse 98, respirations 32. The tampon seemed 'o
interfere with respirations to a considerable extent.
The pulse, temperature, and respiration continued to
rise, and the patient died eleven hours after opera¬
tion. At death the pulse was 120, respirations 45.
and temperature 105 deg. The case presented some
unique features. There was at no time any evidence
of shock, nor at any time were there symptoms
generally regarded as indicative of progressive in¬
ternal heemorrhage. The persistent rise of tempera¬
ture after operation would argue strongly against the
assumption that bleeding had not been arrested.
Hyperpyrexia at death is usually regarded as due to
exaggerated or disturbed metabolism, and the author
considers that perhaps it can be explained in this case
by the disturbance of the peculiar function the liver
has as an internal secreting organ. S.

Mobility of the Kidneys. —H. Mackenzie { Lancet,
Oct. 16th, 1907) discusses the cause and frequency of
this condition. Of 113 cases operated on by fixing
the kidney, 80 were completely successful, 17 were
partially successful, 13 were failures, and 3 died as
the result of the operation. The author believes that
movable kidney is undoubtedly a very common con¬
dition, in the female subject especially so; that in the

Digitized by GoOgle

Nov. 13, 1907.

NEW BOOKS AND NEW EDITIONS. The Medical Press. 535-

great majority of cases it produces no symptoms, and
that it requires no treatment when local symptoms are
absent. When local symptoms are present, a fair trial
should first be made with non-operative methods of
treatment. Only when such methods have failed to
relieve, or when there is good reason to believe that
the kidney may be the seat of disease, should recourse
be had to operation. The operation should consist in
exposing and thoroughly examining the kidnev for any
traces of disease, and, should none be found, fixing
the kidney in a thorough manner back into the loin.

Tumours of the Bladder. —Kolischer {Jour. Am. Ass.,
July, 1907) gives his experience in the treatment of
vesical tumours. He holds that all cases of benign
tumours of the bladder should be approached from
within, all malignant tumours from the outside of
the viscus. In all malignant cases in which the loss
of substance is not too great, ihe bladder should be
closed completely by sutures after the removal of the
tumour. In cases of malignant growths, the incision
into the bladder should be made in accordance with
the location of the growth, as defined by a previous
cystoscopic examination. The permanent catheter
should be absolutely abolished after such operations
on the bladder. It causes much irritation, and does
no good. It is far better to pass a catheter at regular
intervals into the bladder than to leave one tied in.
('.as anaesthesia should be employed exclusively. A
constant cystoscopic surveillance should be maintained
over any bladder that has ever been operated on for
tumour. In cases where the tumour is malignant and
too far advanced to permit of any radical treatment,
the bladder may be opened and the growth freely
cauterised with an actual cautery. This, however,
seldom gives more than temporary relief. The method
of treatment which furnishes more satisfactory results,
consists in establishing permanent kidney fistulae, and
thus preventing any urine passing into the bladder.

A Method of Cyotopexy for Cystocele. —L. Smith
describes (Montreal Med. Jour., April, 1907) an opera¬
tion for this condition, which is easy to perform, and
in his hands has given most successful results. The
abdomen is opened just above the symphysis pubis,
the bladder is seen lying low down in the pelvis, and
must be gently grasped by a bullet forceps, and drawn
up as high as it will go, without employing any force.
Both the peritoneal surfaces on the bladder and on the
anterior abdominal wall are scarified or criss-crossed
with a needle, until there is a slight oozing of blood.
A curved needle is then passed through the abdominal
wall, including all the layers except the skin and fat.
It is then passed under the scarified surface on the
bladder wall, care being taken only to include the
peritoneal and muscular coats, and not to injure the
mucous coit. The needle is again passed through the
abdominal wall at the other side of the raw peritoneal
surface. Three similar sutures are passed, each of
medium chromicised catgut, which snould last for
about a month without absorbing. No precautions
are necessary with regard to emptying the bladder. As
a rule the patient can do this without the help of a
catheter from the very first. G.

Doctor Die* of Cocaine.

Dr. John Ernest Cook, aged thirty-eight, un¬
married, and practising at Darnley Road, Hackney,
was found dead in his dining-room on November 6th,
and the coroner’s inquest, held on Saturday, showed
that he had died from cocaine poisoning.

Witnesses said that Dr. Cook had been doing veil
in his practice, but he suffered much from neuralgia,
rheumatism, insomnia, and other trying complaints,
and twelve months ego he had to be treated by another
medical man for an excessive do9e of cocaine. He
had never spoken of suicide, and left no written state¬
ment.

When found he was lying on the hearthrug beside
an overturned chair, and the gas lights were burning.

After hearing the evidence, the jury found “Death
from misadventure.”

NEW BOOKS AND NEW EDITIONS.

The following have been received for review since the publica¬
tion of our last monthly list: —

Sidney Appleton (London).

The Diseases of Infancy and Childnood. By L. Emmett Holt,
M.D., Sc.D., etc. Illustrated. Fourth Edition, revised and!
enlarged. Pp. 1,171. Price 25s. net.

Baillikre, Tindall and Cox (London).

Cancer. Bv G. Sherman Bigg, F.R.C.S.Edin., M.R.C.S.Eng.,.
L.S.A. Pp. 85. Prioe 3s. 6d. net.

John Bale, Sons and Danlelsson, Ltd. (London).

Syphilis in the Army. By Major H. C. Frenoh, R.A.M.C.
Pp. 126. Price 6s. net.

Adam and Charles Black (London).

Black’s Medical Dictionary. Edited bv John D. Comrie, M.A.,.
B.Sc., M.B., L.R.C.P. Third Edition. Illustrated. Pp. 856.
Prioe 7s. 6d. net.

Church of England Temperance Societt (London).

Side-lights on Alcohol anti its Action on the Human Organism..
By " Medicus Abstinens.” Pp. 185. Prieo 2s. 6d net.
Churchill J. and A. (London).

The Operations of Surgery. By W. H. A. Jaoobson, M.Ch.
Oxon., F.R.C.S., and R. P. Rowlands, M.S.Lond., F.R.C.8.
Fifth Edirion. Volumes I and U. Pp. 2,055. Price 42s. net.
The Book of Prescriptions (Beasley), with an Index of Diseases
and Remedies. Rewritten by E. W. Lucas, F.I.C., F.C.S.,
with an Introduction by Arthur Sullivan, M.A., M.D.,

L. R.C.P. Ninth Edition. Pp. 366. Prioe 6s. net.

L. N. Fowler and Co. (London).

Medical Astrology. By Heinrich Dilath. Pp. 108. Prioe Is. net.
Charles Obiffin and Co., Ltd. (London).

Medical Ethics: A Guide to Professional Conduct. By Robert
Saundby, M.D.Edin. Second Edition, enlarged and rewritten.
Pp. 144. Price 7s. 0d. net.

William Heinemann (London).

The Prolongation of Life. By Elie Metchnikoff. English
Translation. Edited by P. Chalmers Mitchell, M.A., D.Sc.,
etc., etc. Pp. 343. Price 12s. 6d. net.

Homoeopathic Publishing Co. (London).

The Enthusiasm of Homoeopathy. With the Story of a. Great.
Enthusiast. By John H. Clarke, M.D. Reprinted from the
Journal of the British Homoeopathic Society, January, 1907.
Pp. 51.

Hexbt Kimpton (London).

Blood Examination and its Value in Tropical Disease. By
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233 Romford Road, Forest Gate, E.

Christian Science denies the existenoe of illness, but the
.report in the " Christian Science Sentinsl ” of a meeting at
Dixon, Illinois, is headed Dixon, III.— Star.

POISONOUS ENAMEL IN RECEPTACLES FOR FOOD.

A special report has been issued by the Home Offloe on
?the coating of metal with lead or a mixture it lead and tin.
It deals with the effects of employment in the enamelling of
metals and in tinning processes. It recommends that the addi¬
tion of lead to the oovering mixture in the tinning of iron and
metal hollow-ware should be prohibited. Prohibition meets
among other things the dangers such as that common tinned
utensils may constitute a danger to the consumer. After treat¬
ing of precautions, the application of exhaust ventilation, and
other points, the report submits a draft of proposed regulations
whioh define the duties of both employers and persons employed.

R. A.—We shall be happy to publish a letter on the subject
if you will write one and keep it within moderate bounds as
to the length and tone. Wo oan only take general responsibility
.under the circumstances, and give yon the opportunity of reply¬
ing if you think your position has not been fairly represented.

M. D. Black.—W e are sorry not to be able to do as you
wish, but you will admit surely That it is reasonable. We really
cannot write to the gentleman in question and remonstrate,
however heinous his conduct. It may be a matter for the
■General Medioal Council, the Medical Defenoe Union or some
suoh body; but why for us?

Mb. H. Morton.—T he populations of the five cities referred to, a
given officially by the Registrar-General, are:—Birmingham, 553,165s
Leeds, 470,268; Manchester, 643,148; Liverpool, 746,144; Sheffield:
455,563. Of these, during the month of October, Liverpool had the,
highest death-rate, closely pressed by Sheffield.

LAST WORDS OF MEDIOAL MEN.

" 8. W." sends to the W eetmintter Gazette, on “ The Last
Words of Medical Men,” the following historical instance of a
patient’s last words to his medical man:—M. de Oalonne, one of
the last Ministers of Finanoe of Louis XVI., in his last illness
asked for a pencil, and wrote down the following words for the
benefit of the doctor who attended him: “ Dooteur, vous m'aver
assassin^! Si veus 6tes un honntte homme, renon^ex, A la mede-
cine pour jamais.”

jj&eetings of the $orieli*e, VectareB, &c.

Wednesday, November 13th.

Medical Graduates’ College and Polyclinic (23 Chenies
Street, W.C.).—4 p.m.: Mr. M. White: Clinique. (Surgical.)
6.15 pjn.: Lecture: Mr. D. Armour: Head Injuries.

North-East London Post-Graduate College (Prince of
Wales's General Hospital, Tottenham, N.).—Clinique* : —
2.90 p.m.: Medical Out-patient (Dr. Whipham); Dermatological
(Dr. G. N. Meachen); Ophthalmologioal (Mr. R. P. Brooks).
4.30 p.m.: Demonstration:—Mr. Brooks: Selected Eye Cases.

Thursdat, Notembxb 14th.

Rotal Society of Medicine (Obstetrical and Gynecological
8ection) (20 Hanover Square, W ).—7.45 p.m.: Specimens will be
shown by the President (Dr. H. Spencer). Mr. A. Doran. Dr.
Fairbairn, Dr. Macnaughton-Jones, and Dr. C. H. Roberts.
Paper:—Dr. T. Wilson: Pubiotomy (with illustrative oases).

United Services Medical Society (Royal Army Medical Col¬
lege, Millbank, 8.W.).—8.30 p.m.: Paper.—Major W. 8. Harri¬
son, R.A.M.C.: Enterio Fever in War.

Medical Graduates' College and Poltclinic (22 Chenies
Street, W.C).—4 p.m.: Mr. Hutchinson: Clinique. (8urgical.)

Nov. 13, 1907.

ntL£' n M. L ^ cture ; Mr - F. B. Jewett: Carcinoma of th.
Treatment!** Imp0rtanoe of *"*7 gnosis; Symptoms and
North-East London Post-Graduate College (Prince of
WWl* n emr S 1 Tottenham, N.).—8.30 p.m!: Gynseoo-

Operations (Dr. Gilee). Cliniques: —Medioal Ont-nxti#mt
Sulcal Out-patient ’(M?/ C.r^ST I Eat^
B2L» P ,- m - : “ ed '? al Inpatient (Dr. G. P. Chappell). 5 p.m!:
Demonstration at the Mount Vernon Hospital, Hampstead

N.W.:- D r. j.E. Squire: Selected Chest Ca«i. P

|£arefTc S ).S - ^ XesS^oTure™^ «££

II- Tuberculosis

Hospital for 8ice Childben (Gt. Ormond Street, W.C.)—
4 p.m.: Lecture:—Dr. Oolmau: Splenio Enlargement. '

Friday, November 15th.

r^' E JL° a. T l HE g STCDr ™ Childben (11 Chsndos

Street, Cavendish Square, W.).—4.30 p.m.: Oases will be shown
R CI “ tter ^ uok ' Dr - G. Carpenter, Dr. F. J. Poynton. Mr. J.
R. Howard, Mr. R. Warren, and others. Paper:—Dr. G. H
Years 0886 °* Ilheumatio Hyperpyrexia in a Child aged Six

Ubaduates* ^College and Polyclinic (28 Chenies
Street, W.C.).—4 p.m.: Dr. J. Horne: Clinique. (Throat.)

North-East London Post-Graduate Collboe (Prince of
Wales s General Hospital, Tottenham, N.).—10 a.m.: Clinique-
Surgical Outpatient (Mr. H. Evans). 8.30 p.m.: Surgical opera-
AnMi ( v r ’ ^ dmu " d9 )- Cliniques:—Medioal Out-patient (Dr.
LesUe) Mr ' Brooks )- 3 P- m - : Medioal In-patient (Dr. M.

Great Northern Central Hospital (Holloway Road, N) —
3 p.m. Clinical Lecture:—Mr. G. Coats: Some Points in the
Diagnosis and Treatment of Conjunctivitis.

Central London Throat and Ear Hospital (Gray’s Inn
Road, W.C.).—3.45 p.m.: Demonstration:—Dr. D. McKenzie
Thyroid and Cervioal Region.

J^ointmenid.

Luard, H. B., M.B., B.O., D.P.H.Cantab., Certifying 8urgeon
under the Factory and Workshop Act for the' Osmotherlev
District of the county of York.

Lupton, Harry, M.R.C.8., L.R.C.P.Lond., Consulting Surgeon
to the Stratford-on-Avon Hospital.

Macdonald, Gilbert Reginald, L.R.O.P., L.R.C.S.Irel„ Medi¬
oal Officer for the Fourth Distriot by the Wellington (Somer¬
set) Board of Guardians.

Renton, J. Mill, M.B., Ch.B.Glasg., Extra Dispensary Surgeon
to the Western Infirmary, Glasgow.

Roy, J. Allan C., M.B., Ch.B.,Viot., Assistant Medical Officer
at the Royal Asylum, Cheadle.

Uarattats.

Ayr Distriot Lunacy Board—Medial Superintendent. Salary.
£500 per annum, with house (unfurnished), fuel, light, water,
vegetables, and washing. Applications to Mr. J. E. Shaw,
County Buildings, Ayr.

Glasgow Distriot Asylum, Woodilee, Lenzie.—Junior Assistant
Medical Offloer. Salary, £125 per annum, board, lodging,
washing, eto. Applications to Dr. Marr, Medioal Superin¬
tendent.

Haverfordwest Rural Distriot Council.—Medical Offioer of Health.
Salary, £150 per annum, inclusive of all expenses. Applica¬
tions to John E. H. Rogers, Clerk, 7, Dew Street, Haverford¬
west.

Newcastle-on-Tyne Dispensary.—Visiting Medioal Assistant.

Salary, £160. Applications to the Honorary Secretary, Joseph
Carr, Chartered Accountant, 86, Mosley Street, Newcastle-on-
Tyne.

Peck ham House Asylum, London, S.E.—Junior Assistant Medical
Offloer. Salary, £150 per annum. Applications to the Resi¬
dent Licensee. . ,

Parish of St. Giles, Camberwell—Assistant Medioal Offioer for
their Infirmary, Brunswiok 8quare, Camberwell. 8alary, £140
per annum, with apartments, board, and washing. Applica¬
tions to Charles 8. Stevens, Clerk to the Guardians, Guar¬
dians' Offloes, 29, Peckham Road, S.E.

girths.

Corner.— On Nov. 9th, at 37, Harley Street, London. W., the
wife of Edwd. M. Corner M.C., F.R.C.S^ of a daughter.

Simson.— On Nov. 8th, at 35, Cheyne Court, Chelsea, the wife of
Captain Harold Simson, R.A.M.C., of a son. ,

Sfeirs —On Nov. 7th, at The Cedars, Diss, Norfolk, to Dr. and
Mrs. H. Meredith Speire—a daughter.

White —On Nov. 2nd, at Kasaull, i unjab, to the Wife of Capt. F
Norman White, M.D, 1. M.B—a son. (B y oable).

iBarriagea.

Dknst-Hood— On Nov. 7th, at St. Anselm’s Church, Davie*

Street, Edward Henry Marland. second son of the late M"»rd

Maynard Denny, of 11, Bryanston ^ UR "’ L °’i do " y 0 ^md..

Mrs. Key sell, Ware, Herts.

Digitized by LaOOQLe

The Medical Press and Circular.

SALUS POPULI SUPREMA LEX.*

Vol. CXXXV. WEDNESDAY, NOV. 20, 1907. No. 21

Notes and Comments.

A lawsuit in Sydney has raised an
Property in interesting and discomforting ques-
Museum tion for pathologists. It is a well-
Specimeng. known maxim of the British law
that there is no property in a corpse,
thoug»h as a matter of fact public opinion, which
is stronger than any law, would not for a moment
allow anyone but the relatives of a deceased person
to have possession of his body. Now, if there is no
property in a thing, presumably there can be no
property in, and consequently no theft of, its parts.
There is then no harm in the removal of diseased
portions of a body for museum specimens, and
equally—and this is the discriminating point—there
is no harm in anyone walking off with these speci¬
mens whenever they choose. Does a tumour be¬
come property when it is taken from a dead body
and placed in a jar of formalin? Apparently not,
for in the case in question the plaintiff sued the
police for detaining a jar containing a dicephalous
child, which his father had bought twenty-two
years previously for £ 27 , and the judge non-suited
him on the ground that there could be no property-
in a corpse. It is not pleasant to think than an
enterprising stranger might remove John Hunter’s
Collection from the College of Surgeons’ Museum,
and that all the police in Bow Street could not raise
a finger to stop him. But it might be possible to
prosecute a scientific enthusiast of such a kind for
stealing the glass jars and spirit, and even for
damage to the jars. So that without mentioning
the specimen within, possession might be recovered
of the jar, from which the specimen could not be
removed without causing malicious injury.

Homoeopaths

Again.

Our esteemed contemporary, the
British Homoeopathic Review, is,
we are sorry to say, pained by some
comments of ours on the proceed¬
ings of the homoeopathic meeting at
Harrogate last summer. The ideas expressed at
that gathering, though well known, it appears, to
homoeopaths for nearly a century, are “ too novel
and revolutionary for our grandmotherly medical
journals.” But, dense as is our own ignorance, we
are told that there-is one other journal which lags
even behind us in knowledge of the truth about
infinitesimals. Which journal that is we are not
told, but says the editor, “ our readers will have no
difficulty in guessing.” So that, after all, we are
not as grandmotherly as we might be. Let us
hope that as time goes on we may attain to the
enviable position of this more mature progenitress.
At present we can only envy its riper experience.
The British Homoeopathic Review thinks us very
blind not to see the value of the minute doses of
silica and other drugs in spa waters, but it is
chiefly hurt that we should have treated lightly Dr.

Proctor’s “ thoughtful remarks ” about the com¬
bination of mystery and truth in homoeopathy. Is
there not mystery in all laws ? “ Can those who
ridicule us because we cannot explain the law
of similars, explain the action of the law of gravity ?
Why do bodies attract one another with a force
inversely proportional to the square of their distances
and directly proportional to their masses? Is there
not mystery in this, and is not this a mystery that
has led to everlasting discussion amongst astro¬
nomers? Is, then, this mystery a fit object for the
laughter of our orthodox contemporary? ”

We are not sure that we understand
v . what is intended by “ this mystery ”

„ *”°“ 8 in the last sentence, but if either
Myitenes. the j aw c f g rav ity or the laws
of the attraction of bodies in space
be meant, we hasten to assure our contemporary
that from our school days upwards none of
them ever suggested one merry thought. Life
would have been more joyous if they had. We
are not amused at mysteries qud mysteries. For
some, such as the mystery of holiness, we have the
greatest respect; for others, such as the Druce
mystery, we have but little. The greatest mystery
about homceopathy is that since almost every one
of Hahnemann’s doctrines has by this time been
denied by one or other of his followers, and some
of them, we believe, officially abandoned by all, that
the cult has any cohesive force remaining. But
we have to thank our critic for one graceful conces¬
sion. He quotes our remark that the “everlasting

discussion that rages abut homceopathy.

can lead to no useful result,” and adds, “There is
truth in this.” We are obliged for the admission,
and will endeavour to bear it in mind. Where real
knowledge resides criticism will elucidate it; but
where mystery is the bulk of the stock-an-trade dis¬
cussion is about as useful in clearing it up as letting
off pop-gugs would be in dissipating a London fog.
There always will be eccentric people who prefer
the gloom of the fog to the sunshine of the moun¬
tain, and to them the arcana of homoeopathy are
likely to prove irrestibly attractive.

As an example of the bewildering
Human state of the mind of the true homoeo-
Sacriflce. path, we cannot do better than refer
to Dr. Burford's evidence before the
Royal Commission on Vivisection, which is given
in the same number of the British Homoeopathic
Review. It occupies some twenty-five pages, and
the reader who can deduce from it much more than
that Dr. Burford wishes drugs to be tried on man
rather than on animals, is possessed of greater
subtlety of intellect than ourselves. Dr. Burford,
a homoeopathic practitioner, came before the Com¬
mission as representative of the “ World League of

Digitized by

Google

53® The Medical Press

LEADING ARTICLES.

Nov. 20, 1907.

Opponents of Vivisection," and after having
answered nearly a hundred questions, said that he
could not say whether the views he expressed were
those of the League he came to represent or not!
He believed, however, that they wished the sub¬
jects of experiments with drugs to be men and not
animals. New surgical operations and new
suture material, and so on, he thought, also,
should be tried on man before being tried on
animals. Besides these extraordinary doctrines Dr.
Burford held that experiments on animals had
greatly advanced physiological, pathological, and
diagnostic knowledge and skill, and that though
he would restrict experiments on animals with
drugs to such as had been performed on man
previously, he would not abolish the practice, and
he was not sure whether he would abolish physio¬
logical demonstrations on animals to students.
Moreover, he thought that serumtherapy had been
of great use, and had been discovered by experi¬
ments on animals, and though he could not sug¬
gest how it could have been discovered other¬
wise, he believed there was no reason why it
should not have been found out by homoeopathic
methods. How anyone holding such views can
represent a League of Opponents to Vivisection,
or how he can expect to get serum from animals
except by experiments on animals are points that
take the breath out of the plain man’s body.

w The opposition which the medical

Worcester inspection of school-children will

C.C. and
Medical

meet with if not conducted in
accordance with parents’ wishes is

■ .. uciiivv n mi pai lulo nioiiLS to

napcc on ' forcibly illustrated by an occurrence
at Bromsgrove. The Worcester County Council
have appointed a medical woman to inspect schools
under the Education Committee, and it is alleged
that she visited certain schools, inspected the heads
of the children, and found 70 per cent, of them to
be infected with lice. Cards directing the parents’
attention to the fact and suggesting treatment were
sent home by the children in unsealed envelopes,
it is said. The parents were exceedingly angry,
many of them denied the diagnosis, and one
parent went to his own doctor in the evening and
obtained a certificate saying the child’s head was
clean. On the next occasion of the lady’s visit a
hostile demonstration was organised by the
parents. The position was considered at a meet¬
ing of the Bromsgrove Education Committee, and
the following resolution was sent to Worcester :
“That this committee beg to call the attention of
the Education Committee to the fact that con¬
siderable friction has been caused on the occasion
of the inspection by the medical officer at the
schools, and they view with alarm the manner in
-which the examination was conducted, and the
•careless way in which the warning cards were dis¬
tributed.”

Now these proceedings seem to us
Need for to *** P rec 'sely of the ki.nd that
Tact ma - v t * ireaten the medical Inspection
of schools with the unpopularity
that attached itself to compulsory
vaccination. We are not in a position to judge
of the correctness or incorrectness of the state¬
ments made, but it is quite clear that bad feeling
has arisen, and unless the medical inspection of
school-children attracts the gratitude and good-will
of parents in bulk, this most useful provision will
incur odium which may be fatal to it. It is not
necessary to remind British readers that no method
that smacks of autocracy or high-handedness or
want of consideration will ever be acceptable to the
working-classes; indeed, it would be a bad sign if
it were. The question of dirtv heads, as every
medical man knows, is one which raises more in- I

dignation in a poor parent’s breast than anything
else, even when lice are demonstrably present.
On the other hand, if a mistake be made, the
indignation has good basis in fact. Only by the
most tactful methods woukf it be possible to trans¬
form a school containing anything like 70 per cent,
of lousy pupils into a thoroughly clean one; whole¬
sale condemnation at one fell swoop would be likely
to sap all the medical Inspector's influence for good
for ever.

LEADING ARTICLES.

THE RIGHTS OF HOSPITALS IN COMPEN¬
SATION AND OTHER CLAIMS.

That the services of honorary staffs are utilised
in various ways by patients in enforcing claims for
money from employers and from other sources is,
of course, an established fact. We have often com¬
plained of the way in which public bodies like
school boards obtain certificates gratis from the
hospitals as to the fitness or otherwise of scholars
for school attendance. We regard that as an un¬
fair advantage taken of the hospital medical staff
at the expense of their professional brethren out¬
side. The hospitals have only to be firm and
united in the matter and a considerable slice of
legitimate income would be restored to the general
practitioner, or, failing that, a small fee might be
exacted by the hospital authorities for every such
certificate granted by one of their staff. As to the
average club certificate, there is little to be said in
the case of poor patients, although in their case
the document is asked for with the avowed object
of entitling the holder to a more or less substantial
money payment. Another kind of claim, however,
has arisen of late, namely, those of domestic
servants and workpeople under the Workmen’s
Compensation Act. At the present moment there
is no knowing what may be the exact relation
of any injury, trifling or severe, to a future claim.
A mere trivial punctured wound, if sustained in the
course of a labourer’s occupation, may become
septic and lead to prolonged sickness or death. In
such a case the patient may be treated in the
first place at a public hospital, and a certificate
granted stating his disability to work for a
few days on account of the accident. Should the
after-course of affairs be of the untoward nature
above indicated, then the hospital certificate, freely
given in the first instance to help a working man
tide over an apparently trifling emergency, would
assume a vastly different importance as the chief
documentary proof in establishing a claim for two
or three hundreds of pounds sterling. More than
that, a precisely similar train of reasoning applies to
almost all cases of sickness amongst workpeople in
active occupation. The basis of the law of work¬
men’s compensation has been so greatly broadened
that at any moment a great number of maladies
may be asserted to have arisen directly or indirectly
out of a particular occupation. Under these cir¬
cumstances there seems to be good reason for all
medical men engaged in honorary or resident
hospital work to pay some attention to the question
of certificates granted to patients of medical chari¬
ties. Indeed, the subject might well be brought
prominently before the professional bodies which
deal with matters of practical politics. In point of
fact, it is not altogether impossible to imagine that
the medical charities may find on an enquiry that it

,oogi

Nov. 20, 1907.

CURRENT TOPICS.

The Medical Press. 539

would be desirable to refuse sick certificates In any
shape or form. It is tolerably certain that such an
action would to some extent relieve the unfair
hospital competition of which general practitioners
complain. As regards payments from patients to
which the medical charities may be said to have a
moral right, much attention has been drawn to the
point by a recent action of Mr. Justice Darling. In
a case before him in which damages were found
against two motor omnibus companies for personal
injuries caused to a lad, the Judge mentioned
directed that, out of the sum awarded, a certain
amount should be handed to the hospital where the
injured boy was treated. In a letter to the Times,
commenting upon that direction, Mr. Justice Ridley
says :—“ I quite concur with this, and think it
Tight and proper; but I have often thought when
trying cases of this kind, where injuries caused by
the negligence of defendants have been treated
free of expense to them in a hospital (instead of by
a doctor for whose charges they would have had to
pay), that it would not be unfair if the Court had
power to add to the damages such a sum as they
might, within certain limits, assess as a contribu¬
tion to the hospital proper to be paid by those who
•did the wrong.” Judge Ridley asks if it would
not be possible for Parliament to find time for
the passing of such a measure, short, benefioial,
and non-political. Viewed In the light of past
history, we fear no British Government is likely to
favour such a proposal for generations to come.
Even the present Government, which claims to be
liberal and progressive in its social legislation, has
recently saddled the medical profession with another
•gratuitous duty, to be discharged under pains and
penalties, under the Notification of Births Act. On
all hands it is evident that the economic relations
of the hospitals, the public and the medical pro¬
fession stand in urgent need of revision.

CURRENT TOPICS.

The Bristol Infirmary Dispute.

Whatever may be the upshot of the stand taken
by the honorary medical staff of the Bristol Royal
Infirmary against the attempt of the Board to
interfere with their private affairs, it is encouraging
to see the loyalty with which the local medical
profession has rallied to their support. They have
issued a temperate, clear ajid dignified address to
the governors of the charity in question. They
" view with dismay ” the rule curtailing the holding
of outside appointments and restricting the private
practice of the honorary staff. If enforced, they say
such a rule will inevitably lead to the resignation
of the entire staff, and the disaster to this noble
institution will be final and irremediable. They
urge the governors to vote “against this most
objectionable rule in its entirety.” There are no
fewer than 226 signatures to this document. It is
Si most gratifying sign of the times to see medical
men coming forward collectively in defence of
4 heir reasonable rights and privileges. In the
present instance their united action makes it prac¬
tically impossible for the Board, supposing them
to be stiffnecked and strong enough to carry their
obnoxious rule, to replace the medical staff. It is
Inconceivable that any medical man would have the
temerity to apply for one of the vacant posts in face
of such a manifesto signed practically by the whole
local profession.

Earth Fertilisation by Seed Inoculation.

A discovery of vast potentiality has been an¬
nounced by Dr. Bottomley, Professor of Botany at
King’s College, London. It is nothing less than
that of the fertilisation of soil by inoculating seed
with a nitrogen-producing microbe. The possi¬
bility of turning barren land into fertile fields
thereby afforded is certainly alluring, for it satisfies
a scientific dream that has long haunted the mind
of mankind. The present announcement bears all
the air of authenticity and of well-ascertained
results. It is stated, for instance, that a small
holder near Gloucester “ inoculated " a quarter of
an acre of peas, from which he obtained 33J px>ts of
peas, selling at £7 18s. 9d., as against .14 p>ots,
selling at £2 5s. 6d. from a similar area dressed in
the ordinary way with 1 cwt. of superphosphates
and sulphate of potash. It is further said that
Mr. W. T. Stead, the well-known journalist, has
acquired the exclusive right of handling the new
material for twelve months from January next, the
same being supplied to him at the rate of 5s. a
gallon. Mr. Stead’s avowed purpose is not to make
a fortune out of the monopoly, but to confer an
enormous boon up>on the United Kingdom by
bringing many millions of acres of barren
land into cultivation. The Americans have a
corresponding but greatly inferior article, the
price of which is thirty shillings per gallon.
Mr. Stead’s price is six shillings, of which
half will go to Dr. Bottomley and the other
half to advertising and pushing the sale of the
stuff. If there be any surplus to dispjose of, he
proposes to endow a professorship for biological
and botanical research. It is to be hoped that there
is a more practical and substantial foundation for
this “ discovery ” than for that announced from the
Continent a year or two ago, whereby agriculture
was to be revolutionised all over the world. Dr.
Bottomley’s researches appear to have been founded
on the original observations of Hellneght, in 1886,
upx>n the relation of bacteria to the roots of
leguminous plants.

A Sign of the Times.

If there be any truth in the proverb that coming
events cast their shadows before them, then there
is something of significance in the proposal of the
medical staff of the Montrose Royal Infirmary to
charge fees to certain patients in that institution.
This is indeed taking the bull by the horns, and
although the suggestion was not adopted by the
management, it nevertheless gave rise to consider¬
able discussion. The staff appear to have confined
their proposal to private patients sent by them¬
selves to the hospital. As a general rule, the esta¬
blished ethical usage in the medical profession is
scrupulously to avoid anything remotely suggesting
a fee to hospital patients, and it is not a little
startling to hear a plan for systematic payment
coming from a medical quarter. The objections to
such a course can hardly be otherwise than, abstract
and sentimental. If the whole matter be resolved
into a logical analysis, one of the fundamental p>oints
will be the definition of a hospital, and whether a
medical charity is founded for the benefit of those
who can pay fees. If the hospitals attract and
foster patients who can pay fees, are not medical
men entitled to be paid for their services? On
what grounds do the hospitals use funds collected

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54° The Medical Press.

CURRENT TOPICS.

Nov. 20, 1907.

for the poor for the purpose of relieving the well-
to-do? These questions have long vexed the mind
of the general practitioner, but Montrose has pre¬
sented them for the first time in concrete form.

Sylvester’s Method v. Schafer’s.

Some very interesting experiments on the com¬
parative value of Dr. Sylvester’s method for resus¬
citation of the apparently drowned, and that
recently introduced by Professor Schafer, were made
at the London Hospital last week. Mr. W. M.
Fletcher, of Trinity College, Cambridge, lectured
at that institution on behalf of the Royal Life-
Saving Society, and thereby attracted the attention
of the staff and students to the new method. It
was accordingly arranged that a trial should be
made of the tw r o plans, several students offering
themselves as subjects for the experiment. The
tests were carried out under the supervision of
Dr. Keith and Dr. Leonard Hill in one of the small
operating theatres. The experimented had his face
covered with an india-rubber mask to which was
attached an india-rubber tube communicating with
a spirometer. The experiments consisted of two
minutes’ successive trial of the two methods, the
student endeavouring not to breathe voluntarily
during the ordeal. No marked difference was ob¬
tained by the test, but it was admitted to be
unsatisfactory because of the difficulty of excluding
voluntary efforts. Consequently .it was decided to
anaesthetise a volunteer and make the experiment
again. Although the conditions were, of course,
very different from those obtaining in a person
apparently drowned, the result showed a marked
difference in favour of the older method. The
respiratory exchange shown by Sylvester’s plan
mounted to between 500 to 600 cubic centimetres,
whilst under Schafer’s it was not more than 300 to
400, and sometimes only 200. Although Schafer’s
method is certainly more convenient in many ways,
and less exhausting to the operator, it would seem
that it is not so effective in filling the lungs with
air and conducting the exchange.

Dakhyl v. Labouchere.

The echoes of the Dakhyl v. Labouchere case
have not been so loud and frequent as the extensive
reports given to the proceedings by most of the
newspapers seemed to presage. Truth is naturally
pleased, but it treats its opponent in a very mag¬
nanimous manner, even expressing sympathy that
he has been put to so much expense. We have
already congratulated our contemporary, but we
cannot help reverting to the commendable persis¬
tency with which Mr. Labouchere refused to take
the first, and obviously ridiculous, verdict against
him, and fought the case through to a finish. No
one will lose faith in a quack of the rankest species
if denounced merely in a medical paper, and Mr.
Labouchere has silenced a number of the most
blatant of them In the course of his journalistic
career. Indeed, the very rules by which medicine
seeks to control boastful pretenders in its own ranks
are resented by the public. We are specially glad,
then, to call attention to one sentence in Truth's
article on the subject. It runs: “My observations
on the Drouet Institute, as well as on Dr. Dakhyl,
were prompted by regard for the interest of the
public, not of the medical profession, but in the
main the two interests are identical.” [The italics
are our own.] That point we have maintained over

and over again, but the public will never admit it.
Such articles as appeared in other journals dealt
very gingerly with the topic. It is a delicate one for
most of them, as the main advertisement revenue
of most is derived from fraudulent quack announce¬
ments. We fancy that many journals anticipated
a repetition of the first verdict, and would have been
glad to enlarge on the exclusiveness of the pro¬
fession in having no truck with men of the Dakhyl
type. As the verdict was against that Individual
they were content to evaporate into generalities
about the exact definition of a quack, and similar
banalities. It is a shocking thing to reflect that
nearly the whole of the great development of
journalistic enterprise of the last thirty years is
built upon the most pernicious form of extorting
money from the poor, namely, by gross lying to
them about their health on which their livelihood
depends.

A Round Robin.

That the Midwives Act is running a chequered
career is being demonstrated almost every week.
One of the most serious attacks on its administration
was announced a few days ago by Mr. Coroner
Baxter at a Poplar inquest. The investigation was
concerned with a child who died a few hours after
birth. The Coroner mentioned the fact that he had
received a round robin from medical men, refusing
to attend cases where there had been a midwife or
“ handy woman.” It is impossible to avoid a feel¬
ing of sympathy with qualified medical men who
decline to be made the instruments of deliverance
from the Nemesis of unskilled or partially-skilled
midwifery. The Legislature appears to have
reckoned without their host in passing the Mid¬
wives Bill. The medical practitioner, against
whom they were pitting an ignoble rival, was ex¬
pected to take his part in the programme without
demur. If he follows to any great extent the
example of the Poplar practitioners, the Midwives
Act will speedily become a dead letter, for the public
will have to choose between medical men and mid¬
wives. There will be no half-way house if the
medical profession make up their mind to unite
against this insidious form of unqualified competi¬
tion.

Sanitation in Irish Schools.

Some appalling information as to the condition
of the buildings of the primary schools was given the
other day in a public speech by Mr. Starkie, the
Resident Commissioner of National Education and
official head of the primary school system in Ire¬
land. Everyone must agree in the view that it is
of the utmost importance to the health of the nation
that the schooling of the young should take place
under proper sanitary conditions—that the school
buildings should be clean, bright and airy, and that
the children should learn something of hygiene, not
merely from perfunctory primers, but from practical
example. The Resident Commissioner, however—
and he ought to know—is reported to have said :
“They saw in the schools insufficient floor space,
insufficient heating, insufficient class-rooms, and no
means of cleanliness such as the simple form of
lavatory. One of the inspectors, reporting as to a
school in Ballymacarrett, Belfast, stated that on the
day of inspection there were 401 pupils crowded
on a floor space intended only for 209. There
were 61 first standard pupils in a room 14 by 9i

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Digit

Nov. 20, 1907.

PERSONAL.

The Medical Press 54 1

feet, or 133 square feet in all. In another room
there was if square feet for each unit. Thus
the Belfast class-room was not as bad as the Black
Hole of Calcutta by one quarter of a foot for each
unit.” We understand that attendance at school
is compulsory in Belfast. It is hardly necessary to
comment on these scandalous facts. The cruelty
of compelling children to herd together in this
fashion for some five hours a day is only equalled
by its folly. Education is supposed to be given for
the advantage of the child. In what possible way
can a child be benefited by instruction given under
such conditions at the expense of the health of its
life-time? At no period of life are hygienic condi¬
tions more necessary than in childhood. It would
be out of comparison better to let children grow up
unable to read, write, or cipher than attempt to
teach them under the conditions that obtain in

Belfast. --

The Dublin Hospitals and Tuberculosis.

A step of considerable importance has been taken
by Her Excellency the Countess of Aberdeen in
endeavouring to establish special dispensaries for
consumption in Dublin. At present there is no
special dispensary for consumption, and tuberculous
patients attend the Poor-law dispensaries and
dispensaries of the clinical hospitals along with
other patients. Her Excellency as President of
the Women’s National Health Association, has
written to the several hospitals of Dublin, asking
each of them to consider the possibility of starting,
on one day in the week, a special dispensary for
tuberculous patients. By this means, there would
be on each dav of the week a special dispensary
within reach of any part of the city. If this were
done, and a record of the patients kept, the
Women’s National Health Association would, on
its part, guarantee to send visitors to the patients’
homes who would give instructions as to the means
to be adopted to prevent the spread of the disease.
The various hospital boards have the matter at
present under discussion, and we are unable to say
at what decision they will arrive. It is probable
that in the first instance a conference representing
the various hospitals will be held. The plan is in
many ways a good one, and should add little to
the expense of running the existing out-patient
departments, though it is to be remembered that
under present circumstances the chance of infection
being spread by allowing tuberculous and other
patients to attend the same dispensaries is slight.
An alternative scheme, but one probably more ex¬
pensive, would be to establish a central out¬
patient department, which might be worked in
connection with the Royal National Hospital for
Consumption.

Bob Sawyer Redivivus in Paris.

The medical student of to-day is a being far
removed from the days of Albert Smith or Dickens.
He is no longer the rollicking, rowdy trifler with
snatches of work, but has become a serious, sober,
hard-working lad, with brief intervals devoted to
physical exercise. Now and then, it is true, there
are scenes of disorder at some of our universities,
chiefly in those north of the Tweed, at opening
lectures and rectorial addresses. Collisions with
the police, which used to take place occasionally at
snowballing fights or torchlight processions, have
not been heard much of lately. In Paris, however,
the spirit of Bob Sawyer appears to linger. Two
university professors appointed from the town of
Nantes did not meet with their approval, and they
proceeded to pelt them with tomatoes, eggs, and
stale vegetables on their first appearance in the
lecture-room. Outside, the mob of students were
encountered bv the police, who headed off the ring¬
leaders, and thereby promptly quelled the disorder.

The Paris University authorities have adopted the
drastic step of closing the faculty until the end of
the year. An exception is made in the case of
students who, under ordinary circumstances, would
have graduated before December 1st. The reason
of this is that failure to pass within the prescribed
date would entail an extra year of military service.
The students demanded professors from the Paris
schools, and resented those from the provinces.

PERSONAL.

H.I.H the Kaiserin visited the German Hospital
at Dalston on November 14th, and conversed with
some of the patients.

Her Royai. Highness the Duchess of Albany
opens the Infants’ Hospital, Vincent Square, West¬
minster, to-day (Wednesday), at 3 p.m.

Dr. Ironside Bruce has been appointed Radio¬
grapher to Charing Cross Hospital, in place of Dr.
Mackenzie Davidson (resigned).

Principal Donald MacAlister will preside at the
session of the General Medical Council which opens on
Tuesday next at 2 p.m.

Dr. Arthur E. Boycott, Fellow of Brasenose
College, Oxford, has been awarded the Radcliffe Prize
for 1907. Dr. A. G. Gibson received honourable

mention. -

Mr. Haffkine and Dr. Ashburton Thompson
will read papers on “ Plague ” at the Epidemiological
Section, of the Royal Society of Medicine on December

2nd at 8.30 p.m. -

Dr. A. H. Spurrier has been granted the Royal per¬
mission to wear the insignia of the Second-Class Order
of the Brilliant Star of Zanzibar conferred on him by
the Sultan of Zanzibar.

A former President of the Lower House of the
Austrian Reichsrath, Count Vetter von der Lille, who
is over 50 years of age, has recently graduated as M.D.
at the University of Vienna.

Dr. James Little, Regius Professor of Physic in
the University Of Dublin, has been appointed by the
Crown to be a member of the General Medical Council
for a further period of five years.

Sir James Diggf.s La Touche, K.C.S.I., and Sir
Shirley F. Murphy will be the guests of the Irish
Medical Schools’ and Graduates’ Association at their
dinner on Wednesday, November 27th, at the Hotel
Cecil, London, W.C.

Dr. J. R. Bradford has been appointed Examiner
in Medicine at Oxford: Professor Howard Marsh,
Examiner in Surgery; Dr. J. W. Eden, Examiner in
Obstetrics; and Dr. T. M. Legge in Forensic Medicine
and Public Health.

Dr. Koch, who has returned to Berlin after an
absence of 18 months in German East Africa, has
been promoted to the rank of Wirklicher Geheimer
Rath, with the title of Excellency, in recognition of
his valuable researches into the causes of the sleeping

sickness. -

Mr. Rickman J. Godlee, F.R.C.S., Surgeon-in-
Ordinary to H.M. the King, Surgeon to University
College Hospital, will deliver the Bradshaw Lecture
at the Royal College of Surgeons, England, on
December 5th, the subject being, “The Prognosis and
Treatment of Tubercular Disease of the Genito-
Lfrinary Organs.” -

j The period of office of Mr. Clinton T. Dent,

' F.R.C.S., as a member of the Court of Examiners,

1 Royal College of Surgeons of England, having expired,
i the Council announce the vacancy in our columns
' to-day. Mr. Dent, however, is eligible, and will, we
I understand, offer himself for re-election.

y Google

Digits

54 2 The Medical Press.

CLINICAL LECTURE.

Nov. 20, 1907.

A Clinical Lecture

ON

A REFERENCE TO SOME TUBERCULAR DISEASES OF THE KNEE JOINT
AND TO THE TREATMENT OF THE SYNOVIAL CAVITIES.

By R. L. SWAN, FJLCSX,

Surgeon to Dr. Steevens' Hospital and to the Orthopaedic Hospital, Dublin.

Gentlemen, —You have seen in this hospital a
number of cases of disease of the knee-joint, differ¬
ing in their onset; in their appearance; and their
clinical symptoms, to which the generic term
“ tubercular ” was applied. Many of those, although
springing from the same aetiol’ogical factor, were
as varied, as regards the tissues involved and the
appropriate treatment, as if in each case a different
disease existed, la the limited time at my disposal
1 shall only touch on the outskirts of this subject,
in an effort to illustrate some diagnostic features in
tubercular disease of the knee, and, so far as is
yet known, the most successful methods of dealing
with some of its forms.

For practical purposes, we may broadly divide
tubercular disease of this region into two varieties :
(1) Of the bones; (2) of the synovial membrane,
recognising the fact that as the focus, wherever
originally placed, has a progressive tendency, both
structures may become involved from disease of
either.

There are three situations towards which the
osseous focus may extend :—

1. —Outside the limits of the synovial membrane.

2. —At the point of reflection of that tissue.

3. —Towards the articular surface, and by absorp¬
tion of the cartilage, directly infecting the joint.

1. The local signs will be marked. There will
be pain and lameness, and an abscess will develop.
The joint, however, although sometimes showing
effusion, may altogether escape infection. In such
cases close attention to surgical details, especially
to drainage, and the use of bactericidal injections
are of great value.

2. Here the synovial membrane becomes
thickened at the point of infection. This con¬
dition spreads through its entire extent, and abscess
at the point of primary infection is not infrequent.

3. The train of symptoms following direct infec¬
tion of the joint through the eruption of a softened
tubercular focus through the cartilage are acute.
There is severe pain, and the entire joint is soon
infected.

The frequency with which tubercular disease
originates in the synovial membrane and in the
bone is somewhat greater In the first (351 synovial
and 281 osseous—Konig). In the 281 cases re¬
ferred to the patella was affected in 33, the femur
in 97, the tibia in 107, and several bones 48.
Primary foci in the patella may soften and burst
externally, but frequently cause infection of the
Joint. Granulation foci may be met with near the
femoral condyles, and most frequently the internal,
which is also the seat of extensive tubercular lesions
in children. These do not infect the joints so fre¬
quently as in adults, but develop toward the sur¬
face. "Large tubercular deposits are often met with
in the head of the tibia, sometimes softened and
large enough to merit the name of caseous abscess.
Tubercular foci may remain latent in bone for a
prolonged period, and may undergo change into a
calcified and desiccated tissue. During the period
of primarv deposition the symptoms are vague.
There is little or no pain; there is a feeling of
fatigue, and sometimes an effusion into the joint,

which subsides when rest is enforced.

If the fortunate result of calcification of the focus
occurs, there are no further symptoms.

I shall not here allude at all to the treatment of
knee joint disease associated with osseous lesions.

I have nothing new to mention, and you have con¬
stant opportunities of seeing the application of
erasion, excision, or general surgical principles to
those cases.

Hydrops Tuberculosis .—Chronic synovitis, scro¬
fulous synovitis, recurrent synovitis of the older
authors is frequently met with. It is most common
in early youth and young adults, but may be seen
in persons of middle age. Its origin may be
ascribed to some trivial injury. The joint may be
enormously distended, and the synovial membrane
has been known to rupture spontaneously
(NYlaton) : “ Under the influence of rest and treat¬
ment, the swelling usually subsides, to reappear
when walking is resumed.”

Degenerative changes in the diseased synovial
membrane usually occur as time goes on. A
gradually increasing thickness is perceived, some
pain after walking is felt, and occasionally a ten¬
dency in certain movements to locking of the joint.
In such cases it will be found that masses of fibrin
have been detached from the synovial membrane,
and have become moulded by the movements of
the joint into pyriform masses (melon seed bodies),
floating in a grey or semi-opaque fluid mixed with
shreds and flocculi of fibrin, a crepitating sensation
being imparted to the fingers on examining the
joint from .the contact of those masses.

In some cases the synovial membrane is seen to
be studded with polypoidal sessile masses, red on
Ihe surface, and secreting a sanious fluid; some¬
times on removal of the fluid by rest it is possible
to discern those masses, especially in the supra¬
patellar pouch.

Tubercular empyema of the knee is sub-acute in
its nature, and is met with in persons of low
vitality showing other signs of tuberculosis. An
acute form of empyema is met with in young
children, accompanied by pain and pyrexia. The
synovial membrane is said to show miliar)' tuber¬
culosis.

Synovial Fungus (White Swelling ).—Those cases
are happilv not now so often seen, or only in cases
(usually the children of the very poor) who have
been neglected. An advanced condition of disease
exists, it mav either follow primary hvdrops, or
commence with initial signs of synovial thickening.
There is generally pain referred to the tibia or the
centre of the joint. The pain may be intermittent,
and is mostly felt at night. The synovial membrane
progressively thickens. The knee attains a large
size. The skin is shining, with blue veins ramify¬
ing on it. Later on the cartilages become involved,
and suppuration occurs.

It is in disease of the synovial membrane that we
may hope to restore functional usefulness to the
joint in many cases.

Several methods have been adopted.

1st.—Most surgeons recommend that the flexed
position usually existing should at first be rectified
by extension, followed by prolonged fixation for 12
or 18 months.

Digitized by GoOgle

Nov. 20, 1907.

ORIGINAL PAPERS.

The Medical Press. 543

2nd.—Venous congestion by Bier’s method.

3rd.—Injections of iodoform glycerine into the
joint. It may be remarked that the first method
does not aim at functional restoration of the joint,
and owing to the time involved is not applicable to
the poor.

With regard to Bier’s method and iodoform
glycerine injections, the results are not satisfying.
Evidence in the subject shows in some cases im¬
provements, in others none.

In the year 1904 I read a paper at the Surgical
.Section of the Royal Academy of Medicine, showing
the results of the application of pure carbolic acid
to the interior of the joint in tubercular synovial
•disease, and describing the method of operating.
Since that time I have treated numerous cases
with very satisfactory results. It is applicable not
only to recurrent hydrops, without synovial thicken¬
ing, but also to the fibrinous form of tubercular
-disease, to the vascular and polypoidal disease of
.the synovial membrane, and to synovial empyema.

The only modification in the method of operating
is the position of the incision, originally as de¬
scribed in my paper of 1904. I made a transverse
section of the patella. Later on I adopted an in¬
cision of the inner side of the joint, but I have
recently adopted the curved incision of trachea, at
the outside of the joint, and have in some cases
removed a piece of the tibia attached to the liga-
mentum patella, in order that full access to every
part of the joint should be attained.

The restoration of function is usually complete,
and, so far as I have seen, there has been no re¬
lapse. Only a few days ago I received a letter from
a soldier in the Bedfordshire Regiment stationed
at Jhansi, on whom I operated four years ago in
this hospital. He says : “ My knee never gives me
any trouble, and I can march as well as anyone
-else.” The following are a few illustrative cases
R. F., a shopkeeper from the West of Ireland, has
been troubled with his knee for two years. There
'is considerable effusion, with some synovial thicken¬
ing. In September, 1905, I opened the joint and
gave exit to a whey-coloured fluid, with some
shreds and fibrinous masses. The synovial mem¬
brane was roughened, and of an ashy grey colour.

I washed out the joint, removing all the fibrinous
shreds with a sterilised loofah, especially dealing
■with the sub-crureus bursa. Having dried the
surface, from which a small quantity of blood was
now oozing in some places, I applied pure carbolic
acid freely with a stick, and again irrigated the
joint, closing it without drainage. This man re¬
covered perfectly—I saw him about a month ago.
There was no trace of disease. Mr. E. was sent
to me from Kilkenny by my friend Dr. O’Hanlon
of Castlecomer. He had the usual symptoms of
recurrent hydrops, and was in some anxiety about
the possibility of retaining his situation owing to
the frequency of his disablement. His knee had
been affected for three years. When I saw him it
was much swollen and somewhat flexed. Rest in
’bed was followed by subsidence of the swelling,
which returned when walking was resumed. I
advised operation, and with the assistance of Sir
'C. Ball, adopted the plan described above. Six
months later he came in to show his knee, which,
except for the scar of the operation, was indis¬
tinguishable from the other.

Mrs. R. C., a lady, aet. 32, from the South of
’Ireland, accustomed to an active life, has been two
years suffering from her knee. I saw her in
June, 1905, she was then unable to walk for any
•time without pain, and an increase of swelling in
the joint, which was never quite free from effusion.
An irregularly felt thickening of the synovial
membrane was observed, especially in the supra¬
patellar bursa. She suffered some pain at night.
T opened the joint on July 3rd. I found the interior

of the synovial membrane of a purple colour and
studded * with sessile masses resembling purple
grapes. The joint was filled with a red and oily
looking fluid of the consistence of thin gum arabic.
The synovial membrane was thickened and
although apparently vascular, was not really so.
The surface was subjected to a vigorous rubbing
with sterilized loofah, irrigated and carbolic acid
freely applied. In April, 1906, I received a letter
from her husband stating :—“ My wife is better
than she has been for years. She can walk and
ride as well as ever she did, and has no trouble
with her knee.”

J. S., a young man, aet. 23, in broken health,
with scars of tubercular glands in the neck, was
admitted into the Orthopaedic Hospital (October,
1902). The knee showed a uniform swelling, was
flexed and somewhat painful. On passing an
exploring needle into the joint, a fluid resembling
pus was withdrawn. The joint was incised, a large
quantity of this fluid was withdrawn, the cavities
thoroughly washed and rubbed, carbolic acid was
applied, and it was closed without drainage. He
made an uninterrupted recovery, and under the
influence of good food and treatment, his general
health became improved. I saw him some time
ago; his knee showed no trace of disease.

The following condition may be mistaken for
tubercular disease of the'knee :—

1st. Syphilitic guinmata.

2nd. Arthritis deformans.

3rd. Staphylococcus lesions from Brodie’s abcess,
either in tibia or femoral condyles.

4th. Charcot’s disease.

5th. Gonorrhoeal anthritas.

6th. A sarcoma, growing most frequently from
the lower end of the femur.

7th. The non-tubercular form of loose cartilage.

8th. The bleeder’s knee, met with in hemophiles.

Note. —A Clinical Lecture by a well-known teacher
appear! in each number of this journal. The lecture for
newt week will be by Jama Morrieon, M.D Lond., Hon.
Phytician Accoucheur Farringdon Dispensary and Lying-
in Institution. Subject: Lingering Labour; its Causa
and Treatment .”

ORIGINAL PAPERS.

THE ANATOMY OF THE SO-CALLED

UGAMENTUM PECTINATUM IRIDIS

AND ITS BEARING ON THE

PHYSIOLOGY AND PATHOLOGY OF
THE EYE. (a)

By THOMSON HENDERSON, M.D. Ed., Ch.B.

Nottingham.

The author stated that the so-called pectinate
ligament was a part of and belonged to the sclera.
The principle on which it was constructed was
perfectly simple, being exactly the same as that
which obtained in the fibres of the neighbouring
tissue in which it lay, as an open network, composed
of non-sclerosed interlacing fibres, which were in
direct continuation with the circular and longi¬
tudinal bundles of the sclera surrounding the
venous sinus of Schlemm’s canal. The circular
fibres were made out in tangential and transverse
sections of the pectinate ligament, while the longi¬
tudinal fibres were seen in radial sections. The
criterion of a true radial section was that it showed
the anatomical connection and continuation often
suggested, but hitherto never yet demonstrated’ of

( 0 ) Abstract of Paper read before the Ophthalmologleal Society,
November 14th, 1907.

Digitized by G00gk

544 Th e Medical P r ess.

the hyaline layer of the ciliary body with the
posterior limiting layer of the iris. Arising as a
continuation of the innermost lamellae of the
cornea, the pectinate ligament should be divided
into (i) a small outer or scleral portion, where
fibres at the posterior end of Schlemm's canal
became lost in those of the sclera, and (2) an inner
larger or ciliary division, which could be still
further sub-divided into (a) a portion which pierced
the scleral ring to give attachment to the meridional
fibres of the ciliary muscle, (b) a part which passed
internally to the scleral ring to terminate in the
connective tissue stroma of the circular portion of
the ciliary muscle. None of the fibres of the
ligament turned round into the root of the iris, as
was described, but this appearance was the result of
an oblique section and emphasised again the im¬
portance of studying only true radial preparations.

The iris root was attached to the circular bundles
of the ligament at a point just posterior to the
scleral ring, which attachment to the ligament was
quite a different matter to fibres of the ligament
being said to bend round into the iris, which they
did not. He considered that the term ligamentum
pectinatum iridis was thus not only altogether
inappropriate but also wrong and misleading, as in
man it was neither a comb-like structure nor was it
a ligament to the iris. On this account, and
because of its retiform or cribriform structure, and
further, on account of it being a ligament in the
true sense of the word to the two portions of the
ciliary muscle, the term “cribriform ligament of
the ciliary muscle ” was much more appropriate.
This ligament showed a most marked histological
difference in its structure and nature at different
periods of life. In youth it was cellular, while as
age progressed it became more and more fibrosed.
It was this physiological sclerosis in excess that
he considered was the fundamental catisa causatis
of primary glaucoma, in the causation of which
two factors must be separated—the one constant,
the other accessory.

The first and constant factor was sclerosis of the
filtration network and a consequent diminished
outlet.

The second and variable agent was vaso-motor
in nature, and it was this which determined the
acute attack, in which there was super-added to the
first an inflow out of proportion to the available and
already reduced channels of exit from the eyeball.
Viewed in this light, all the phenomena of glau*-
coma, clinical and pathological, could be explained.

A closer study of this sclerosis of this filtration
network gave a clear view of the process of develop¬
ment, and stages of formation of connective tissue,
with definite histological proof that white and elastic
tissue was not a direct conversion of the cell pro¬
toplasm, but was derived indirectly from alteration
and transformation of a homogeneous substance
which was itself the product of cellular activity.
The alveoli of the filtration network were connected
with the lymph spaces of the cornea and sclera,
whose fixed corpuscles were brought into direct
association with the endothelial cells of the anterior
chamber. It was in consequence of this anatomical
continuity that the cornea, by diffusion, received its
nourishment from the aqueous. This fact would
explain a great deal, and would have the utmost
bearing on the pathology of corneal diseases.

A meeting was held in Chester Town Hall on
November 12th for the purpose of promoting a memo¬
rial to the late Dr. Everett Dutton, of Chester, in con¬
nection with the Tropical School of the University of
Liverpool. Dr. Dutton, it will be remembered, died
in the interior of Africa some lime ago while investi¬
gating the cause of sleeping sickness.

Nov. 20, 1907.

PUBIOTOMY. (a)

WITH NOTES OF AN ILLUSTRATIVE CASE.

By THOMAS WILSON, M.D.Lond., F.R.C.S.Eng.,
Obstetric Officer to the General Hospital, Birmingham, andtoibe
In-Patients at the Maternity Hospital.

In the intermediate degrees of pelvic contraction,
when the conjugate diameter measures between 2j and
3$ inches, efforts have continually been made, at least
since the middle of the eighteenth century, to devise
a method of securing a living child without at the
same time increasing the risks of the mother. These
efforts have taken two directions—to enlarge the bony
circle of the pelvis on the one hand, and, on the
other, to procure a smaller child. When the patient
is seen early in pregnancy, the latter object is sought
to be attained by the induction of premature labour,
which was first introduced as an obstetrical procedure
in this country, where it was performed successfully
by Macauley in 1756, and has ever since been regarded
with peculiar favour.

The results of induction of labour in cases of con¬
tracted pelvis have been gratifying so far as the mother
is concerned. Sarwev (Winckel’s Hand buck dtr
Geburtshiilfe, Bd. 3, Tl. 1), in a collection of 2,200
cases in the 15 years from 1890 to 1904, found a
maternal mortality of 32, equal to 1.4 per cent., 13 of
the women having died of puerperal infection. As
regards the child, the results are, as might be expected,
much less satisfactory. In the same series of cases
Sarwey found that 21.8 per cent, of the children were
born dead, and another 15.5 per cent, died before the
mothers were discharged from hospital, so that only
1,380 children, equal to 62.7 per cent, of the whole,
were discharged living. The risks of the first year of
life are greater in premature infants than in those
born at full term, and on this point Sarwey inquired
into the fate of 500 children in his collection who were
discharged living from 12 different institutions. Of
these, 406, equal to 81.2 per cent., were alive at the
end of the first year. I have quoted these figures
because they are the most favourable large statistics
of the results of induction of premature labour that I
have been able to find. It follows from them that
not more than 50 per cent, of the children obtained
by this operation are alive at the end of the first year,
a result that calls for grave consideration, more espe¬
cially at a time when the birth-rate in these islands
shows a continuous and somewhat rapid diminution.

In cases where premature labour is indicated, and
where craniotomy has often to be performed, a safe
and not too difficult method of widening the bony
pelvis has long been sought. For this purpose, division
of the pubic symphysis was first recommended in
France in 1768 by Sigault, who put the operation to a
practical test in 1777. His patient had a rickety pelvis
with a true conjugate diameter of 6.5 cm., and had
previously bome four dead children. Two months
after the operation the patient walked with consider¬
able difficulty, and had a urinary fistula, which never
healed. In the following two years 8 cases were made
known, with the deaths of 4 of the mothers and 7 of
the children. After such experiences symphysiotomy
fell into disrepute until the latter part of last century,
when it began to be recommended again by Morisani
in Naples in 1866 and Pinard in Paris in 1892.

In the five years 1887 to 1892, Morisani operated on
55 cases, with 2 deaths of mothers, equal to 3.6 per
cent., and 4 deaths of children, equal to 7.3 per cent.
Pinard, in 1892 to 1894, performed 49 symphysiotomies,
with 2 deaths of mothers and 5 of infants. Zweifel
until 1899 had done the operation 35 times without a
maternal death ; then in 11 weeks he lost 3 mothers.
His total maternal mortality was thus 6.5 per cent.,
while 4 of the children, equal to 8.7 per cent., died.

In this country symphysiotomy has never been re¬
garded with general favour, and the only paper on the
subject of any practical importance is one by Herman
in the Obstetrical Transactions for 1901, Vol. XLI 1 -.
p. 282, in which the author describes the subcutaneous
method of performing the operation. A sharp teno¬
tomy knife, having a blade an inch long, and one-

(a) Read before the Gynaooloplcal and Obetetric SeoUoa of Ibe
Royal Medical Society, Thursday, November 144b, 1907.

ORIGINAL PAPERS.

d by Google

Nov. 20, 1907.

ORIGINAL PAPERS.

The Medical Phess. 545

eighth of an inch in diameter, is inserted opposite the
middle of the symphysis pubis, and the joint is divided
by cutting first down, then up. The advantages
claimed for this method are simplicity, quickness, 1
small risk of sepsis, insignificant haemorrhage, absence
of a gaping wound, and of subsequent scar. The
only risk at present inseparable from the operation is
considered to be that of injury to the urethra, which |
is likely to happen in excessive separation of the pubic I
bones in cases in which an attempt is made to deliver ’
by symphysiotomy too large a child. In Herman's
paper three cases are described, and four others re¬
ferred to, as having been performed with good results
in the London Hospital.

The apparent simplicity of the operation is attractive,
but on attentive consideration it appears that in the
immediate neighbourhood of the part chosen for divi¬
sion are many structures which it is very desirable to
avoid. The clitoris and its corpora cavernosa can
hardly escape injury, and may be the sources of severe
haemorrhage difficult to control. Behind the symphysis
is a large and important plexus of veins, while the
bladder and urethra are in imminent danger of being
crushed during the delivery of the child, or torn by
the separation of the bones. In practice the operation
has by no means proved to be an easy one, and its
difficulties and dangers have resulted in its being rarely
practised in this country.

In the last few years an attempt has been made,
more particularly in Italy and Germany, to establish
another operation for widening the bony pelvis by
dividing the pubic bone instead of the symphysis. This
procedure appears first to have been recommended by
Champion de Bar le Due and Stoltz at the beginning
of the nineteenth century. According to Zweifel
(Zentralblatt fur Gyntik., 1906, p. 1), Galbiati operated
in 1832 by sawing through the pubic bone on one side,
and in 1841 by sawing through the pubes on both sides,
but the results do not appear to have justified an
extensive use of the operation. In 1893 Gigli recom¬
mended that the pubes should be divided by means
of his saw, which resembles a length of piano wire,
but the operation was not actually employed on the
living subject until five years later, when, in 7898,
Bonardi employed it for the delivery of a IV.-para with
a simple flat pelvis who had already had several diffi¬
cult labours. Bonardi was soon followed by Calderini
of Bologna, and Van de Velde in Haarlem, and then
the operation rapidly became popular in Germany,
where it has been specially practised by Dflderlein,
Leopold, Fritsch, Baumm, and Olshausen. In the last
four years considerably more than 200 cases have been
reported, and almost an equal number of papers and
references have appeared, especially in the Zentralblatt
fur Gynakologie (a).

Two methods of performing the operation have been
devised—the open and the subcutaneous. In the
former a free incision is made down to the pubic bone,
which is then divided by the wire saw. This method has
many disadvantages, among which the dangers of ex¬
cessive haemorrhage and of wound infection are the
chief. These dangers are avoided by the subcutaneous
method, which is named 1 after Dbderlein, and is now
almost universally preferred. In this method the
patient is placed upon the back with the knees bent,
and the thighs abducted and slightly flexed. A small
vertical incision three quarters of an inch in length
is made straight down upon the pubic spine; a large,
specially constructed curved needle is then carried
down behind the pubes, care being taken to keep the
point of the needle in close contact with the surface
of the bone. The point is made to emerge at the outer

(a) In this country Berry Hart (Edin. Obst. Tran*., 1903-04, toI.
xxix.) was the first to try the operation, which ha* reoeired
the various name* of pubotomr or pubiotomy, lateral section
of the pelvis (Gigli), hebotomy (Van de Velde), and pubosteotomy.
In Hart's case the operation was quite successful in effecting
delivery, but the patient died of late chloroform poisoning. The
case on which this communication is founded was the second
to be performed here. In the May number of the "Journal
of Obstetrics for the British Empire ” for this year papers
appear by Gibson and Hastings Weedy, each of whom has
performed the operation with success three times. In Tweedy’s
first case there were great difficulties and alarming complica¬
tions, but the conjugate diameter measured only slightly more
than 2Ain. The total number of pubiotomies so far done in
these Islands appears to be eight, all the children being born
alive, and one mother dying from the results of anesthesia.

side of the labium majus, the wire saw is attached,
and the needle withdrawn. The bone is then divideo
in a line nearly parallel to, and at a distance of hall
an inch from, the symphysis. As the bone is divided
there is seme bleeding, usually moderate in amount,
but occasionally profuse ; in the latter case pressure
for a short time suffices to stop the loss. The child
is then delivered by the method that appears best, the
position of the legs being varied according to circum¬
stances. Afterwards the upper wound is closed by
one or two sutures, and the lower wound is also closed,
or in some cases drained by a narrow strip of iodoform
gauze. The pelvis is supported by a sandbag on either
side, or by a broad strip of strapping acro'-s the front,
or by an elastic bandage. The patient in most cases
can get up without pain or discomfort on the sixteenth
or eighteenth day.

This short description of the operation requires to
be amplified in several important practical directions.
The side chosen for the incision in vertex presentations
is usually that on which the occiput lies, unless there
is some contra-indication, such as varicose veins or
hernia on that side. If the bladder is clearly on one
side, the incision should be made on the other. \ an
Cauwenberghe claims that his observations on the
cadaver show that widening is greater on the divided
side, and in unequally contracted pelvis he recom¬
mends, therefore, that the cut should be made on the
smaller side. The method of passing the needle varies
with different operators. Usually this is done from
above down, but Walcher and other operators pass the
needle from below up, a method recommended by
Tandler as the result of his anatomical researches
The main source of bleeding in pubiotomy is injury
to the crus of the corpus cavemosum on the side of
the division, and by cutting down on the lower border
of the pubic ramus, separating the periosteum, and
with it the crus from the bone, and then passing the
needle from below up, it is thought that injury to the
crus may be avoided. Even then, however, there is a
risk of the crus being injured by the movements of
the saw in dividing the bone, and as the bleeding is
usually moderate and easily controlled by pressure,
the little additional complication appears to be un¬
necessary. . .

In the method of delivery the greatest variation has
appeared. That which has been chiefly employed is
extraction by forceps, though many operators have
preferred version. Recently there has been an in¬
creasing tendency, after dividing the bone, to leave
the labour to the natural efforts. This was first recom¬
mended by Zweifel, and tried by DOderlein, and it is
claimed that it offers less danger to the maternal soft
parts, and at the same time gives a better chance to
the child. On the other hand, it has been suggested
that it increases the liability to the formation of a
haematoma. The position of the patient s legs at the
different stages of the operation requires careful atten¬
tion, and will be considered in connection with the
description of the changes produced in the pelvic
cavity by the operation.

The dangers of the operation include, in the first
place, bleeding, which has rarely been so copious as to
call for opening up of the wound and the application
of ligatures; generally the haemorrhage is moderate in
amount, and easily controlled by pressure. A slight
degree of haematuria has been observed in a consider¬
able proportion of cases, and appears usually to be
caused by bruising of the wall of the bladder against
the cut edges of the bone. In one case reported by
Baumm the bladder was ruptured ; in no case have I
seen mention of injury to the urethra. Commonly in
the hours after delivery a haematoma forms at the site
of operation, but usually this remains small, and
becomes absorbed without giving rise to trouble in the
course of a week or ten days. (Edema of the vulva is
commonly present in the first two or three days.

(Edema of the leg from thrombosis of veins has
been several times described, sometimes on the same
side as the division, and sometimes on the opposite.
The risk of infection in cases that are placed under
satisfactory conditions from the commencement of
labour appears to be slight, and where the operation
I has been performed in cases of pre-existing infection
j the results have been on the whole satisfactory, as
• shown in cases reported by Schauta, Sitxenfrey, Arndt,

Digitized by GoOgle

54^ The Medical Press.

ORIGINAL PAPERS.

Nov. 20, 1907^

and others. It has been suggested by Von Franque
that the operation can be done by hands which do not
touch the genitals, and so can be carried out with
reasonable safety in patients already infected. The
principal danger arising out of the operation is that
of laceration of the vagina, by which the subcutaneous
division of the bone is converted into a dangerous
compound fracture. This accident appears to be fairly
common, especially in patients with narrow vagina
and small vulva, and in such cases it appears better
to make a deep perineo-vaginal incision on the side
diagonally opposite to the division of the pubic bone.
In every case the vagina should be carefully examined
after delivery is completed, and if the-e is any lacera¬
tion this should be treated by careful suturing, with
provision for drainage. By these means it is possible
either to prevent laceration taking place or to secure
favourable union.

The results of the operation as regards both mother
and infant have been excellent. The patient is able
to get up on the fourteenth to the sixteenth day, and
in a large proportion of cases to be sent home on the
twentieth day. There is no difficulty or pain in walk¬
ing. Union of the bones takes place first by formation
of fibrous tissue, and later by bone. A considerable
amount of callus is thrown out on the anterior surface
of the bone, but it appears to be the rule, and certainly
occurred in my case, that only an extremely small
quantity is thrown out on the inner surface of the
bone, an important observation from the point of view
of subsequent labours. In cases where pregnancy
supervenes soon after the operation, it has appeared
in several cases that bony union is delayed for many
months, and it has been claimed, though without suffi¬
cient evidence, by some observers, that a permanent
widening of the bony pelvis takes place.

The following are the notes of my case :—

R. J., aet. 30, was admitted to the Birmingham
General Hospital on October 23rd, 1905, for the eighth
labour, which was estimated to be due on the 29th.
The first four labours were terminated by forceps, all
the children being born alive, the first and third still
surviving. The fourth labour was attended by Mr.
N. H. Turner, who recommended that the next should
be induced at the eighth month.

I had first seen the patient in her fifth labour at
term on September 28th, 1901. The labour was ob¬
structed. On my arrival the vulva and anterior lip
of the cervix were oedematous, the child was present¬
ing in the left occipito-anterior position, the head more
in the right side of the pelvis. By forceps an average
sized male child was delivered, with an extremely
moulded head, a deep groove on the left parietal bone
parallel to the coronal suture, and facial paralysis due
to pressure of the end of one blade of the forceps.
The facial paralysis disappeared in a fortnight, and
the child lived for 3$ years. The pelvis was reniform,
the sacral promontory forming a considerable pro¬
jection into the brim. The external pelvic measure¬
ments were :—

Dist. sp. il., 25. cm.

Dist. cr. il., 27.5 cm.

Ext. conj., 18.75 cm -

Diag. conj., 11.5 cm.

The patient said she had been delicate as a child,
was late in learning to walk, and had to work hard
from her early girlhood.

The sixth labour was induced three weeks before
term by hot injections and bougie on December 17th,
1902. Fifty hours after the introduction of the bougie
a well-developed male child was delivered under
chloroform by bi-polar version, with forceps to the
after-coming head. The child was with difficulty re¬
vived, and died the same evening. The seventh labour
was induced at seven and three-quarter months on
September 3rd, 1904. Forty-five hours after the intro¬
duction of a bougie a female child 4} lbs. in weight
and 17J ins. long was easily delivered by forceps. It
died the next day.

On the present admission the patient was said to
have last menstruated on January 25th. Labour pains
began on the evening of November 21st, 1905, and at
3 p.m. on the 22nd the cervix was fully dilatable. The
child lay with its back to the right, the head freely
movable above the brim; the foetal heart, 150 to the

minute, was heard far back on the right side. About
three pints of liquor amnii escaped when the membranes-
were ruptured. In spite of strong pains, the head,,
which entered into the third vertex presentation, failed
to engage firmly.

Operation .—The patient was anaesthetised, andi
forceps applied. Forcible traction was then made at
intervals of three minutes, but entirely failed to bring
the head through the brim. Pubiotomy was deter¬
mined upon, and was carried out by the modified sub¬
cutaneous method. A vertical incision inches in
length was made upwards from the pubic spine on the
left side. The incision was carried down to the bone,
and a Gigli’s saw was then, by means of a Seeligmann’s-
director, passed downwards close to the posterior sur¬
face of the left pubic bone, and brought out at a point
on the outer side of the left labium majus. The bone
was easily sawn through, and the divided ends imme¬
diately sprang apart, leaving a gap of i inch or there¬
abouts. The upper end of the division was a little
internal to the pubic spine. The forceps were again
applied, and the child very easily delivered, the occiput
coming forward into the second vertex presentation at
the outlet. Ergot was now administered subcu¬
taneously ; the placenta was expressed from the vagina
after 15 minutes. The upper incision was closed by
silkworm gut sutures; the lower small one had ragged
edges from the action of the saw ; it was partly closed
by one suture and drained by a small strip of iodoform
gauze. A broad strip of adhesive plaster was brought
across the front of the pelvis from side to side. The
child weighed 8 lbs., and soon began to cry vigorously.

Result .—The subsequent course of the puerperium
was normal in every respect. There was moderate
oedema of the left labium majus, which gradually dis¬
appeared in seven days. The upper wound united by
first intention, and the lower one was firmly healed
by the end of the second week. On the twelfth day
after operation a thick callus was felt along the line
of division on the outer aspect of the bone ; on the
inside the division felt like a slight depression, and
there was no exudation making prominence above the
surface.

At the end of the third week the patient was allowed
to sit up, which she did quite comfortably. Two days
later she was radiographed, a clear space about $ inch
wide showing between the divided portions of bone.
During my absence from hospital for a few days, my
Resident interpreted this clear line to mean that no union
had taken place ; he therefore ordered the patient back
to bed. As a consequence, when I next saw the woman
she had developed a well-marked neuromimetic
paralysis of the left leg. Every movement of the limb,
including abduction, adduction, and rotation of the
thigh, could be performed perfectly by the woman as
she lay in bed ; but when asked to stand she collapsed,
and would have fallen to the right, the left leg at the
same time becoming extended and rigid. There was
no affection of sensation, the limb remained normal in
nutrition and appearance, and there were no alterations
in the deep or superficial reflexes. Electricity, massage,
and the exercise of patience were followed in a few
weeks by the return of normal power in the limb.
The patient has had no further pregnancy, but has
remained well and able comfortably to carry on all
her household work. The child died at the age of
ii years from some wasting disease.

The operation, in my opinion, is a good one, appear¬
ing to possess the advantages claimed for symphysio¬
tomy, while avoiding some of its more serious dis¬
advantages. The wounds are small, and placed well
away from the vaginal orifice ; the divided bone readily
unites, first by fibrous and later by osseous tissue. The
situation of the division on one side of the middle
line greatly lessens the risk of injury to important
structures. The only likely source of haemorrhage is
the crus of the corpus cavernosum, which is usually
divided at the same time as the bone is saw n through;
pressure for a short time suffices to stop the bleeding.
The relations of the wound in the bone to the clitoris,
the bladder, and more particularly to the urethra, are
much less close than in symphysiotomy, and thus the
particular dangers of the latter operation are obviated.

With the same degree of separation of the bones,
the amount of widening of the pelvis, according to

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Nov. 20, 1907.

ORIGINAL PAPERS.

The Medical Press. 547

comparative observations made on the cadaver by
Sellheim, is the same after pubiotomy as after
symphysiotomy, but after the former operation the
separation requires three times greater force than after
symphysiotomy. The divided ends of the bone are
held in contact by the attachments of the adductor
muscles, and only separate to an extent sufficient to
allow the passage of the child. The sudden springing
apart, which has occasionally been attended by serious
injuries to the soft parts in symphysiotomy, is not
likely to occur here. The limit of safe separation of
the divided bones appears to be about 6 cm., any
further widening being likely to cause rupture of the
sacro-iliac joints. Morisani said that after symphysio¬
tomy with a separation of 6 cm., the conjugate diameter
is increased by 13 to 15 mm., and that the bulging
of the soft parts increases the enlargement to about
22 mm. Ddderlein says that in this amount of sepa¬
ration the superficial area of the brim is increased by
about half, from 105 to 155 square cm.

As the bones become separated the inclination of
the pelvis is increased (Ahlfeld), while the cavity
becomes funnel-shaped and at the same time shallower
from above down, the last effect depending upon the
raising and flattening of the pelvic floor by the un¬
yielding sacro-sciatic ligaments. Kroemer draws
special attention to the effect upon the separation of
the bones produced by alteration in the position of
the legs.

The indications for the employment of pubiotomy
are the same as those for symphysiotomy. the pelvis
must not be anchylosed, and must have a conjugate
diameter of not less than 2J inches in a flat and not
less than 3 inches in a generally contracted pelvis ;
below these limits Caesarean section is a safer and
better operation. If there is a probability that the
patient is already infected, craniotomy will usually
be preferable. Auscultation must afford proof that
the child is living and strong. Labour must have
advanced so far that the cervix is fully dilated or
fully dilatable, or dilatation should have been com¬
pleted by the hydrostatic bag; sufficient time must be
allowed for the natural efforts to mould the head. If,
then, in spite of strong pains, no progress is made in
two hours in a multipara, or four hours in a first
labour, or if the maternal pulse rises so that it remains
at 100 in the intervals between the pains, delivery
should be attempted by the high forceps operation
under chloroform. The attempt should not be pro¬
longed or repeated, but immediate recourse had to
pubiotomy.

DEATH FROM HAEMORRHAGE
FROM A MEDICO-LEGAL POINT OF
VIEW.

Part III.

By PROFESSOR HENDRICK, M.D.,

Of Hamburg.

(Specially reported, by our German Correspondent.)

Concluded prom page 521.

hatal haemorrhage in the new-born occurs first
from not ligaturing the umbilical cord.

Although omission to tie the cord occurs more fre¬
quently in precipitate labour, in concealment of birth,
infanticide, and exposure, yet in these cases death
from the omission is only rare, as under normal cir¬
cumstances, after separation of the placenta, the um¬
bilical arteries contract, the intima doubles on itself,
thrombi form, and the blood pressure falls in con¬
sequence of the development of the lesser circulation.
For this reason fatal haemorrhage frcm the unliga¬
tured umbilical cord was formerly denied. On the
other hand, others considered that death always fol¬
lowed when the tying was omitted. For ?n explana¬
tion of these contradictory views we must assume that
for the occurrence of this fatal haemorrhage special
abnormal pathological and physiological conditions
jure necessary, although, from the small number of
cases that occur, no sufficient proof of this has been
established. These causes may be (Beckert) (54) an

abnormal condition of the vessels of the cord, unusual
thinness and softness, abnormal course, increased
blood pressure when the lesser circulation does not
become established or only imperfectly so, or haemo¬
philia.

Besides this, the following are to be considered as
favouring factors (Caspar-Liman) : When the cord is
cut very close, although fatal haemorrhage may occur
when it is cut long (as case 448 of Caspar-Liman
shows); further, when the division is effected by tear¬
ing and not by cutting; also when the cord is gela¬
tinous and soft, as in such a case the ligature may
become loose and fall off from the cord drying in.
The diagnosis of fatal haemorrhage from the umbilical
cord is based on the general anaemic condition of the
organs, anaemia from wasting being excluded;
secondly, signs of bleeding having taken place, which
may, however, have disappeared ; thirdly, division of
the cord between the umbilicus and the placenta, and,
fourthly, exclusion of all other causes of death. From
the fact that the cord has been tied or left untied, no
proof can be drawn either for or against fatal haemor¬
rhage, as a ligature can be applied after death, and,
on the other hand, one applied during life may have
become loose and fallen off, or it may have been tied
firmly and bleeding still have taken place. Caspar-
Liman mention three cases (Nos. 449, 450, 451) in
which fatal haemorrhage took place in spite of a long
cord and firm tying. Finally, the diagnosis will be
much strengthened by proof of the pathological or
physiological abnormalities already mentioned.

In a case mentioned by Ahlfeld (56), the cord, which
was very thin and poor, was torn by the midwife 3 cm.
from the umbilicus, and the child died from fatal
haemorrhage. On the right arm of the child was a
furrow as from a ligature, which showed that a good
deal of pulling had taken place. This rare case shows
at the same time that caution should be used in con¬
demning a midwife. Beckert (54) (Zeitschr. f. Med.
Beamte, 1880, S. 569) quotes two cases by Haberda
and Brouardel in which intra-menineeal haemorrhage
prevented the establishment of the pulmonary circula¬
tion, and rendered possible fatal haemorrhage from
the cord. Haemophilia cannot be recognised on the
cadaver, but only through heredity being proved.

The experiments of Caspar-Liman and Hofmann on
the tearing-point of the cord, made by hanging on
heavy weights of 500 to 1,000 grm., are of no practical
value, as they are too little imitated on the living
subject. We should not therefore conclude, when the
cord is torn in a case of precipitate labour, that no
blame attaches to the mother. It seems remarkable
that no experiments have been made on the dead body
to solve the question whether when the cord is firmly
tied as the midwife is instructed to do it it can so far
shrink and loosen that fatal haemorrhage can take
place. The elucidation of the question of blame in
cases of fatal haemorrhage from the umbilical cord is
of special importance from a medico-legal point of
view, and sometimes very difficult. The medical wit¬
ness may be asked : Is the omission on the part of the
mother to tie the cord from ignorance or from design,
or in consequence of thoughtless want of preparation
for her confinement? Secondly, in case the cord has
been tied and has become loose, so that fatal haemor¬
rhage has taken place, has the midwife been guilty
of causing death by criminal negligence, or of pro¬
ceedings against the security of life? Views on these
points are divided. Hofmann (1) states with emphasis
that proof that omission to tie the cord has been
intentional cannot be established, as we cannot prove
that primaparae, who are chiefly concerned, have any
knowledge of this manipulation. Caspar-Liman take
the view that in a case of the loosening of a cord that
has been tied, the midwife should not be blamed with¬
out further information. Here an opinion would be
arrived at from the surrounding circumstances as to
intention or not. Thus Dittrich (55) (Aerz. Sachveret.-
Zeit., 1897, 43 and 44) mentions a case of fatal haemor¬
rhage from the cord in which from the circumstances
design could be excluded : A girl was going to the
hospital in company with other people to be confined,
when labour took plice in the railway carriage ; she
severed the cord ignorantly, and wrapped several turns
of a bandage round the stump. The child died of

,oogle

54® The Medical Peess.

ORIGINAL PAPERS.

Nov. 20, 1907.

haemorrhage. Between the cord and the ligature a
thick sound could easily be passed. Beckert, who has
recently interested himself with the question of blame
in cases of fatal haemorrhage from the umbilical cord
(Zeitsch. f. Med. Beamte, 1899, S. 569), reports a case
in which a midwife escaped conviction through differ¬
ence in opinion amongst the medical witnesses, and
as amongst the published cases he has met with only
two convictions he is of opinion that the witnesses
have been too lenient, being afraid of the conse¬
quences that might follow a conviction. He would
have a charge made in every case in fatal haemorrhage
from the ligatured cord ; the midwife has a great
responsibility, as such haemorrhages can be avoided
in every case by careful and conscientious tying of
the cord. In any case the question of blame where
fatal haemorrhage takes place when the cord has been
tied has not yet been satisfactorily settled.

A child may also bleed to death from the cord
during birth in cases of insertio velamentosa, when
the advancing part of the child lacerates the vela-
mentum. Volland (53) has collected 15 such cases
from literature. Death may also take place from
tearing of the cord when it is too short. Further,
when there is a common placenta, a twin may bleed
to death after the birth of the first one if its cord is
not tied doubly (Sachs).

Besides death from bleeding from the cord, fatal
haemorrhage may also take place from injuries and
ruptures occurring during labour, whether intentional
or unintentional, along with proper or improper expert
assistance, and whether the organs are healthy or dis¬
eased. To this category belong: Fatal haemorrhage
from tearing out of limbs, perforation, morcellement,
rupture of blood vessels (particularly cerebral haemor¬
rhages), rupture of organs (the liver, spleen, intestines),
fatal bleeding from parenchymatous organs.

It is to be noted that bruises and ecchymoses appear
on the tumours of the head, buttocks, and shoulder,
but they do not fall under this category. As conse¬
quences of obstetric operations, ruptures of the liver
and spleen, for example, have been observed. Kdrber
(St. Petersb. med. Wochenschr., 1892, No. 51) relates
a case in which rupture of the liver occurred as a
result of swinging the child in the way recommended
by Schultze in cases of suspended animation. The
question of blame in cases of rupture of organs is
frequently very difficult from a medico-legal point of
view. It has to be ascertained (Geill) whether the
ruptures of organs found after death really took place
during birth— i.e., whether they were produced during
spontaneous labour, under special circumstances
(lingering labour from irregular presentation, con¬
tracted pelvis, rigidity of the soft parts), by assistance
given by the mother herself, by the obstetrician in
attempts to restore animation in a child apparently
stillborn, by ignorant treatment of a child born alive
(rupture of bowel by enemata), by infanticide, spon¬
taneous rupture (of the spleen), by improper manage¬
ment of the stillborn child, or by any other cause.
Dittrich (57) is of opinion that as manipulations that
are to be looked upon as proper are carried out in
normal labour also, it may be properly assumed that
ruptures of internal organs may occur during labour,
in which all mechanical violence independent of that
of the maternal organism can be excluded. Kratter (71)
concedes this as regards ruptures of organs, but not
for haematomata of internal organs. In my opinion
it appears certain that every case must be examined as
to whether the force employed by the obstetrician or
the midwife was necessary, or whether it was more
than was allowable. Fatal haemorrhage from ritual
circumcision in cases of hemophilia is to be men¬
tioned.

Fatal haemorrhage from the female genital parts
occurs from solution of continuity in the region of
the clitoris, from wounds of the vagina from coitus,
from wounds of the uterus during pregnancy, and in
connection with labour. Cases of fatal haemorrhage
from the region of the clitoris, in which parenchy¬
matous bleeding from the corpora cav?rnosa clitoridis
may be fatal, as already mentioned, are rare. Nie¬
mann (Henke’s Zeitsch., Bd. 392, S. 310, quoted from
Hofmann) reports the intentional killing of a woman
by a cut in the external genital parts.

More frequent, and more difficult to decide from a
medico-legal point of view, are fatal haemorrhages
from wounds of the vagina from coitus. From statis¬
tics collected by Neugebauer (Monatschr. f. Geburt-
shilfe u. Gyn., 1899, IX., S. 22, iu. 289), out of 157
observations, there were 22 cases of fatal haemorrhage.
As to whether the wounds were produced simply by
manipulations during coitus, opinions differed.
Caspar-Liman’s collection shows only cases in which
the injuries were caused by the introduction of the
finger or instruments. Maschka denies the occurrence
from coitus, and explains five cases of wounding the
vagina by the forcible use of the fingers. Hofmann
concedes the possibility of such an occurrence, and
attributes it to the brutality of the man, and want of
proportion between the man’s penis and the vagina.
Mennicke (62), from his own observations, comes to
the conclusion that the possibility of lacerations of
the vagina occurring sub coitu cannot be completely
excluded, as they were formerly, when some of the
following predisposing causes are present: Drunken¬
ness and the use of brutal force on the part of the
man, a peculiar position during the act, want of pro¬
portion between the size of the penis and that of the
vagina (for example, attempted rape of little girls);
on the part of the female, status infantilis of the
genital parts, climacteric age, antecedent gynaecolo¬
gical operations (colporrhaphy operations on the
perineum). Mennicke relates a case in which the
hostess of an inn, aged 55, died suddenly in the night,
although she had been quite well the evening before ;
the husband had the reputation of being brutal and
of leading a loose life. The autopsy revealed lacera¬
tion of the vagina, and death from haemorrhage. The
medico-legal opinion agreed with the superior opinion
of a professor, that the laceration might have b« en
produced by coitus, and consequently not necessarily
by another injury which was not excluded. Wichmann
(63) (Aerztl. Sachverst. Zeit., 1900, No. 4, S. 671,
reports on a case of laceration of the vagina, with
subsequent fatal hsemorrhage from intercourse with a
factory girl who was in the ninth month of pregnancy,
and after inquiry into the case, comes to the same
conclusion as Mennicke. Warmann (66) (Zur aetiologie
u. forens. Bedeutungder Scheidenruptur, Zentralbl. f.
Chirurgie, No. 24, 1897) finds the cause of rupture of
the vagina, not in the disproportion between the size
of the penis and that of the vagina, nor in too little
power of resistance, nor in the altogether too stormy
intercourse on the part of the man alone, but too
much vigour on the woman’s part, and maintains that
when the woman strives against the act, rupture of
the posterior wall of the vagina is impossible ; such
ruptures are not consistent with rape.

In my opinion deaths of this kind must from a
medico-legal point of view, be judged individually,
not only as regards the autopsy, but taking in all the
accompanying circumstances (see Mennicke’s case) ; no
general rule can be laid down concerning them.

Fatal haemorrhage may also take place from rupture
of the foetal sac in ectopic gestation. The rupture is
spontaneous as a physiological necessity, or from
injury, which may be only very slight, as the foetal
sac has but little resisting power. These cases are of
importance forensically, when an injury that might
be the cause of the rupture has preceded it, whether
the rupture is spontaneous or not. It is naturally
difficult to arrive at a decision.

During labour fatal haemorrhage may take place
from wounds of the genital passages—ostium vaginae
(especially the region of the clitoris), vagina, uterus
(cervix and fundus)—which may be caused naturally
from want of proportion between the foetus and the
maternal parts, or from medical assistance being
omitted or improperly rendered (Sachs). Here it has
to be determined forensically whether the person
responsible for the course of the labour (physician
or midwife) had rendered the assistance demanded in
a skilful manner, and kept the patient sufficiently
long under observation after the completion of labour,
whether she has been left too soon, and that whether
thereby the aid that was demanded could not be ren¬
dered.

Fatal hsemorrhage from rupture of the uterus is of
special importance. According to Schroeder, rupture

Digitized byG00Qle
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Nov. 20, 1907.

ORIGINAL PAPERS.

of the uterus occurs during pregnancy from the third
month on, later on more frequently, but upon the
whole very rarely from any considerable crushing.
Any force acting from before backwards against the
vertebral column is more likely to be followed by
rupture than one acting from the side ■, spontaneous
ruptures during pregnancy are very rare. It must be
assumed that some congenital or acquired thinness or
softness of the uterine walls (Caesarean section in a
previous pregnancy, or softening from inflammation)
is necessary for a rupture to take place. Rupture can
then take place from slight causes, lifting a weight,
a jump, a push, a fall, a cough, vomiting, or any
other strain of the abdominal walls, or even without
any apparent cause. The point of rupture—in contrast
to those occurring in partu—is regularly in the fundus
or at least in the adjacent parts (Schroeder). Jelling-
haus (68) (Archiv. f. Gynaekol., Bd. 54, H. 1) relates
a case of rupture from thinning of the muscular walls.
Ruptures of the uterus may occur spontaneously
during labour, or they may be favoured by the patho¬
logical conditions mentioned, if when any hindrance
to the passage of the child occurs—abnormal pre¬
sentation, normal presentation, but contracted pelvis,
hydrocephalic head of the child, and the lower seg¬
ment of the uterus is over stretched, so that it tears;
after such an event fatal haemorrhage frequently takes
place.

Such cases may become the subject of medico-legal
inquiry if improper methods of treatment have been
taken by the medical attendant or midwife, intro¬
ducing the hand too far in, for instance, and thus
contributing to the rupture. It will mostly be very
difficult to decide whether a rupture has been un¬
avoidable and would have taken place from the pains
alone, or whether the fault lay with the medical
attendant. Here also the circumstances may prove
of value in arriving at a decision. In my earlier years
of practical work I was called to the assistance of a
colleague in a difficult case of labour. As I made my
appearance the patient had just died, whilst the sur¬
geon was rendering assistance in a case of rupture
of the uterus and subsequent fatal haemorrhage. No
medico-legal inquiry took place, as the known good
position of the medical man in question excluded any
question of incompetence. The discovery of a morbid
condition of the uterine muscles makes the diagnosis
more simple. Heydrich (70) (Centralbl. f. Gynaekol.,
1897, No. 20) reports on a rare case, important from a
medico-legal point of view, in which a very pen¬
dulous abdomen was the cause of the rupture, in con¬
sequence of which the posterior wall of the uterus
•was greatly stretched and rubbed through by the
advancing head. Much more can be done from a
medico-legal point of view in those numerous cases
in which death results from injuries of the female
genital organs that have been brought about by too
rough or careless handling, or those fatal accidents
when the treatment on the part of the persons respon¬
sible has been quite correct (v. Sachs).

Medico-legal records of errors in the performance
of obstetric operations by surgeons, midwives, and
quacks are very numerous. Penetration of the vagina
and uterus by instruments are the most frequent occur¬
rences. Injuries of the bowels in connection with
rupture of the uterus also occur. As a curiosity a
case quoted in the “Vierteljahrsch. f. gerichtl. Med.,
Bd. 21, S. 80, may be mentioned, in which the whole
uterus was torn away in removing the placenta. In
these cases, mostly of grave injury caused by violent
manipulations, fatal haemorrhage is frequent. The
question of blame is usually not difficult to decide.
After labour fatal haemorrhage may occur from atony
of the uterus, and it may be the subject of medico¬
legal inquiry if the woman confined has been left too
soon after delivery, or if it can be proved that the
person responsible failed to make use of the usual
internal remedies or manipulations, although it must
be remarked that death may follow in spite of their
employment. Secondly, if the placenta has been
separated by the hand and a portion left behind, proof
of blame in such cases is not difficult to establish.
Thus Mair (85) mentions a case of fatal hemorrhage
from atony of the uterus, where the midwife removed
the after-birth without satisfying herself that the

The M edical Press. 549

uterus had contracted. The blame might easily have
been fixed upon her in such a case.

TftF. Relation ok Death from Hemorrhage to the
Accident Insurance Law and to the Civil
Code.

The forensic surgeon may be placed in a position in
which, in cases of death from haemorrhages of persons
who are insured against accidents, of having to decide
whether the death has been caused by the accident
whilst at work, or whether it has been spontaneous as
the natural outcome of an illness. On this decision
hangs the right of the heirs to the insurance moneys ;
further, whether the death in question was connected
causally with ?n earlier accident or an earlier injury
or not. The -ight to compensation for injury on the
part of survivors, according to par. 844 of the Civil
Code, may hang on this decision. The cases belonging
to this class are not numerous, so that there is a
scarcity of material for icference. In general these
questions are difficult to decide. In an earlier place
a case reported by Danger has already been mentioned
(28), where proof could not be Educed that death was
due to an accident that occurred seven years before.
But even when it is only a matter of days between the
injury and death, it is not always possible to establish
the connection. In Friedrich, s. Blattern of 1852, a
case is reported where a woman in stealing wood was
struck with a stick. Four days afterwards she died
from haemorrhage from an aneurysm (it was probably
an aneurysm of the aorta, but this is not shown in
the proceedings). The connection between the injury
and the death could only be established as probable.
In the Aerztlich. Sachverstand. Zeit., 1898, No. 8,
S. 167, a case is mentioned of sudden death from
bleeding from a gastric ulcer whilst at work, in which
the trade society objected to pay the claims on the
ground that the death was the natural outcome of an
advanced degree of disease of the stomach. In a trial,
however, they were held liable on the ground that on
the day on which the deceased met her death the work
was particularly heavy, that this caused unusual action
of the heart, and that the hemorrhage was due to
that. In another place (77) a case of hemorrhage from
the lungs is mentioned that occurred four days after
an accident in a man who was suffering from intes¬
tinal tubercle, the deceased striking his right side
against a wooden corner in falling into a filter pit.
The connection between the accident and the death
in this case was confirmed by the medico-legal expert,
although denied by the medical officer to the man’s
trade society, and the money claimed was paid. In
another case (76) the connection between fatal haemor¬
rhage from the lungs and the performance of work—
lifting a heavy chest—was denied for want of sufficient
evidence that it was due to any one distinct act.
Markwald (74) mentions the following case: A joiner
whilst at work, sawing a beam, was taken suddenly
ill with violent pain, vomiting, spitting of blood,
inability to move or speak, and died in a few hours.
Three minutes before commencing to saw he had lifted
a heavy beam. The autopsy showed arteriosclerotic
changes in the aorta, free haemorrhage, an aneurysm
that by eating through the bronchial vein had allowed
the passage of blood into the bronchus. Markwald
denied any connection between the bleeding and the
sawing, as there was no proof that this, the proper
work of the joiner, was the cause of the bleeding.
He gave a warning against a too wide-reaching humani-
tarianism, and demanded only a searching, scientific
criticism of the cases and opinions, lest at a not distant
date every disease should be looked on as the result
of an accident. From this small number of examples
it will be seen that no general principles can be laid
down for the treatment of these questions ; each case
must be decided by itself.

The results of this work may be summed up in the
following conclusions :—

(1) The usual course of death from hemorrhage is
this: that immediately on the occurrence of a spon¬
taneous or traumatic solution of continuity of the
vascular system internal or external hemorrhage takes
place, and, hindered by nothing, continues uninter¬
ruptedly until in a few minutes death takes place from
cerebral anemia.

(2) The principal deviations from the usual course
are: interruptions in the course of the bleeding (death

jOoq le

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55° The Medical Press.

ORIGINAL PAPERS.

Nov. 20, 1907.

from secondary haemorrhage, late haemorrhage), as
well as complications through the secondary effects of
the bleeding (pressure on the brain, heart, lungs,
blocking of the air passages, air embolism).

(3) The deviations from the usual course in the
various injuries that may be followed by fatal haemor¬
rhage show themselves in the following manner:—

(a) In fatal haemorrhages from wounds of the heart
all the deviations mentioned may occur.

( b) Fatal haemorrhage from injuries of the great
blood vessels deviate from the usual course in pro¬
portion to the smallness of diameter of the vessel
injured.

(e) In death from haemorrhage from rupture of
organs, the mode of origin of the rupture was the
first point in the medico-legal inquiry whether the
rupture was due to traumatism or whether it was the
spontaneous result of some disease of the organ, or
whether both modes came into consideration, and, if
so, in what relation did the trauma stand to the dis¬
ease.

(4) The diagnosis of death from haemorrhage is
based on the proof of a solution of continuity in the
vascular system, of haemorrhage having taken place,
and of a high degree of anaemia of the body generally
when not decomposed, the evidence of other causes of
death not being discoverable. In these cases the diag¬
nosis is not difficult on post-mortem examination.

(5) If the body is decomposed, or if there is evi¬
dence of other causes, the diagnosis is more difficult,
and circumstantial evidence must be appealed to.

(6) For the purpose of distinguishing deith from
haemorrhage from allied forms—injury of vital organs
—it is an advantage to distinguish between simple
and complicated deaths from haemorrhage :—

(a) It is simple when due to loss of blood and
nothing else.

(£) Complicated when death results from the
secondary effects of the bleeding (paralysis from pres¬
sure on the brain, heart, lungs, blocking of the
respiratory passages by blood, air embolism).

Note. —Those cases are allied to complicated death
from haemorrhage where the bleeding is from a body
in which there is a deficient supply of oxygen from a
morbid condition of the heart or lungs. Here paralysis
of the brain and death will come on earlier, so that
absence of blood in the organs may not be as com¬
plete as under ordinary conditions. Further, haemor¬
rhage that would do no harm under ordinary circum¬
stances might be fatal (as in abortions, for example).
This statement can at present be given as hypothetical,
as no practical examples are so far recorded.

(7) Principles regarding the determination of fatal
haemorrhage from the umbilical cord in infants, when
it has been tied, but become loose, cannot yet be laid
down.

(8) The determination of the origination of injuries
of the vagina (sub coitu ) that lead to fatal haemor¬
rhages is, for want of agreement amongst inquirers,
very difficult, and cannot be reached without a know¬
ledge of the circumstances.

(9) The causal connection between a death from
haemorrhage and an earlier injury or accident when
there is a question of compensation on the part of
heirs, or of an accident pension, is frequently impos¬
sible, especially when a considerable time has elapsed
between the injury and death.

LITERATURE.

( 53 ) Volland, Tod des Kindes durch Zerreissung von
Gefasse der Volamentis inserierenden Nabelschnur.
Dissertation. Aerztliche Sachverstandigen Zeitung,
1900, S. 223, No 11.

(54) Becxert, Zur forensischen Beurteilung des
Todes Neugeborner durch Verblutung aus dtr
Nabelschnur. Zeitschrift fur Medizinal-Beamte, 1899.

(55) Dittrich, Ein Fall von Verblutung aus der unter-
bundenen Nabelschnur. Aerztliche Sachverstandigen-
Zeitung, 1897, S. 471.

(56) Ahlfeld, Zerreissung der Nabelschnur eines
reifen Kindes wahrend der Geburt. Aerztliche Sach-
verstandigen-Zeitung, 1897, S. 282.

(57) Dittrich, Ueber Geburtsverletzungen der Neuge-
borenen und deren forenische Bedeutung.' Viertel¬
jahrsschrift filr gerichtliche Medizin, 1895, Bd. IX.

(58) Hecker, Verblutung aus der Nabelschnur.
Friedreich s Blatter fur gerichtliche Medizin, 1871,
S. 215.

(59) Courant, Zerreissung der Nabelschnur. Aerxt-
liche Sachverstandigen Zeitung, 1898, No. 8.

(60) Freund, Ueber einen Fall von spontan intrau-
terin gerissener Nabelschnur. Zeitschrift f. Medizinal-
Beamte, 1894.

(61) Westphalen, Beitrag zur Kasuistik der Nabel-
schnurverletzungen unter der Geburt.

(62) Mennicke, Ueber pldtzlichen Tod durch Ver¬
blutung sub coitu. Vierteljahrsschrift fiir gerichtliche-
Medizin, 1902, Bd. XXIV., S. 268.

(63) Wichmann, Ein Fall von tftdlicher Cohabita-
tionsverletzung. Aerztliche Sachverstandigen Zeitung,
1900, No. 4, S. 67.

(64) Himmelfarb, Zur Kasuistik der Scheidenvtr-
letzungen durch Koitus, Zentralblatt fiir Gynakologie,
1890, S. 680.

(65) Dworack, Blutungen unter primum coitum..
Vierteljahrsschrift fiir gerichtliche Medizin, 1885,
Bd. 43, S. 36.

(66) Warmann, Zur iEtiologie und forensischen
Beurteilung der Scheidenrupturen. Zentralblatt fiir
Gynakologie, 1897, No. 24.

(67) Hermes, Zur Verletzung der Scheide beim
Koitus. Zentralblatt fiir GynaJtologie, No. 32.

(68) Jellinghaus, Zur Kasuistik der Uterusrupturen,
wahrend der Schwangerschaft. Archiv. fiir Gyna¬
kologie, Bd. 54, H. 1.

(69) Kleinerts, Kin Fall von spontaner kompletter
Uterusruptur. Zentralblatt fiir Gynakologie, 1902,.
No. 40.

(70) Heydrich, Ein Fall von spontaner L'terus-
ruptur. Zentralblatt fiir Gynakologie, 1897, No. 20.

(71) Kratter, Zur Kenntniss und forensischen Wurdi-
gung der Geburtsverletzungen. Vierteljahrsschrift fur
gerichtliche Medizin, 1897, Bd. XIII., S. 354.

(72) Reinstadter, Die uterusrupturen in foro. Vier¬
teljahrsschrift fiir gerichtliche Medizin, 1882, Bd. 37,
S. 80 u. 247.

(73) PrOlls, Ein Fall von Uterusruptur mit todlichen
Ausgang. Freidrich’s Blatter fiir gerichtliche Medizin r
1902, Heft. 4.

(74) Markwald, Ruptur eines Aneurysmas und Un-
fallrente. Miinchener medizinische Wochenschrift r
No. 1. Zeitschrift fiir Medizinal-Beamte, 1904, No. 5,
S. 156.

(75) Aus der Reichsversicherungsamt, Ursachlicher
Zusammenhang zwischen Unfall und Tod durch
innere Verblutung aus einem Magengeschwiir. Aerzt¬
liche Sachverstandigen Zeitung, 1898, No. 8, S. 167.

(76) I.ungenblutung und Tod keine Folge des-
Betriebsunfalls. Aerztliche Sachverstandigen Zeitung,
1898, No. 20, S. 443.

(77) Nach einem Fall Blutsturtz und Tod. Ursach¬
licher Zusammenhang bejaht. Aerztliche Sachver-
standigen-Zeitung, 1898, No. 2, S. 39.

(78) Orth. Kompendium der pathologisch-anato-
mischen Diagnostik. 6, Auflage, 1900.

(79) Falk, Plotzlicher Tod nach einer Ohrfeige.
Vierteljahrsschrift fiir gerichtliche Medizin, 1881.

(80) Fahrlassige K&rperverletzung Entfernung der
Gebarmutter onstatt der Nachgeburt durch einen Arzt^
Vierteljahrsschrift fiir gerichtliche Medizin., Bd. XXI.,.
S.-8o.

(81) Kob, Spontaner Schlagfiuss ohne Gehimblutung
in folge von Schlagen Vierteljahrsschrift fiir gericht¬
liche Medizin, Bd. IX., S. 129.

(82) Ritter, Ueber Verletzungen des Darmkanals in
gerichtlicher Beziehung, Friedreich’s Blatter fur
gerichtliche Medizin, 1902, H. 3.

(83) Wegener, Zur gerichtsarztlichen Beurteilung der
Darmverletzungen Vierteljahrsschrift fiir gerichtliche
Medizin, 1897, Bd. XIV.

(84) Chlumsky, Fehlen der Totenflecke an drei
aufeinanderfolgenden Tagen beobachtet. Vierteljahrs¬
schrift fiir gerichtliche Medizin, Bd. 1895, Bd. X. r
S. 22.

(85) Mair, Fall von Verblutung ex atonia uteri.
Friedreich’s Blatter fur gerichtliche Medizin, 1870*
S. 253.

zed by GoOgle

Nov. 20. 1907.

OPERATING THEATRES.

The Medical Press. 55 1

OUT-PATIENTS’ ROOM

ROYAL FREE HOSPITAL.

Epithelioma of the Cheek.—New Operation.

By J. Cunning, M.B., F.R.C.S.

Amongst the out-patients was a man, ast. 56, who
complained of soreness of the inner side of the cheek,
which came on, he said, a fortnight previously. On
examination an ulcer was discovered, in extent about
the size of a florin, reaching from close to the angle
of the mouth backwards to about the second molar
tooth. The ulcer was deeply excavated, with irregular
raised edges and a nodular base ; the whole ulcer and
its margins were very hard and not specially tender;
there was a dirty, foetid discharge from it. In the
submaxillary region two small hard glands could be
felt. The diagnosis, Mr. Cunning said, was the first
point to be established. Ulcers of this type were
usually epithelioma; the ether ulcers which had to
be considered were primary sores and dental ulcers.
Dental ulcers could be excluded in this case, for they
were always in the neighbourhood of a ragged tooth,
and were never of a deeply excavated character. A
primary sore might look very like an epithelioma, but
as the patient’s age was an ordinary one for epithe¬
lioma, which is a more common disease than primary
sore in the mouth, one would be entitled to assume
that this is more likely to be an epithelioma than a
manifestation of syphilis. The glands under the jaw
would be enlarged in either case, so that they could
not be looked upon as helping the diagnosis in either
way. There were two ways, he remarked, of settling
this point: one was by giving mercury, the other by
removing a piece for microscopical examination. The
latter of the two methods, he thought, was the better,
as it involved no delay. With regard to treatment,
Mr. Cunning pointed out that, assuming this was an
epithelioma, it could be completely removed, as it was
quite free from the jaws; it would mean that a large
area of the cheek, certainly as much as the palm of
the hand, would have to be taken away. This meant
that a very wide gap would have to be filled in. The
plan he had devised for doing this was to begin by
turning up a large flap covering the submaxillary
triangle, and removing the submaxillary and salivary
glands from this area, before touching the cheek.
The cheek would next be excised. Then the flap raised
from the submaxillary triangle would be divided at
the junction of its posterior and middle thirds ; the
anterior section of this flap would then be twisted
upwards and fixed to the upper edge of the gap in
the cheek close to the angle at which the remainder
of the lips would be stitched to one another; the
posterior third of the flap would next be pulled for¬
wards and upwards, and stitched not only to the re¬
mainder of the upper portion of the gap in the cheek,
but also to what is now the posterior edge of the
twisted-up anterior portion of the flap. It is now
found that a very good new cheek has been formed,
which can be covered by a beard in a male patient.
It finally only remains to cover the bare area in the
situation of the submaxillary triangle; this can be
done quite easily by under-cutting the skin of the
neck, sliding it upwards, and stitching it to the skin
at the level of the lower jaw. In a previous case in
which this plan of operation devised by Mr. Cunning
had been carried out by him, a very large gap had
been filled up with surprising ease, and when the
patient returned two months after discharge from the
hospital, having in the meantime grown a beard, it
was almost impossible to tell that an operation had
been done, therefore Mr. Cunning now proposed to
perform a similar operation on the present patient.

OPERATING THEATRES.

ROYAL FREE HOSPITAL.

Radical Cure of Hvdrocf.le.—Mr. Willmott
Evans operated on a man, ast. 28, who had been
admitted for chronic hydrocele. For some five or six
years the patient had suffered from a hydrocele of the

right side; it had been tapped many times and liquids
had been injected in order to affect a cure, but without
avail; the fluid had always re-collected. The presence
of the hydrocele was troublesome to him, and he was
anxious to have a radical cure. When the patient was
anaesthetised the surface of the scrotum was well
scrubbed with soap and antiseptics. An incision was
then made the whole length of the swelling and
extending down to the tunica vaginalis; this was laid
open, the contents were evacuated, and the greater part
of the parietal portion of the tunica was removed ; it
was somewhat thickened, doubtlessly owing to the pre¬
vious treatment. The edges of the wound were then
brought together with catgut sutures, and a dressing
was applied. Mr. Evans said that the question of the
best method of. treatment depended greatly on the age
of the patient: in small children hydrocele was
common, but he had never seen a case in a young child
in which even tapping was required, for, according to
his experience, cases such as these always got well
without any form of operation. In the aged tapping
was all that it was advisable to do, at least in the
majority of cases, for such patients required to be
tapped only once or twice a year, and it was surely
better in such cases not to run the risk of a radical
cure, slight though that risk might be; yet there were
cases even amongst the old in which a radical opera¬
tion was perfectly justifiable, but the patient must be
in good general health and young for his years.
During the middle period of life it occasionally
happened that a single tapping was sufl 5 cient
to cure a hydrocele, or perhaps the fluid
might not re-collect after the second or third
tapping ; usually, however, it was not pos¬
sible to cure a hydrocele simply by removing the fluid,
and something more was required to be done. In many
cases injections of certain liquids after lapping the
sac led to a cure. Many liquids have been used for
this purpose which are quite discarded now. At one
time it was advocated to re-inject the fluid which had
been 'withdrawn ; port wine was also a favourite in¬
jection. At the present time there are only two liquids,
which are much used for injection in these cases;
one i9 a weak solution of iodine, the other is carbolic
acid. It is important in employing these liquids that
the inner opening of the cannula should be definitely
within the sac, otherwise the liquid is liable to escape
into the loose connective tissue superficial to the
tunica vaginalis, setting up a severe and painful,
though aseptic, cellulitis. Whatever fluid is employed,
the whole of it should be evacuated through the
cannula. This method is sometimes successful; its.
mode of action is by no means certain. The cause of
a persistent hydrocele is the excess of secretion of
hydrocele fluid over the absorption. This may be
produced in either of two ways: the amount secreted
may be abnormally great or the power of absorption
may be diminished. Even in a perfectly healthy
tunica vaginalis fluid is always being secreted and
always being absorbed. How the injection acts is not
' clear. At one time it was thought that the injection
I led to obliteration of the sac of the tunica vaginalis,
but this certainly does not occur; probably the in¬
jection diminishes the secreting power of the lining
epithelium without impairing the absorptive power.

The radical cure of hydrocele consists in the
removal of part of the whole of the parietal layer.
When this method was first introduced, after the
tunica had been incised and more or less of it re¬
moved, the wound was plugged and allowed to-
granulate up from the bottom; in fact, sometimes an
incision was simply made without any removal of the
parietal tunic; the method was effective, but very
tedious. It is far preferable to excise the whole of
the parietal layer and to close the wound; no

zed by G00gle

Digiti:

Nov. 20, 1907.

552 The Medical Press. TRANSACTIONS OF SOCIETIES.

drainage is required. The theory of the method is I
this: By removal of the parietal tunic we diminish I
the secreting area by at least half, and sometimes by
much more in cases where the sac has been much
dilated ; moreover, what remains of the cavity is made
to communicate with the extensive subcutaneous tissue
of the scrotum, all the interspaces of which communi¬
cate freely with the lymphatic system, so that its
absorptive power is almost unlimited. The method is
very satisfactory, but the utmost care must be taken
to secure asepsis, and it is recognised that it is excep¬
tionally difficult to render the skin of the scrotum
aseptic. The higher the incision is made, the smoother
the skin, and the less the chance of sepsis, and by
turning the tunica vaginalis inside out, it is possible
to excise its parietal layer through an incision com¬
mencing immediately below the pubic crest.

The wound healed by first intention except for one
stitch abscess. No recurrence took place.

TRANSACTIONS OF SOCIETIES.

ROYAL ACADEMY OF MEDICINE IN IRELAND.

Section of Surgery.

Meeting held Friday, November ist, 1907.

The President, Sir Henry Swanzy, in the Chair.

SOME UNUSUAL ABDOMINAL CASES.

Mr. Graves Stoker read a paper in which he gave
the clinical history of a number of interesting
abdominal cases. In one of these, a woman, who
had suffered for a number of years from almost
incessant vomiting and extreme emaciation, and who
had been diagnosed by a late distinguished Dublin
surgeon as having malignant disease of the stomach,
obtained complete lelief from her symptoms after an
exploratory laparotomy in which the stomach was
found to be quite normal. In another case, apparently
of hydronephrosis, the patient, a woman, had the
power of emptying the sac, whose capacity was several
pints, more or less at will.

Dr. Wheeler said all the cases showed points of
interest; and spoke with approval of the results
obtained through the adoption of the method of con¬
tinual saline injection as practised by Murphy, of
Chicago. The theory advanced by Murphy to explain
the great improvement in his results was that the
lymphatic circulation in the abdomen was reversed,
and the saline pouring in prevented the toxins of pus
going the other way.

A CASE OF LIGATURE OF THE INNOMINATE ARTERY.

Sir Thomas Myles read his communication on this
subject. In the course of his extremely interesting
paper he described the symptoms and signs presented
by a male patient, aged twenty-nine years, who
suffered from a right sub-clavian aneurysm. He gave
the reasons why he was led to Teject treatment by
Symes’ method of opening the sac, followed by liga¬
ture of the artery on the proximal and distal sides,
and also the treatment by distal ligature alone in
favour of ligature of the innominate artery. The
chief of these was that the most frequent cause of
failure in previous attempts—namely, secondary
haemorrhage induced by sepsis—could now almost
certainly be prevented. Most of these operations had
been carried out in the pre-antiseptic era, while Mt.
Coppinger’s case, which was brilliantly successful,
was performed with strict antiseptic precautions. He
then discussed the methods of approach of the artery,
finally selecting a median incision in the lower part
of the neck, the ligature being accomplished without
either division of the sterno-mastoid, resection of the
inner end of the clavicle, or trephining the sternum.
In addition to securing the innominate he placed a
double ligature on the right common carotid dividing
the artery between. He expressed the opinion that in
carrying out this step he left too short a distance
between the two ligatures, and that to this the failure
of the operation was due. He then detailed the sub¬

sequent progress of the case, which was at first very
favourable. The wound healed by the first intention,
the pain caused by the aneurysm disappeared, and the
patient felt very well. The pulsation in the aneurysm,
however, persisted. About ten days after the opera¬
tion a large subcutaneous haemorrhage occurred,
which was treated by reopening the wound and securing
the bleeding vessel, which could not be identified.
Subsequent haemorrhages, however, took place
necessitating further operations which for a time
checked the bleeding. The wound now began to sup¬
purate, the haemorrhages continued to take place, and,
finally, the patient died about a month after the first
operation. The post-mortem examination showed that
the source of hemorrhage was the carotid artery from
which one of the ligatures had slipped.

Mr. William Taylor said there were, after all, only
two reasons why success should not attend the effort
to ligature the innominate artery—first, failure in the
establishment of the anastomotic circulation of the
brain ; and, second, sepsis. One ought to be able to
control the latter, and, therefore, should be able to
control the secondary hffimorrhage. Yet they all knew
how possible it was for some septic infection to creep
in, and in Sir Thomas Myles’ case it was just possible
that there may have been some source of infection in
the bottom of the wound in the deep structures. Bar-
well had drawn attention to the fact that death in such
cases almost invariably arose from secondary hemor¬
rhage, and had stated that if ever he came to ligature
the innominate artery he would ligature the vertebral
artery as well as the innominate and carotid.

Sir Thomas Myles, in replying, stated his belief
that the cause of failure was that the ligature on the
common carotid had slipped.

OPHTHALMOLOGIC AL SOCIETY OF THE
UNITED KINGDOM

Meeting held Thursday, November 14TH, 1907.

Mr. R. Marcus Gunn, F.R.C.S., President, in the
Chair.

Mr. J. Herbert Fisher read a paper on some cases
of

interstitial keratitis from acquired syphilis.
Before reading notes of four cases which he had
personally observed, he expressed his surprise that so
few instances of interstitial keratitis from acquired
syphilis had been brought before the Society: this was
the more regrettable seeing that Mr. Jonathan
Hutchinson, when vacating the Presidential chair,
had especially directed the attention of members to
this subject as one upon which information might
usefully be collected. The text-books dismissed the
subject with very brief reference, and gave no authori¬
tative statements as to frequency, date of onset,
severity, and prognosis of the disease. After reading
notes of his four cases, and alluding to one of corneal
inflammation which rapidly followed the primary
inoculation of syphilis on the lower eyelid, Mr. Fisher
expressed his opinion that interstitial keratitis from
acquired syphilis was generally a tertiary manifesta¬
tion: that it appeared usually to attack only one eye,
and that the infiltration frequently limited itself to a
portion only of the cornea—that the keratitis, as far
as it went, was identical in clinical appearances with
that due to inherited disease, and that the statement
which had been made by Nuel, that it was usually
secondary to irido-choroiditis, was by no means
universally accurate. Mr. Fisher further read notes
of a case of interstitial keratitis in the child of
a mother who had herself inherited syphilis, and who
had in consequence suffered from kerato-iritis, with
choroiditis and deafness. The question of the trans¬
mission of syphilis to the third generation was raised
upon this case : assuming the husband of a woman,
who had inherited syphilis, to have acquired syphilis,
the point was raised whether she was more or less
likely than a wife free from inherited taint to bear
syphilitic children to him. Other practical points of
discussion were raised, and members were invited to

zed by GoOgle

Nov. 20, 1907.

TRANSACTIONS OF SOCIETIES. The Medical Press. 55 ?

contribute their experiences, in hope that evidence
might in time be obtained which would be of guidance
both to ophthalmic and general surgeons, in answer¬
ing the questions which might be addressed to them
as to the advisability of marriage by patients who were
the subjects either of inherited or of acquired syphilis.

Mr. Thomson Henderson (Nottingham) read a paper
on the

ANATOMY OF THE SO-CALLED L 1 GAMENTUM PECTINATUM
1 RIDIS, AND ITS BEARING ON THE PHYSIOLOGY AND
PATHOLOGY OF THE EYE,

a full abstract of which will be found under the head¬
ing of “Original Papers,” page 543.

WEST LONDON MEDICO-CHIRURGICAL
SOCIETY.

Clinical Evening.

Meeting held November ist, 1907.

The President, Mr. Richard Lake, F.R.C.S., in the
Chair.

The following patients were shown :—

Dr. Arthur Saunders.—A boy, aet. 6, with chronic
disseminated myelitis. The patient was attacked with
scarlet fever a year ago, this was followed a fortnight
later by the onset of paraplegia with anaesthesia of
the legs and lower part of the trunk. His condition
has remained practically stationary since that time.

Dr. F. S. Palmer. —A boy, aet. 15. Primary pro¬
gressive myopathy of the facio-scapulo-humeral type.
No nervous disease in family. Five brothers and two
sisters living and well. Patient was quite well until
18 months ago, when he first complained of fatigue
and weakness in arms and shoulders, at the same time
it was noticed that the facial muscles were weak. The
wasting and weakness have been steadily progressive.

Dr. Blair. — (1) A youth with congenital absence of
iris. In the right eye the iris is entirely absent, and
the lens is deficient at its lower edge, and has a small
anterior pyramidal cataract. The left eye has
practically the same defects. His father and sister
have somewhat similar congenital anomalies of the
iris. (2) A case of misplaced pupils.

Dr. Seymour Taylor. —Man, aet. 34. Perforation
of aortic valve. The patient had lead colic on two
occasions, and has a typical Hue line on the gums.
While lifting a heavy weight experienced severe pain
in upper zone of chest, choking sensation in throat,
and faintness. There is a diastolic thrill all over the
front of the chest, and a loud diastolic musical
murmur is heard all over the chest, back, and front;
also over the upper half of each humerus.

Mr. McAdam Eccles. —Man, aet. 45. Charcot’s
disease of left knee. Signs of locomotor ataxy for
three years. The pupil reaction is only present on the
left side. The joint became largely distended with
fluid in three days and without pain. Fifteen ounces
of fluid were aspirated from the joint, and a plaster
case applied. While this was on no re-collection of
fluid took place, but on its removal the joint became
distended in the same time as before.

Mr. Aslett Baldwin. —(t) Female, aet. 29. A case
of excision of the rectum for carcinoma by an ab-
domino-anal method. Admitted with complete intes¬
tinal obstruction of 10 days’ duration. Colotomy was
performed. Later the abdomen was reopened and the
attachments of the rectum divided as high as the sig¬
moid flexure. The anus dilated, and the bowel and
growth forced out through the anus, forming an in¬
tussusception. This was cut off externally, and the
bowel united by circular suture and returned. The
sigmoid is attached a short distance above the anus.
The patient has perfect control and normal action of
bowels. (2) Man. Lengthening of left leg and exten¬
sive nevus of left half of body. A venous ntevus
occupies the left side of the trunk and most of the
left thigh, leg and foot. The left leg is 2$ inches
longer than the right, and the left foot is $ inch longer,
but the left calf measures 11J inches in circumference,
whereas the right measures 13 inches. Varicose veins
are also present in the left leg. (3) Man, aet. 30. Car¬
cinoma of right breast. Noticed lump about 10

months, which has been ulcerated about a month. Two
secondary growths in skin near the primary one,
numerous hard, enlarged glands in axilla. A micro¬
scopical section of one of the secondary growths
showed typical scirrhus carcinoma. (4) Girl, aet. 4.
Tumour of scapula, etc. The enlargement of the right
scapula was noticed two months ago. The lower end
of the right fibula is markedly thickened, and nodules
can be felt on the metacarpal bones and phalanges of
the right hand. There appears to be no pain or tender¬
ness.

LIVERPOOL MEDICAL INSTITUTION.

Meeting held November 7TH, 1907.

Mr. T. H. Bickerton, Vice-President, in the Chair.

AN UNUSUAL CASE OF ATAXIA.

Dr. F. J. S. Heaney described and showed a case of
ataxia presenting an unusual combination of symptoms
and some difficulty in diagnosis. The patient, a
painter, aet. 52, developed a spinal curvature in the
dorso-lumbar region when two years old, presumably
as the result of caries. The curvature had caused no
symptoms, and the patient had never had syphilis.
Ataxia, Rombergism, absence of knee-jerks, numbness
of the feet, and diminution of pressure sense over the
lower extremities appeared six months ago. There
were no Argyll-Robertson pupil phenomena, no
lighting pains, and no interference with the fields of
vision or with cutaneous sensation. Muscle power and
sphincters were normal. Cutaneous reflexes were
normal, the plantar being flexor in type. The only
alterations in his condition in the last six months were
a transient left ankle clonus and a recent slight return
of right knee-jerk. The differential diagnosis between
tabes, combined system degeneration, and recurrence
of spinal caries with focal myelitis and posterior
column degeneration was discussed, Dr. Heiney de¬
ciding in favour of the last diagnosis.

Dr. T. R. Bradshaw said that the unusual fea¬
ture in the case was the temporary restoration
of the knee-jerk. The present condition, apart from
the history, would justify a diagnosis of tabes, and
often in cases which were obviously specific, no history
of infection could be obtained. The Argyll-Robertson
pupil was only observed in about 80 per cent, of cases
of tabes. If the knee-jerks returned again, he would
suggest that the ataxia was due to a neuritis possibly
caused by lead (there was a history of lead colic),
producing a condition analogous to alcoholic pseudo-
tabes.

_Mr. R. J. Hamilton gave a short description of
Kroenlein's operation, and showed a successful case
in which this operation had been done for a tumour
surrounding {he optic nerve and causing considerable
proptosis. The tumour was a spindle-celled sarcoma,
and measured ij by i| inches. The results were—an
eye with good vision, perfectly free movements, and
very little scarring in the temporal region, the seat of
the incision.

Dr. K. Grossmans remembered being consulted by
the same patient, who had been told at an eye hospital
that the proptosis was due to one-sided exophthalmos,
and recommending an operation. At that time a hard
tumour could be felt between the lower outer orbital
margin and the eyeball, and it was an open question
whether it could not have been removed by a simple
incision along the lower margin of the orbit. He
considered that Kroenlein's operation was suitable for
cases of retio-ocular tumour which could not be re¬
moved from the front without severe damage to the
eyeball. Dr. Grossmann described some of the modi¬
fications of the operation.

Dr. Stoopes and Mr. E. M. Stockdalf. also spoke.

Mr. C. Thurstan Holland showed, and explained
the working of, the Levy-Dorn Orthodiagraph, which
had been in use at the Royal Infirmary since last June.
This pattern allowed of the patient being examined
either lying down, standing, or sitting. It was pointed
out that the lying down position was undoubtedly the
best, and for this Mr. Holland had found the instru¬
ment devised by Professor Moritz the more reliable
and the easier to work. Tracings of hearts at different

Digitized by GoOgle

554 The Medical Pres s.

ages were passed round. Mr. David Morgan gave his
experience of this and other methods.

Mr. Douglas-Crawford read a note upon two cases
associated with elongated meso-caecum : (i) Volvulus
of the caecum in a woman, aet. 39, the toxsioned mass
lying above the umbilicus on the left side. Early
operation resulted in a successful untwisting of the
mass, and the patient made a good recovery. (2)
Malignant caecum in a man of 3?. The “ lump ” lay
in the right lumbar region, moved freely with respira¬
tion passing up behind the liver, and down as fai as
the iliac crest, but not reaching the iliac fossa. The
mass was excised, and later the faecal fistula closed,
but only after a lateral anastomosis had been effected
between the ileum and the transverse colon. The
patient was perfectly well one year after the excision
of the growth.

Dr. F. M. Gardner-Medwin gave a demonstration
of the

ROTH-DRAGER OXYGEN-CHLOROFORM APPARATUS,
with a short note and report on 25 cases. The advan¬
tages of the apparatus were—regular doses of known
quantity and the easy control of the concentration of
atmosphere. It was compared with other mechanical
apparatus, and stated to be of great value in serious
cases when ether narcosis was contra-indicated. The
cases reported were all serious ones and mostly of
long duration. They all showed complete absence of
cyanosis, and in cases where ether had caused profuse
salivation and venous engorgement the apparatus was
particularly useful. One case of empyema, although
the patient was unable to lie down and coughed up
pus continually, after a few breaths of free oxygen
easily bore the gradual exhibition of chloroform, and
was able to lie down and take the anaesthetic quite
easily. . .

Dr. Fingland said that the method of administering
oxygen with chloroform was suggested by Mr. T. G. H.
Nicholson, of Liverpool, some years ago, and that his
apparatus was figured in the British Medical Journal
in 1896. Mr. Nicholson’s theory was that the lessened
blood pressure produced by chloroform, and the
corresponding slowing of respiration and circulation,
interfered with the elimination of carbonic acid and
caused its accumulation as an active toxine, which
condition would be prevented by the administration
of oxygen with the chloroform vapour. But Dr.
Fingland was of opinion that the effect of the
admixture of oxygen with the chloroform would be
•to inhibit to some extent the combination of chloro¬
form with the red corpuscles of the blood, and by
this means remove the real danger of chloroform
narcosis. After referring in detail to several points of
the Roth-Drager apparatus, he suggested the more
extensive use of ether by the Rochester method of
administration as possessing the advantages of a safe
and natural anaesthesia.

Dr.. F. W. Bailey thought that the length of time
required for induction, and the difficulty which would
be probably met with in the case of full-blooded,
strong workmen, and the complications of the
apparatus, would prevent it coming into general use
in hospital practice, while its cumbersomeness and want
of portability would make it difficult to use in private
practice, and furthermore, he saw difficulties in the
way of using it for mouth operations. The admini¬
stration of anaesthetics could not be reduced to “rule
■of thumb.”

Mr. G. P. Newbolt said Dr. Medwin had used the
apparatus many times in major operations on patients
under his care. He was convinced that it was a most
efficient way of administering chloroform. Patients
appeared to suffer less from shock, and their condi¬
tion was better than when chloroform was given by
one of the usual methods. He was not certain
whether the oxygen caused some slight bronchial
irritation, and suggested that it should be warmed
before being inhaled.

The Public Health Committee of Leith Town
Council, at a meeting on November 12th, agreed to
recommend the Council at their January meeting to
adopt the new Notification of Births Act. They also
resolved to ask a remit from the Town Council to intro¬
duce a system of supplying Buddeised milk.

Nov. 20, 1907.

CORRESPONDENCE.

1**011 OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Part*. Nov. 17th, 19*7.

Broncho-Pneumonia in Young Children.

Broncho-pneumonia affects particularly scrofulous
children or those with some hereditary taint, but also
children recovering from some secondary affections as
grippe, measles, diphtheria, whooping cough, and is
particularly prevalent in the winter season. Over¬
crowding in schools exercises a real epidemic influence
where the dust carries, not a specific microbe as has
been proved, but variable micro-organisms distinct
from the agent of the initial cause. All kinds of
germs are found, pneumococci, streptococci, baccilli of
Friedlander, to which are added the septic flora of the
buccal cavity and of the air inspired. Hence the
necessity of careful antisepsy of the nasal fossae and
of the mouth, and the periodic ventilation of the school
rooms.

The bases of the lungs are first affected ; dry
crepitating riles constitute the first signs, followed
soon afterwards by murmur, at first soft, then loud
and frequently surrounded with sibilant riles.

The dyspnoea is intense, the cough short and pain¬
ful. Very young children do not expectorate, but
those of two or three years expectorate mucus at the
period of coction.

Antisepsy of the nasil foss® and the mouth is
always necessary. For the former, the following oint¬
ment should be introduced : —

Salophen, £ dr.

Boric acid, £ dr.

Menthol, n gr.

Vaseline, 1 oz.

While the mouth and throat should be sprayed with : —
Phensalyl, 10 gr.

Chloride of sodium, £ dr.

Boiled water, 1 pint.

The patient should be isolated from other children,
when possible, and kept in a warm room, and the air
charged with the vapour of eucalyptus and thymol: —
Eucalyptus oil, 15 gr.

Menthol, 15 gr.

Thymol, 15 gr.

Ess. of lavender, 1 dr.

Tincture of tolu, 2 dr.

Proof spirit, 4 oz.

A teaspoonful in a saucepan of boiling water and
covered with a funnel. Where this method cannot be
employed, essence of turpentine poured on a plate
placed near the bed of the child and renewed from
time to time is good practice, as turpentine sends off
ozone vapors.

Revulsives, such as cupping, blisters (carefully
dressed with iodoform ointment), warm poultices
powdered with mustard, are always indicated, but in
very young children rubefacient friction with the
following liniment should be preferred : —

Ess. of turpentine, 1 oz.

Liq. ammonia, £ dr.

Lini sinapis co, 1 dr.

Lavender spirit, 2 oz.

Under five years of age, the lower extremities of the
children should be enveloped in absorbent cotton,
covered with impermeable tissue in order to provoke
sudation of the limbs with consequent vaso-dilatation
of the vessels.

Calomel, quinine, aspirin are indicated during the
first few days, and the heart should be sustained with
digitalis, rum, punch, etc. When expectoration
appears it should be encouraged by

Antimonial wine, 20 drops.

Syrup of poppies, 1 dr.

Gum water, 4 oz.

A teaspoonful every two hours.

Artificial Abscess.

Artificial pyogenesis, says Prof. Thiroloix, should
always be regarded as an exceptional method reserved

Digitized by CjOCK^Ic

CORRESPONDENCE.

Nov. 20, 1907.

CORRESPONDENCE.

The Medical Press. 555

.for the gravest cases, those that might be called
“desperate.” It should never be currently employed,
as in the first place it provokes great pain, and,
secondly, it requires during its development careful
aseptic treatment.

When, in presence of acute or sub-acute septicaemia
■{without localised visceral suppuration), due to
streptococcus, staphylococcus, or pneumococcus, and
resulting from an attack of grippe, pneumonia,
broncho-pneumonia, from scarlatina, typhoid fever,
or puerperal injection, the first treatment should con¬
sist in injections of antistreptococcal serum or pre¬
parations of yeast. If this agent has no effect, intra¬
venous injections of collargol should be tried :—
Collargol, 15 gr.

Sterilised water, 4 oz.

One drachm injected into the cephalic vein or one
of the large superficial veins of the leg.

Subcutaneous injections of nucleinate of soda (1 gr.
■every six hours) have also a salutary effect.

If all this treatment seems of little avail, a last
chance should be given to the patient by the creation
of an artificial abscess. For this purpose the region
selected for the abscess (flank, deltoid region, middle
and external third of the thigh) should be disinfected
by soap and water, followed by proof spirit and
■ether. With a sterilised hypodermic syringe, 20 drops
of essence of turpentine are injected into the cellular
tissue and the parts immediately covered with anti¬
septic gauze.

A few hours after the injection the patient com¬
plains of smart burning pain, and soon patches of
inflammation appear, and the region becomes oedema-
tous. This diffuse inflammation lasts one or two
■days, when the tumefaction becomes circumscribed,
the pain disappears, and the abscess begins formation.
The reaction can be either nil, moderate, or acute.'
Where it is nil, the prognosis is very grave, as it indi¬
cates that the infection is going to terminate fatally.
The organism is not able to react to the solicitation
of the chemical agent. Where the reaction is
moderate, the abscess continues to slowly develop. In
such cases it should not be opened too soon, and,
above all, not until all unfavourable symptoms have
disappeared. Perhaps the creation of another abscess
may be necessary. In any case, subcutaneous in¬
jections of nucleinate of soda should be given as a
general stimulant to the organism.

Acute reaction of artificial abscess is a very good
sign, and renders the prognosis very favourable.

GERMANY.

Berlin. Nov. 17th. 1907. _

The Archiv. f. Klin. Chirurgie, 83, I., contains a
paper by Dr. Berger on

Injuries to the Abdomen by Blunt Force,
in which four cases of operation of special interest
are related.

The first was a case of rupture of the spleen. A
soldier, 19 years of age, fell out of bed, striking the
left side of his body on the comer of a footstool. The
general symptoms (great pallor, an anxious expression
of face, difficult breathing, small frequent puls'e)
pointed to haemorrhage into the abdominal cavity ; the
local symptoms (increased dulness in the splenic region
-that did not change on change of position, and
abrasion of the skin over the ninth rib) pointed to the
spleen as the source of it. The anaemia, which was
rapidly increasing, demanded immediate operation.
This, performed 24 hours after receipt of the injury,
showed a rent in the spleen 8 cm. in length, reaching
to the hilus, with blood still flowing from it. Plain
signs of internal haemorrhage had not shown them¬
selves until within 12 hours of the injury. As the
quickest and safest mode of treatment, ligature and
■extirpation of the injured organ were performed. In
the after-treatment saline infusions were many times
demanded and made use of. Eight weeks after the
operation the patient was quite well, with the excep¬
tion of some paleness, which the writer attributed to
slowness in blood regeneration. No swelling of the
lymph glands or of the thyroid was observed. The
literature of cases hitherto published (241 cases) gave
the mortality as 39 per cent (2) Traumatic chole¬
cystitis. There were two cases of this. In the first

case a man was thrown from a horse, dragged 50 yards,
and received several kicks on the right side, after
which a chronic cholecystitis developed. At first there
was great pain without any objective symptom ; later
on the pain diminished, and at tim>s ceased alto¬
gether. At last attacks came on with great pain in
the region of the liver, vomiting, slight jaundice, and
some fever. An operation, performed three months
after the injury, showed coffd-like adhesions between
the omentum and the anterior abdominal wall, firm
adhesions between the lower margin of the liver and
the same wall, and the gall-bladder, which was free
of stones, and was long, flaccid, and half-filled, was
adherent to the colon. Cystotomy was performed after
separation of the adhesions. Permanent closure of the
fistula took place four months later.

In the second case a woman fell with her right side
on to the edge of a water pail. The day after she felt
a longish movable tumour in her right side, but felt
well. On the second, symptoms of peritonitis appeared
which indicated a serious condition. An operation
showed the presence of gall-stones (17 in number),
which, as they were formed into a firm conglomerate,
had not up to then set up any irritation of the mucous
membrane. It was only the injury caused by the fall
in which the mucous membrane was bruised between
the sharp edge of the pail and the gall-stones that per¬
mitted the invasion of bacteria to set up any injury.
Here again cystotomy only was called for, and healing
was complete 39 days after the operation.

The next was a tumour of the mesentery after an
injury. This case proved fatal, but the surprising con¬
dition met with at the autopsy made it very interesting.
A soldier, aet. 24, who had previously always been
healthy, felt a violent stabbing pain in his right side
as he sprang over a ditch, but did not make any com¬
plaint until four days afterwards. At first some ten¬
derness on the right side of the abdomen, with slight
resistance, gave rise to a suspicion of typhlitis. In
the evening, after energetic bodily movement, there
was considerable increase of pain, along with vomit¬
ing, and the following morning a tumour the size of
a child’s head was felt to the left of the umbilicus.
Vomiting was present with meteorism, no flatus or
stool passed, and the pain was extremely violent. On
an operation being performed, a tumour of ihe mesen¬
tery was found that had been latent up to then, but
which had got considerably larger through haemorrhage
into it. The tumour was a sarcoma. Drawn out over
the tumour, flattened like a cord, and rather sharply
kinked, ran the ureter, too much compressed to allow
the urine to flow freely, so that the kidney was in a
state of acute hydronephrosis. The tumour could not
be completely removed, as it passed too deeply down.
The next morning collapse took place, with loss of
consciousness, rigidity of pupils, convulsions both of
the trunk and extremities, and later on Cheyne-Stokes'
respiration. As uremia was suspected, the right,
kinked, ureter was drained. The breathing became
quieter and the convulsions ceased. The following
morning, however, the patient died, in spite of saline
infusions and excitants. The autopsy quite cleared up
whatever was doubtful. There was a tumour (sarcoma)
the size of a hen’s egg of the posterior lobe of the
brain, numerous metastases the size of walnuts in both
lungs, a metastatic tumour of the glands extensively
adherent to the vena cava, and to some extent pene¬
trating it.

It was remarkable that all these growths had so
little affected the vital organs that the soldier was on
duty up to a few days before his death. All that had
been observed was that for a few weeks he had been
morose and negligent, there had been twitching of the
left eye, and he had once complained of weakness of
sight. The cause of death was the cerebral haemor¬
rhage, of which the first symptom was the vomiting
that took place the day after the operation.

AUSTRIA.

Vienna. Nov. loth, 1907.

Radiation and Necrosis.

At the Gesellschaft. Churmont exhibited a case on
which he had repeatedly operated for empyema in the
frontal bone from excessive use of the ROntgen rays.
By separating a portion of bone and periosteum from

Digi

556 The Medica l Press.

CORRESPONDENCE.

the margin of the wound, he succeeded in closing the
wound completely.

Schopf recorded a similar case of an osseous defect
in the left frontal bone involving the orbital margin
and ethmoid bones. He used Fraenkel's celluloid
heteroplastic appliance, and obtained an excellent
result, both cosmetically and functionally.

Hypertrichosis.

Halban showed a gravid guinea-pig with an enor¬
mous profusion of hair on the body which always
occurred in pregnancy. He has devoted two years to
this subject in the lying-in hospital, and finds this is
the case in the skin of females of the human sex also
Detachment of the Retina.

Sachs described what he termed a new method of
treating detached retinas, and exhibited a woman,
set. 49, on whom he had performed the operation for
blindness of the right eye owing to the retina being
completely separated from the sclerotic base. Later the
left eye commenced in the upper quadrant, which he
treated by puncture, injections of a salt solution, and
a bandage.

His new operation for the right eye was described as
first anaesthetising by means of cocain, separating the
superior rectus muscle, then with a curved knife cutting
the ball equatorially parallel to the ora serrata, and
liberating the serous fluid from below the letina. The
result was a replacement of the retina, and a rapid
healing of the linear incision, as the precaution of
cutting the rectus muscle hastens the repair. In this
case a small amount of fluid collected afterwards
behind the retina between the cicatrix of the incision
and the ora serrata, but this did not interfere with the
field of vision. He thought this opening produced a
mole or dam to the extension backwards of the fluid.
He had operated on several cases with perfect success,
and thought he saw in this operation as great a future
as that of aspirating the thorax for pleuritic effusion.

Miiller thought that great caution was necessary
where ablatio retinae existed, as other operators in
different countries had not obtained such favourable
results—indeed, they condemn the operation as abso¬
lutely injurious. Every form of puncture was dele¬
terious and damaging to the eye, more particularly in
those advancing in life.

Secondary Vaccination.

Mautner showed a child from Prof. Monti’s Klinik,
set. s, with secondary vaccination on the right side of
the tongue. The child was vaccinated on the right
arm previously, which took very well, but after the
vesicles of the arm broke it became very itchy, which
caused the child to rub them with its fingers, which it
subsequently put in its mouth, with the result that a
large vesicle formed on the right side of the tongue.
The child appears to have had a carious tooth that cut
the tongue in the first place, admitting the virus to
the system, and producing the usual primary vesicle.
Now arises the question—would the child have taken
small-pox as easily as if it had never beer done in the
first instance? It seems all the susceptible matter was
not used up, or the second vaccination should not have
been successful. This subject is still far from satis¬
factory.

Necrosis of Bone.

Eiselsberg showed a patient on whom he had
operated for necrosis in the upper arm. The entire
humerus was removed, but the periosteum preserved,
from which restitution was expected. The function of
the arm was now good, while the muscles were strong,
and the grip of the hand as firm as ever. The Rontgen
rays revealed a small lamella of bone at the distal
end of the humerus, and a small spicula about the
middle of the upper arm. The upper arm can be
twisted round 360 degrees, entirely checking the pulse
at the radial artery.

A Giant Growth.

Kienbock, amid some amusement, brought in an
Anak, aet. 27, in excellent health. He was 202 centi¬
metres, = 6 ft. 8 in. in height, and weighed qq kilos.,
or 15} st. The hands and feet were proportionately
long, 24 and 32 centimetres respectively. The cranium
was not increased in proportion to the body, being
56.5 centimetres in circumference ; forehead low and
face long ; heart orthoscopic on the Rontgen shadow,
and measuring 13 centimetres horizontally.

Nov. 20, 1907.

FROM our special

CORRESPONDENTS AT HOME.

SCOTLAND.

Clinical Teaching in Glasgow.—A discussion on
this subject has been going on in the columns of the
daily Press for some weeks, the question at issue being
whether the Western Infirmary is able to give adequate
instruction, or whether the other Glasgow hospitals
should take part in clinical teaching. Though there
is no compulsion on the students to attend the
Western Infirmary, its proximity to the University and
the fact that the Clinical Professors, who are the
examiners, teach there, offer a strong inducement to
the students, with the result that some of the clinics
are overcrowded. It is suggested by way of remedy
that all the Glasgow clinical teachers should be made
examiners, whether they are attached to the Western
Infirmary or not, and that cars should be run at
special hours, so as to get over the difficulties of
distance. The supporters of the status quo urge that
what is required is a more uniform distribution of the
students among the clinics of the Western Infirmary.
On the medical side of the hospital the students are
fairly well divided among the examining and the non¬
examining physicians, but on the surgical side two-
thirds of the students crowd to one teacher of clinical
surgery, while the remaining five teachers, though one
is an examiner, have only one-third of the students.
Evidently, therefore, it is very desirable that some
means of dividing the students among the six surgeons
should be devised ; were this done, it would be easy
to limit the clinics to about 25 men, and to arrange
that each student should attend the wards of several
teachers in succession.

Edinburgh University : Lord Rector’s Assessor.
—The Rt. Hon. R. B. Haldane has appointed Mr.
James Walker, C.A., his assessor on the University
Court in succession to Lord Dundas. No better repre¬
sentative of the interests of the students could have
been selected than Mr. Walker, who for years as
treasurer of the union has laboured indefatigablv on
their behalf. His appointment will be deservedly
popular.

Glasgow Graduation Ceremonial.— The disorderly
scenes which were witnessed at the recent graduation
ceremonial were discussed at a mass meeting of the
students held on the nth inst. A resolution was
passed expressing regret at the disorder, particularly
as it had been constnied as showing a lack of
sympathy with the Principal, and apologising for the
same. Mr. W’atson, President of the S.R.C , said be
confessed they had unwittingly insulted the Principal—
at least he regarded their conduct in that light. In
view of this, the only manly course was to offer an
apology to Principal MacAlister. The apology was to
the Principal personally, not to the Senatus. Two
students were appointed to wait on the Principal, and
convey the apology to him in person. The cause oi
the disturbance is alleged to be the Insufficient accom¬
modation provided in the Bute Hall. It had been
desired to secure the St. Andrew’s Hall for the gradua¬
tion, but the proposal was overruled by the Senatus—
hence the rowdyism.

BELFAST.

The Irish University Question.— The questions
connected with Irish University education, and
specially the question of the desirability or otherwise
of having a Northern University in Belfast, are a
good deal before the public now, partly on account
of Mr. Birrell’s recent speech, and partly on accou™
of the plain words of Lord Kelvin in his address
read at the opening of the new laboratories at Queen s
College a few weeks ago. During the past week there
have been two public references to the question in
Belfast. On Monday night Professor Moore, oi
Liverpool, gave an address to the Medical Students
Association at Queen’s College, in which he dealt
with University education generally, and reterrea
specially to local conditions m Ulster. He expresses

Nov. 20 , 1907 . _CORRESPONDENCE._ The Medical Press. 557

in the strongest possible terms his belief in the de¬
sirability of an Ulster University and his confidence
in its success. On Friday, at the distribution of prizes
by Lord Shaftesbury, the Lord Mayor, to the boys of
the Royal Belfast Academical Institution, one of the
speakers, Mr. R. T. Martin, a solicitor closely con¬
nected with College affairs, spoke in much the same
sense. There can be no doubt that the public gene¬
rally is being educated up to the idea of a local
University, and a project which a few years ago was
openly derided and scoffed at by most University
men, and all non-University men, is now seriously
discussed on all sides, and received with a large
amount of favour.

The Milk Supply. —Mr. Nathan Strauss, of
Heidelberg, has offered to the Belfast Corporation a
complete outfit for the Pasteurisation of milk, but the
offer had to be refused, as the necessary expenditure
for the working of the scheme would not be legal, and
would certainly be surcharged by the Local Govern¬
ment Board auditors. Mr. Alec Wilson, whose model
dairy at Belvoir Parle was inspected by Lord and
Lady Aberdeen during their recent visit to Belfast,
has written an interesting letter to the local Press on
the question of tuberculosis and milk. He says that
experience shows clearly that a slight increase in price
will pay the dairyman well for his trouble in cleaning
up and supplying milk for which he can produce
medical and veterinary certificates; but to sell milk
warranted free from tubercle is a much more serious
affair. If one is content with a certificate that there
are no clinical signs of tubercle, and that the udders
of the cows are free from disease, the milk may be
sold at fourpence a quart from the dairy worked on
modern hygienic lines. But to warrant the milk free
from tubercle means the systematic testing of the cows
with tuberculin, and the slaughter of some 30 per
cent, of those tested, as well as many precautions to
avoid infection by other tuberculous animals, such
as pigs. This in practice will add about 25 per cent,
to the price of the milk, and it remains to be seen
whether there is a demand for such milk. If there is,
it will soon be supplied.

LETTERS TO THE EDITOR.

DISEASES OF TWINS.

To the Editor of The Medical Press and Circular.

Sir, —Will you kindly permit me to make use of
the columns of your medical journal under the fol¬
lowing circumstances?

On re-reading Francis Galton’s “History' of Twins,”
published in his work, “ Inquiries into Human
Faculty,” it occurred to me that, as he has proved
the greater strength of Nature over Nurture in this
investigation, the same material slightly modified
would be able to conclusively establish the relative
importance of the factors of individual constitution
and specific invading organisms in the production of
disease.

Accordingly, I had, as a beginning, 200 circulars
and addressed return envelopes printed, and subse¬
quently dispatched a little over 50 of them to test the
kind of response I was likely to meet with. I had
replies from over 40 per cent., and although I took
the precaution of sending only to general practitioners
of more than ten years’ standing, the evidence obtained
was decidedly disappointing. I had imagined, as twin
births are said to occur once in about every 90
maternity cases, that most practitioners who had been
in practice for a fev years would have had some
experience on this subject, even allowing for the fact
that twin children frequently die.

To my surprise, no less than 45 per cent, of my
replies stated that no experience had so far been
obtained ; 8 to 10 per cent, apparently do not practice
midwifery, or discourage it, and have not attended
twins at any later age period ; and only 45 per cent,
have had any experience, however meagre. Of these,
most appear to have had a few maternity cases, though
the answers were not always clear on this point: in
addition, 25 per cent, have once attended twin children
and 30 per cent, once adults. I am not quite certain

| whether one of these latter did not attend adult twins
; twice.

The number of replies is, of course, far too small
to make any generalisation upon the matter. A practi¬
tioner may possibly be unaware that he is treating a
twin when the pair are separated. Still, allowing for
this, the scarcity of material is remarkable. The
explanation may be possibly due to an error in
assuming that hospital statistics, drawn from the
poorest citizens, apply equally to all classes. In any
case, it is evident that I must appeal to a much larger
circle of medical men than can be done by any method
of private correspondence, in order to obtain the
necessary information.

Would any of your readers, therefore, who have in
their possession evidence on the points mentioned
below, kindly communicate with the writer whose
address is appended?

Twins, if they are true twins, are usually of the
same sex, and are most frequently either much alike
or much unlike.

(1) Of like twins of the same sex at any age period,
have you any medical experience of their sufferings
simultaneously or independently from like or unlike
diseases in like or unlike (separate) surroundings?

(2) Of unlike twins of the same sex at any age period,
have you any medical experience of their suffering
simultaneously or independently from like or unlike
diseases in like or unlike (separate) surroundings?

Please name specifically all diseases referred to, aa
this point is very important.

Any additional information on the subject would be
welcomed, and all remarks will, of course, be treated
confidentially.

I would be greatly obliged if Continental journals
would insert this letter in their issues.

Thanking you and your readers in anticipation for
your kindness in considering my letter,

I am, Sir, yours faithfully,

J. Lionel Tayler, L.R.C.P., M.R.C.S.

8, Adys Lawn, Willesden Green, London, N.W.

ANTI-TUBERCULOSIS DISPENSARIES.

To the Editor of The Medical Press and Circular.

Sir, —In your leading article of yesterday on the
Medical Officer’s report to the Local Government
Board, you lay due emphasis on the significance of
anti-tuberculosis dispensaries. The article suggests,
however, that these are extra-British in conception and
development. You suggest that they constitute a
French experiment, worthy to be carefully watched
with a view to possible imitation. I would remind
you, however, that both the conception and evolution
of the anti-tuberculosis dispensary are essentially
British.

In the campaign against tuberculosis, which was
initiated in Edinburgh in 1887, “the first step ” (I am
quoting from the official report) “was the establish¬
ment of the consumption dispensary. The purpose of
the dispensary was the formation of a central institu¬
tion, to which persons of the poorer classes, affected
by tuberculosis, might be invited and directed. The
idea was a novel one twenty years ago. For more than
a decade the Victoria Dispensary for consumption was
alone of its kind. Familiarity with its object has led
more recently to widespread recognition of the sig¬
nificance of die Dispensary. During the past half-dozen
years, consumption dispensaries have been created in
Belgium, France, and Germany, and in the last year or
two similar dispensaries have been founded in America,
the United Kingdom, and the Colonies. It is matter
for congratulation that the conception has proved to be
of such universal application and value.”

In the important Memorandum on the Administrative
Control of Pulmonary Phthisis, issued by the Local
Government Board for Scotland on March 10th, 1906,
the significance of dispensaries for pulmonary phthisis
is thoroughly recognised. “In towns and other thickly
populated localities, where the number of phthisical
patients is large, the local authorities will find it
advisable to institute a dispensary or dispensaries. In
Edinburgh, the Royal Victoria Dispensary for Tuber¬
culosis, organised by Dr. R. W. Philip, has worked
• successfully for 18 years, and the suggestions here

Digitized by GoOgk

558 The Medical Press.

OBITUARY.

Nov. 20, 1907-

made are largely based on the experience of that Dis¬
pensary.” .

At the inauguration of the new buildings in con¬
nection with the Royal Victoria Hospital for Con¬
sumption on October 25th last, Dr. Leslie Mackenzie,
speaking on behalf of the Local Government Board
for Scotland, said:—“We adopted his scheme as a
national system for the administration of the campaign
against tuberculosis in Scotland. The Dispensary in
Dr. Philip’s scheme is the centre, the exchange, the
information bureau, the nucleus of the whole system.

In the Victoria Dispensary we have a type of what we
hope to see realised in the district of every local
authority in Scotland. The function of a Dispensary
is to act as an information bureau, a supervision
bureau, a centre of treatment for such patients as do
not need hospital treatment, but who can benefit by
supervision at their own homes.”

These quotations will, I think, suffice to show that
the Consumption Dispensary is no longer at the experi¬
mental stage, nor does it seem necessary for us to go
outside our own country for a working model.

I am, Sir, yours truly,

Alexander Christison, Bart., M.D.
Edinburgh, November 15th, 1907.

HOT-WATER OPERATING TABLES.

To the Editor of The Medical Press and Circular.

Sir, —As I can claim priority for suggestion of hot-
water operating tables as a preventive of shock during,
or subsequent to, sustained operations (abdominal or
otherwise), 1 should feel much obliged if any members
of the surgical staff of hospitals would kindly state
their opinion of such a form of table. My suggestion
(which was adopted by most surgical instrument-
makers, and who still stock the said table) appeared
so long ago as 1889 in The Medical Press and
Circular and the other medical papers, so there has
been ample time to judge of the practical value of my
suggestion, and I should much value the opinion of
those who have found it has contributed to the pre¬
vention of shock and the assistance to recovery after
operation.

• Yours very truly,

Alexander Duke, M.D.

London, W.

A ROYAL COMMISSION ON QUACKERY.

To the Editor of The Medical Press and Circular.

Sir,—O ne of your medical contemporaries has
sought to throw some cold water on the project of a
Royal Commission on illicit practice, by the statement
that medicine is not an exact science, and that quacks
would produce patients who had been cured under
their treatment, and thus would scatter dust in the
eyes of the Commissioners. Does the State ask
whether political economy and the operations of the
money market are exact sciences before devising laws
to protect the people against common swindlers,
burglars, and pick-pockets? The State acknowledges
that its duty is to protect the people, and especially
the weak and simple, against the wiles or the violence
of the predatory classes. If the arts of medicine and
surgery together could not claim a single scientific fact
upon which to base themselves, it would be still easy
to demonstrate to all sensible men the fact that
fraudulent quackery is founded solely upon falsehood—
a mass of lies gross as a mountain, open, palpable.
Many cases within late years in the civil and criminal
courts have shown that the production of many patients
“cured ” by quackery is not enough to prevent the
ruin of a quack even when defended by leading
counsel. The average juryman is quite able to
recognise that the quack’s claim as a healer really
amounts to a claim to be a miracle worker; and the
juryman can see that miracles cannot be wrought in
the removal of organic disease by the inert messes in
way of drugs, or the bogus apparatus, which form the
stock-in-trade of the quack. In civil cases where the
exooser of quackery is on his defence—and even the
difficulties which civil procedure gives rise to are
great—the quack always comes out a sorry figure ; how
much more certainly would he fare badly before a

tribunal like a Commission, which, although it might
include some weak or prejudiced members, would be
composed in the main of sober-headed men of judg¬
ment. The result of the Australian one-man Com¬
mission, has, it seems to me, demonstrated the
practicability and the hopefulness of a Commission
(which would be armed with much wider powers at
home); and I sincerely trust that you will continue to
exert your influence in support of the movement first
suggested in your paper.

Yours, etc.,

Reformer.

November 15th, 1907.

rWe should welcome the outspoken views of readers
on this most important and practical of professional
topics.— Ed., M. P. & C.] _

OBITUARY.

SIR CHARLES F. HUTCHINSON, J.P., M.D.Ed.,
M.R.C.S. . .

It is with great regret that we record the death ot
Sir Charles Hutchinson, which took place last week.

It was known that Sir Charles had been desperately
ill for some time, but the accounts had been more
satisfactory of late, and his friends hoped he had
weathered the storm. Sir Charles Hutchinson was
educated at Edinburgh University, where he graduated
M.B. and C.M. in 1872, and M.D. in 1874. After
some preliminary steps, he settled down in practice in
the Riviera, where he attained great populantj and
had a large clientele for many years He gave up
practice to stand for Parliament, and he will always
be remembered in political circles as the Victor ot
Rye ” His sensational victory in that constituency
was the harbinger of the many late .
at the polls. Unfortunately he lost his seat at the
General Election, though he was wont to sa; y he
sixty other candidates to win theirs. All who knew
Sir Charles Hutchinson, whether they were on his side
of politics or not, were his admirers. His genuu p
sence, his warm heart, his witty speeches, and bs raq,
manner won all hearts. His defeat at the Gen«al
Election pained him greatly, at' »

in an atmosphere that just suited him. The Govern¬
ment, by way of consolation, gave him a knighthood,
and we are sure it was as popular an honour as anj
in the list. _

FLEET - SURGEON FREDERICK HARVEY,

We regret to record the loss of Fleet-Surgeon
Frederick Harvey, whose death took place cn Novem¬
ber 12th, in his 89th year. He entered the Na ^ “
assistant surgeon two years after Queen Victoria
ascended the Throne. The first vessel to which he wa,
appointed was the “Beacon,” employed on survejnng
duty in the Mediterranean. He was employed on
similar duty in the following year, and during the
winter of 1842-43 was in medical charge of the officer*
and men appointed to search for sculptured tombs and
marble antiquities in Xanthus. In 1849 h ? 2 p, j£
moted to the rank of surgeon, and joined the
“Sphinx,” Captain C. F. A. ShadweU. m the East
Indies When trouble arose with Burmah in 1852, in
this vessel he took part in the various operations, and
received the medal and clasp. He was promoted to
Fleet-Surgeon in 1861, end retired from the active list
in 1874. He was awarded a Greenwich Hospital pen¬
sion in 1894.

A. MacTIER PIRRIE.

We regret to announce the death, at the early age
of twenty-eight, of Dr. A. MacTier Pirrie, who, after
gaining high honours, including the Carnegie Research
Fellowship, in anthropology, was appointed an thro-
pologist to the Wellcome Research Laboratories at the
Gordon Memorial College, Khartoum and went out
to the Soudan in the autumn of 1906. Under the
direction of Dr. Andrew Balfour, the director of the
laboratories, Dr. Pirrie made his first expedition up
the Nile to the southern limits of tl ? e J

penetrated to remote parts of the Bahr-eM.haxal. A
second expedition took him to the borders of Abyssinia.

Diqi

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The Medical Press_ 559

Nov, j o, 1907._ REVI EWS

On the latter occasion he contracted fever, and was
compelled to return to England. He presented a
paper on his expeditions at the last meeting of the
British Association, but was prevented from being
present on account of his illness. Dr. Pirrie brought
Back a valuable collection of objects of anthropological
and other scientific interest, and at intervals during his
illness he was engaged on his report to the Carnegie
Institute and the Wellcome Research Laboratories,
Khartoum, for which institutions he acted jointly in
the work he carried out in the Soudan.

JOHN GARNER, M.A., Dub., L.R.C.S. and P., Ei>.

Dr. John Garner, Inspector-in-Chief of the
3 -lgyptian Public Health Department, died at Cairo on
October 26th after a short illness. He was third son
of Dr. W. Hastings Garner, for over 30 years Resident
Medical Superintendent of Clonmel Asylum. He was
Si graduate in arts of Trinity College, Dublin, and
L.R.C.P.S., Edinburgh. He began his professional
career as assistant surgeon of the Co. Down Infirmary,
and, after some subsequent service, went out with the
Austin expedition for the delimitation ot the
Abyssinian frontier in the capacity of surgeon in
charge. On his return from this expedition he obtained
a post in the Egyptian service, in which he worked
until his death. In 1905 he married Miss Hastings, of
Downpatrick, and so leaves a young widow to mourn
his early death.

ROBERT FITZROY BENHAM, M.R.C.S.

We regret to announce the death of Mr. Robert
Fitzroy Benham, of Earl’s Court Square, a well-known
surgeon, who founded the Queen's Jubilee Hospital,
Richmond Road, Earl's Court, which has since been
re-named the Kensington General Hospital. Mr.
Benham, who was fifty-four years of age, was the
inventor of numerous surgical and other appliances.
He was educated medically at St. George's College,
and took the diploma of M.R.C.S.England.

LITERARY NOTES.

We are at a loss to conceive what motive could have
prompted Dr. Herbert Hart to publish “Some Suc¬
cessful Prescriptions,” written, we are informed, “on
Monday, August 12th, 1907, after the evening sur¬
gery.” Under the head of “Skin Diseases,” without
any further explanation, we are recommended to give
15-grain doses of salicin. This, the author states,
splits up into carbolic acid and salicylic acid, which,
when absorbed, “ meet and destroy the pathogenic
microbe,” apparently whether present or otherwise.
All the 17 or 18 prescriptions are stock formulas, with¬
out the slightest claim to originality.

The second edition of a book on “The Hair
and Its Diseases ” has just been published by
Messrs. Bailliere, Tindall and Cox. Its author,
Dr. David Walsh, has devoted a good deal of
special study to this strangely neglected subject.
IIis advice to general practitioners to acquire the
elements of the subject is sound enough, for they
would be thereby enabled in many instances to keep
their patients from drifting into the hands of quacks.
This little handbook is short and concise, but covers
all the ground likely to be broken in ordinary practice.
From a casual inspection it appears to register a con¬
siderable advance on the first edition, and to be well
worthy of the general practitioner's attention.

■*##

It would be difficult to over-estimate the value of
the “ Index-Catalogue ” of the library of the Surgeon-
General’s Office, United States Army, Vol. XII.,
Second Series, which has just reached us. Especially
interesting must it be to those engaged in literary work,
as it renders available the literature of modern medi¬
cine and enables the student to trace the evolution
of scientific medicine. From the report of Surgeon
McCaw, the librarian, we learn that the present volume
contains 5,476 author-titles, 10,996 subject-titles, and
35,324 titles of articles in periodicals. So far as pub¬
lished, this great Index-Catalogue contains 290,862
author-titles, 367,104 book-titles, and 882,301 titles of

OF BOOKS.

articles in periodicals. But the mere enumeration of
figures gives a very inadequate idea of the value of
the work and of the obligation of the medical profes¬
sion to the United States Government for their en¬
lightened liberality in preparing and providing for the
benefit of students such a stupendous, accurate, and
practically useful publication, which in no niggardly
spirit they bestow on the medical libraries of the

Messrs. Bailliere, Tindall and Cox are announc¬
ing a particularly attractive and valuable set of new
medical works. First of all we notice “Axenfeld’s
Bacteriology of the Eye,” a standard book which has
been translated by Dr. Angus Macnab. Then we have
an important work on “Tropical Medicine,” by
Castellani and Chalmers, two authorities who have
studied their subject first hand in hot climates.
Freyer is represented by a volume on “The Surgery
of the Urinary Organs.” Major Herbert has a mono¬
graph on “Cataract Extraction,” founded on extensive
work in India. Kelynack contributes a volume on
“Tuberculosis in Infancy and Childhood,” a subject
on which he is entitled to speak with authority. A
practical book on “Operative Midwifery” has been
written by Professor Kerr, of Glasgow; and “ A
Manual of Pathology,” by Professor R. T. C. Leith,
of Birmingham, is in the press, and a much-needed
handbook on “Meat Inspection” is contributed bv
Dr. W. Robertson, Medical Officer of Health, Leith.
Swan is the author of a note-book in the “ Aids ” series
I on “ Genito-Urinary Diseases,” and Turner publishes a
| “Pocket Osteology.” Baker Las a work on “The
I Spectroscope,” and Gardner one on “ An®sthesia for
Surgical and Dental Operations.” This is a remark¬
ably good reco rd of new productions for a single firm .

REVIEWS OF BOOKS. -

SURGICAL APPLIED ANATOMY (a).

This deservedly popular handbook is a marvel of
compactness, and in its present form leaves little to
be desired. Forty-three specially prepared figures have
been added, and many of the others have been re¬
drawn, while colours have been freely used to make
the illustrations more effective. Surgical anatomy is
not subject to fashion, and is less amenable to progress
than certain other sciences germane to medicine ; but
wherever current views have been modified in defer¬
ence to greater knowledge, the change has been duly
embodied in the text. Well printed, and neatly and
solidly bound, this little volume will certainly con¬
solidate its hold on students of medicine.

, NERVE DISEASES (b).

This is a very handy little guide to the study of
disease of the nervous system, especially intended for
the general student, only the commoner conditions,
such as every medical student may expect to meet with,
coming under consideration. After describing the
essential features of the anatomy of the nervous
system, which is, of course, an indispensable step to
the comprehension of the pathological conditions, the
author leads up to the methods of investigation, first
general, then particular. In reading this little volume,
wc have been struck by the concision and lucidity of
the author's literary style, and we do not remember
ever having seen these morbid states and their pheno¬
mena described with such sobriety and plainness. It
is 10 be feared that students are not infrequently dis¬
couraged by the extraordinary terminology and com¬
plexity that have seemed to be inseparable from this
subject, but we recommend any such to invest in Dr.
Clutterbuck’s unpretentious little manual, which will
assuredly give them a working familiarity with all dis¬
eases of the nervous system likely to require diagnosis
at their hands.

(a) "8urgiesl Applied Anatomy." By Sir Frederick Treves.
Bart., O.C.V.O . C.B., F.R.C.S.; Sergeant Surgeon-in-Ordinary
to H.M. the King, Consulting Surgeon to the London Hospital,
etc. Fifth F.dition. Revised by Arthur Keith, 11. D., F.R.C.S.
Cassell and Co . Ltd. 1907.

(b) “Nerve Diseases.” By L. A. Clutterbuck. M.D., B.S.
fDurhanO; lion, l’hrsician St. Marylebone General Dispensary,
etc. London : Scientific Press. 1907. Price 3«. net.

Digitized by GOOgTe

560 The Medical Press.

WEEKLY SUMMARY.

Nov. 20, 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Mbdical Press and Circular.

RECENT GYNAECOLOGICAL AND

Vaginal Ovariotomy Daring Pregnancy.— Democh
(Monaisschrift fur Geb. und Gyn., Bd. XXVI., Hft. 2)
begins a paper on this subject with a review of the
cases of ovariotomy per vaginam during pregnancy
and during parturition which have already been
recorded. He then describes a new case. The patient
was a IV.-para in the second month of her pregnancy.
A cyst the sire of a child’s head, and very adherent,
lay behind the pregnant uterus, and being thus a grave
danger during labour, it was removed by posterior
colpotomy. The pregnancy was uninterrupted. The
author concludes that in general the vaginal route is
to be preferred for ovariotomy during pregnancy.

Appendicitis Daring Pregnancy and Daring the
Paerperium. —Stahler ( Monatssch . fur Geb. und Gyn.,
Bd. XXVI., Hft. 2), having first described a case of
appendicitis during pregnancy which he had observed,
and having mentioned similar cases from the literature,
comes to the following conclusions. Appendicitis,
especially the severe forms, is rare during pregnancy
and the puerperium. The causes of the origin of
appendicitis during pregnancy are not different from
the causes of origin during the non-gravid state. A
greater liability to recurrence during pregnancy does
not exist; at most as a result of the exertions of the
uterus during labour old foci may be temporarily
re-awakened. The author then describes the symptoms,
the diagnosis, and the differential diagnosis of ap¬
pendicitis during pregnancy. As regards the treat¬
ment, he advises early operation in acute as well as
in acute recurring appendicitis in pregnancy. The
proposal of some authors that the appendicectomy
should be followed by immediate emptying of the
uterus is in the author’s opinion quite wrong. Drain¬
age of the abscess cavity through the posterior fornix
of the vagina, if such should be necessary, is not very
dangerous, even though labour should come on, as a
consequent infection of the uterine cavity has not been
observed in any of these cases in which it has been
performed. G.

Heboiteotomy and its Position In Practical Obstetrics.

—Leopold, at the 79th congress of the Deutscher
Naturforscher und Aerzte ( Zentralblatt fur Gyndk.,
Nr. 43, 1907), described his technique as follows :—
With the patient under an anaesthetic and with the
help of an assistant, a small stab is made through
the skin down on to the pubic tubercle either on the
left or on the right side of the symphysis. Through
this Doderlein’s needle is inserted and pushed from
above downwards behind the os pubis under the control
of the index finger in the vagina, so that The point of
the needle appears between the smaller and the greater
labia about a finger’s breadth away fiom the angle
of the pubic arch. The saw is now fitted to it, and
when it has been drawn backwards the bone is sawn
through. From his experience of over sixty cases
Leopold comes to the following conclusions. The
hebosteotomy is of most value when the conjugata
vera varies from 6} to 8 cm. The subcutaneous inser¬
tion of Doderlein’s needle is best performed from
above downwards. When there has been sufficient
practice and experience of the operator injuries to the
bladder are scarcely possible. After the hebosteo¬
tomy, which is only performed when the cervix is
fully dilated, the uterus should be immediately emptied
by either the forceps or version, according to the
presentation of the child. Lacerations of the vagina
must be carefully sutured. If the urine should be
bloody a catheter must be kept in the bladder for
several days. Leopold considers gonorrhoea to be a
contra-indication to the performance of hebosteotomy,
and advises instead the Porro operation, the extra-

OBSTETRICAL LITERATURE.

peritoneal Caesarean section, or even the perforation
of the living child. Leopold considers that only an
obstetrician who fully understands the operation and
all its possible complications should undertake it,
otherwise, when it is impossible to send the patient
to a hospital, it would be better to perforate the child.

The Relationship between Diseases o! Women aaf
Disease of the Intestine was discussed by Mueller

(Miinchen) at the same congress (Zentralbl. fur Gyndk .,
Nr. 43, 1907). As a result of the inflammations of the
intestinal mucous membrane, both mechanical and
chemical, and of that produced by constipation, the
development of intestinal polypi, intestinal ulcers,
haemorrhoids, periproctitis and periproctitic exudates
and abscesses, parametritis, endometritis, ante-flexion
and retroposition, retroversio and flexio uteri, parame¬
tritis and perimetritis atrophicans retrahens, pelvic
peritonitis, perimetritis, and salpingo-oophoritis is
brought about. Through stenosis of the rectum, which
is a result of posterior parametritis, catarrh of the
large intestine, intestinal atony, sigmoiditis, left-sided
odphoritis and cystitis are produced. From the
vermiform appendix arises salpingo-odphoritis dextra,
more rarely sinistra, pelvic peritonitis, etc. From the
intoxication which is produced, chlorosis, rheumatism,
gout, neurasthenia may result, or if already present,
are aggravated. The treatment consists in warm
applications and massage. It is important to obtain
soft motions and through antiseptics, etc., to bring
about healing of the diseased intestine. The author
considers that it is wrong to believe that 90 pier cent,
of inflammatory diseases in the female are due to
gonorrhoea ; in his opinion 90 per cent, are due to the
intestine. G.

Thrombosis and Embolism after Gynecological
Operations. —Zurhelle read a papier on this subject at
the same congress ( Zentralbl . fur Gyndk., Nr. 43, 1907I.
Post-operativ; thrombosis is most frequently seen after
myoma operations. The author saw it in 2*75 pier cent,
of all the myoma operations in the Frauenklinik Bonn.
The cause is probably the chronic anosmia, the ergot
treatment, and the other disadvantages of the pallia¬
tive treatment when the heart has already been
injured by the presence of the myomata. Next in
frequency as a cause of piost-opierative thrombosis come
the malignrnt tumours, when cachexia, ascites, etc.,
are present, marantic thromboses can be easily
explained. For other gynaecological diseases, for
example, tumours of the adnexa and displacements of
the uterus, there are no special causes for thrombosis
to be observed, but more general causes, for example,
infection, cardiac changes, and anaemia. Other causes
for this complication are the cooling of the abdominal
cavity during laparotomy, injuries to the blood
vessels, injury to the heart by the narcosis, obstruction
to the circulation of the blood in the legs through
tight compresses, meteorism, prolonged rest on the
back, etc. The thrombosis is as a rule not due to
one cause, but to quite a number of causes of which
many work together. Better class patients are more
liable to post-oj>erative thrombosis than women of the
working class. This is probably due to want of
exercise, feeble circulation, want of muscle nutrition,
and especially of the heart. There are three forms of
thrombosis after gynecological operations which are
to be differentiated from one another :—(1) Thrombosis
of the pelvic veins. The diagnosis is very difficult,
and the condition very often produces pulmonary em¬
bolism, probably because the pelvic veins are without
valves. (2) Thrombosis of the femoral vein, the most
frequent form of post-operative thrombosis. It also

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Nov. 20, 1907.

MEDICAL NEWS IN BRIEF.

The Medical Press. 5^1

leads to pulmonary embolism. It usually commences
just underneath Poupart’s ligament, or in the popliteal
vein. It is generally a form of marantic thrombosis,
and in the majority of cases is produced mechanically
in cases of weak cardiac action. (3) Thrombosis of
the saphenous vein, with reddening of the skin. On
palpation this feels like hard cords and knots. This
form does not produce pulmonary embolism. The
author has never been able to prove from anv of his
cases the correctness of Mahler’s observation that in a
typical thrombosis chart a gradual rise of the pulse
rate is to be found with a normal temperature.

Treatment of Peritoneal Wounds. —As the result of
examination of a large series of cases, Pankow
(Monatssch. fur Geb. und Gyn., Bd. XXVI., Hft. 2)
concludes that cauterisation of the parietal or visceral
peritoneum is followed by easy recovery of the peri¬
toneal wounds as long as there is no haemorrhage in
the abdominal cavity, and that the formation of
adhesions only occurs in exceptional cases. Wounds
of the parietal peritoneum so severe as to produce
diffuse points of haemorrhage lead fairly often to
adhesion formation. Healthy peritoneum affords the
animal a greater protection against infection than that
which has been injured and then treated with the
thermocautery and absolute alcohol. The most un¬
favourable results are obtained when infection occurs
in peritoneum which has been injured and not treated.
In such cases adhesions are practically always formed.
Consequently, during operation, all hasmorrhage
should be controlled as far as possible, whether with
the thermocautery or with absolute alcohol, in order
that the danger of infection and of adhesion formation
may be diminished. G.

The Scope of Treatment of Acute Pelvic Infections
In Women by the General Physician.— Wesley Bovee
(Amer. Jour. Obst., October, 1907).—The writer’s sug¬
gestions are, first, that the treatment of acute pelvic
infections is, as a rule, not operative, but one of
palliation and expectancy ; second, that, practically,
analgesics, other than the external application of ice,
are not needed, and are harmful; third, that if sur¬
gical intervention becomes necessary during such acute
stage of pelvic infection, it will be a simple procedure
of vaginal incision and drainage, though extremely
rarely will abdominal incision for this purpose be
required ; fourth, that a certain percentage of such
infections result in symptomatic relief or cure by such
palliative treatment. A very much larger proportion
<the suppurative cases) will require operation, of
which the vaginal incision and drainage, whether
■during the acute stage or later, will be sufficient, and
when it fails radical surgery will have to be employed ;
and, fifth, that very rarely indeed will radical ab¬
dominal operation be required during the acute stage
of pelvic infection.

Toxsmia of Pregnancy Relieved by the Adminis¬
tration of Thyroid Extract.— Fry (Amer. Jour. Obst..
October, 1907).—The patient suffered from headache,
insomnia, and indigestion ; the specific gravity of the
urine had fallen to .1005, and the urea was less than
one-half of 1 per cent. No albumen or casts were
present. No change whatever was made in the diet
or mode of living, but 5 grs. of thyroid were given
-t.i.d. The examination of urine made 36 hours after
treatment was begun showed a rise of specific gravity
.1018 and . percentage of urea to 2.5. The above
symptoms disappeared, and the tablets were then ad¬
ministered twice daily for some weeks. F.

Prolapsus Funis: A New Method of Treatment in
Cephalic Presentations. —Stowe (Surg. Gyn. and Obst.)
describes his new method, in which his idea is to try
to restore the normal conditions of the first stage of
labour by introducing into the uterine cavity normal
saline solution to take the place of the liquor amnii
and to provide a substitute for the membranes.
Through a Voorhees bag, from base to apex, he has
a separate rubber tube fixed without any connection
with the interior of the bag, and when the bag is in

position in the cervix, sterile salt solution is slowly
injected into the uterine cavity. About one pint is
generally sufficient. The cord is, of course, replaced
before the bag is introduced and filled. The bags are
made in two sizes. If there is very little dilatation
of the os, the smaller one is used, to be replaced later
on by the large one. When the larger one is expelled,
the os is fully dilated, and immediate delivery by
version can be done. If too much fluid is injected
into the uterus, the pains will become very severe.
Some of the fluid should then be allowed to escape.
If there is much leakage by the side of the bag, fluid
should be injected from time to time. F.

Medical News in Brief.

Royal College of Surgeon* of Eng'and.

An ordinary meeting of the Council of the Royal
College of Surgeons was held last Thursday, Mr.
Henry Morris, F.R.C.S., President, in the chair.
Eighty-seven candidates who had passed the required
examinations and conformed to the bye-laws were
admitted Members of the College (a complete list will
be found under the heading, “Pass Lists”). No fewer
than forty-two of these candidates wore University
students.

A letter from the deans of the medical faculties of
the Universities of Leeds, Liverpool, and Sheffield
suggesting the desirability of altering the times of
year at which the primary examination for the fellow¬
ship of the college are held was read and referred to
a committee for consideration.

The President reported that the Bradshaw Lecture
would be delivered by Mr. Rickman J. Godlee, Vice-
President of the College, on December 6th, at 5 p.m.,
and that the subject of the lecture would be “The
Prognosis and Treatment of Tubercular Disease of
the Genito-urinary Organs.”

A report was received from the Museum Committee
with reference to the appointment of a Conservator
of the Museum. It was determined that the recom¬
mendations of the Committee should be further con¬
sidered at the next meeting of the Council, on Decem¬
ber 12th, and that the vacant appointment should be
advertised after that date.

A letter was read from Dr. Liveing reporting that
the appointment of Mr. Edmund Owen, F.R.C.S., as
Visitor to the Egyptian School of Medicine for the
examinations to be held at Cairo in December next
had been confirmed by the Royal College of Phy¬
sicians. It was determined to add Giggleswick
School, Settle, Yorkshire, to the list of institutions
recognised by the examining board in England for
instruction in chemistry and physics, and Wyggeston
School, Leicester, which is already recognised by the
Board for instruction in chemistrv and physics, was
also recognised for instruction in biology.

THE DIRECT REPRESENTATION OF MEMBERS ON THE
COUNCIL.

The Secretary announced the notices of motion for
the annual meeting of Fellows and Members on Thurs¬
day, November 21st, at 3 p.m., to be as follows:—

To be moved by Mr. Frederick W. Collingwood:
“That the President and Council of the Royal College
of Surgeons be asked to use their moral influence with
hospital authorities to recognise Members of the Col¬
lege (who are also in almost all cases Licentiates of
the Royal College of Physicians) as having equal
rights with provincial, Scotch, and Irish graduates to
become candidates for hospital appointments.”

To be moved by Mr. Joseph Smith: “That this
twenty-third consecutive annual meeting of Fellows
and Members again re-affirms the desirability of
admitting Members to direct representation on the
Council, which as now constituted does not represent
the whole Corporation.”

To be moved by Dr. W. G. Dickinson: “That this
meeting regrets that the Council has omitted from their
report any reference to the opinion of his Majesty’s
Government on the question of the representation of
Members, and requests the President to .supply the
omission by communicating the same forthwith.”

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562 The Medical Press.

MEDICAL NEWS IN BRIEF.

Nov. 20, 1907,

To be moved by Mr. George Brown: “That this
meeting notes with satisfaction that the Council intends
to take a poll of the Fellows and Members on the
whole question of admitting women to the diplomas of
the College, and this meeting further urges that a
similar course be taken with regard to the proposal
for direct representation of the Members upon the
Council.”

To be moved by Mr. H. Elliot-Blake (Bognor):
(a) “That this meeting of Fellows and Members of
the Royal College of Surgeons wishes the Council to
report as to their willingness to join the Royal Col¬
lege of Surgeons and its work with the University of
London (so as to form an Imperial University of
London), and whether they will approach the Royal
College of Physicians for a similar conjoint action.”
(£) “That this meeting requests the Council to add a
hood to the gown already worn by Fellows and
Members. ”

Royal College of Surgeons In Ireland.

Notice has been given of an alteration of some
importance in the regulations respecting admission to
the Fellowship. Hitherto candidates have been
divided into two classes—those who are graduates or
Licentiates in Surgery of over ten years’ standing, and
those who have held such diplomas or degrees for
less than that period. In the case of the former no
examination has been imposed in anatomy and
physiology, as apart from surgery; the test which has
been imposed in their case being known as Grade 2.
After the date mentioned Grade 2 will cease to exist,
and all candidates alike will have to pass under the
scheme known as Grade 1. This entails examination
in anatomy and physiology and histology and surgical
pathology, as well as in systematic, clinical, and
operative surgery. The alterations will take effect
from January 1st, 1910.

The Cork Medical and Surgical Society.

The annual dinner of this Society was held on
November 9th in the Imperial Hotel, Cork. The
President of the Society, Dr. Moore, occupied the
chair. After dinner, the following toasts were pro¬
posed :—“The King”; “The Cork School of Medi¬
cine,” proposed by the City High Sheriff, and responded
to by Professor Corby and Professor Pearson ; “ Our
Guests,” proposed by Dr. Lee, replied to by Professor
Molohan and Alderman Meade; “The City High
Sheriff,” proposed by Dr. Cotter. Professor Pearson
also proposed the healths of the two newly-appointed
professors at the Queen’s College, Dr. Windle and
Dr. Barry, and Dr. Barry, in the absence of Dr.
Windle, replied. The last toast was that of the
Honorary Secretary, Dr. Booth.

IrUb University Education.

The latest pronouncement on the subject of
University Education in Ireland was made by the
Chief Secretary for Ireland at the opening meeting
of the Catholic University College Literary Society.

In this connection Mr. Birrell, who was subjected to
some cross-questioning, said: “All I will say is that
I believe that that question can be, and ought to be,
and, please God, will be, solved in the next session of
Parliament. I know no cause to which I would more
willingly devote my life, and I know no cause in
which I would more willingly suffer political extinc¬
tion, than the cause of securing for the Irish people
that higher education which justice demands that they
should have, which it is imperatively necessary that
they should have if they are to discharge the important
duties already imposed upon them, and the still more
important duties which cannot long be withheld from
them. This battle will be a hard fight. Opposition
there will be, I doubt not, both in Ireland and in
England, to any such measure as I hope to be able
to propose. ... It can only be done by general
support, by sympathy, and by feeling. I, at all events,
pledge myself to do the very best that mortal man
can do in this next session of Parliament, and if I
fail, why then, gentlemen, I can promise vou this—
that you will be troubled with me no more.”

Mr. Birrell has not as yet divulged the nature of
the solution which he intends to offer for this long-

standing question, but many things point to a pro¬
bability of a rearrangement of the Royal University,
either with or without the establishment of local
Universities in Belfast and Cork. Our Belfast corre¬
spondent, in the present issue of this journal, refers
to the growth of a feeling in Belfast in favour of a
separate University, but there is at the same time
in that city a strong body of feeling which opposes
what it believes would be a University under the
control of Presbyterian clerics. Mr. Bryce was dog¬
matic, and he failed. Mr. Birrell is optimistic, and
there are many who hope that he will succeed, if,
and only if, his sole end is the improvement of higher
education in Ireland.

Devon Medical Man’s Divorce.

Ix the Divorce Court, on November 13th, Dr
William Pitt Palmer, of Babbacombe, Devon, was
awarded a decree nisi and ^2,000 damages on the
ground of his wife’s misconduct with Major Charles
Barchard. There was no defence.

Mr. Willock said the marriage took place at Torquay
on June 5th, 1895, the petitioner residing at Torquay.
One son was born, in April, 1896. The co-respondent
described himself as a retired major of the West Yorks
Regiment. The petitioner strongly objected to his wife
associating with the co-respondent. Mrs. Palmer began
to neglect her home, and was frequently excited through
drink. She went away from home, and would not give
any explanation as to where she had been. He found
she spent Christmas Day, 1906, at the co-respondent's
house.

Dr. Palmer subsequently received a letter from the
co-respondent posted in Bristol, in which he threatened
to take proceedings against Dr. Palmer for defamation
of character in alleging that he and the respondent had
stayed as man and wife at Charing Cross Hotel. A
few days later came a telegram from Major Barchard.
Upon receiving this message the petitioner and his
brother went to Bristol, and found the respondent and
co-respondent together. Afterwards the respondent and
co-respondent went to another address in Bristol, stay-
inf? together as man and wife, the co-respondent finally
going away, leaving the respondent at the place. Dr.
Palmer filed his petition, and the co-respondent, not
having insulted him enough, sent him a postcard
“Am in receipt of citation for divorce re your wife
and yourself. As I do not intend to take all the
responsibility on my shoulders, I shall cite others. 1
shall also prefer charges of collusion, crueltv, and
neglect. ”

The petitioner gave evidence of his wife’s relations
with Major Barchard.

The Judge, in summing up, said he could hardly
remember a case where the conduct of the co¬
respondent had been so serious.

The jury awarded £ 2,000 damages, and his lordship
granted the petitioner a decree nisi, with costs, and the
custody of the child.

Limerick Union Medical ONlcerablp Election.

It is stated that the authorities, acting on the repre¬
sentation of the Local Government Board, have ordered
the prosecution of some 16 persons, who, as alleged,
were concerned in the election of Resident Medical
Officer of Limerick Workhouse several months since,
and respecting which election a sworn inquiry was
opened in the month of June, and continued on various
dates. It is further stated that the charge will be one
of conspiracy and corrupt practices, and that the sum¬
monses will be served in the course of a day or two.

Interesting Workmen’s Compensation Case.

Before Judge Willis, K.C., in the Southwark County
Court, on November 4th, an action was brought by
Frederick Reeves, a shield driver, against Messrs. Price
and Reeves, contractors, to recover damages under the
Workmen’s Compensation Act.

Counsel for plaintiff said the latter in Mav last was
working for the respondents in Rotherhithe' Tunnel,
whfen, in passing from one stage to another, he slipped
from a plank and fell upon a man who vras using a
large spanner. Plaintiff's iaw struck the spanner, and
he subsequently went to the London Hospital, where
an operation was performed upon him, a portion of

zed by GOO^C

Nov. 20, 1907.

PASS LIS I S.

The Medical Press 563

his jaw-bone being removed. On July 29th he returned |
to work and continued working until August 19th,
when he was compelled to again go to the hospital, and 1
had been unable to work since. Counsel added that
cancer supervened, and the plaintiff had to have a '
portion of his tongue cut away. The respondents con- i
tended that the formation of cancer in no way resulted
from the accident, but the plaintiff’s case was that it
was directly due to it.

Several doctors gave evidence for and against the
plaintiff’s contention that the blow caused the cancer.

His Honour came to the conclusion that the cancer
did result from the blow, and he ordered the plaintiff
to be paid £1 per week during the time he remained
incapacitated.

Cape Doctors Censured.

A special meeting of the Cape Colonial Medical
Council was held recently, at which there were pre¬
sent:—Dr. C. F. K. Murray (President of the Council),
Sir Edmond S. Stevenson, Dr. Darley Hartley, Dr.
Wood, and Dr. Johnston, with Advocate J. T. Molteno,
legal adviser to the Council. In the case of Dr.
NlcMullen, who was charged with having prescribed
opium for purposes other than bond fide medicinal pur¬
poses, and in which judgment on a former occasion
had been reserved, it was notified that the Council had
found Dr. McMullen guilty of “infamous and dis¬
graceful conduct in a professional respect.” A similar
charge was preferred against Dr. Frederick R. Kruger
of Cape Town, and he was found guilty of “improper
and unprofessional conduct,” and reprimanded accord¬
ingly.

The Mineral Water Hoepltal, Bath.

The C.overnors of this ancient charity have found
it necessary to decrease the number of beds owing to
lack of funds. The hospital is really a national insti¬
tution, being very little used by patients from Bath
itself owing to the intentions of the original Founder.
Of the 149 inmates at present in the building, 148
come from other towns, cities and rural districts
throughout the British Isles, and the Hon. Treasurers
feel that they are justified in appealing for national
help at the present juncture. Most other hospitals
are largely supported by annual subscriptions ; but in
consequence of the liberality of this institution in
admitting patients without subscribers’ recommenda¬
tions, it is to a great extent deprived of that source
of income, the total annual subscriptions received
last year from private persons being only about ^600.
We trust that this appeal, which is made officially by
the Mayor of Bath, will meet with the success it
merits.

The Irish Medical Schools and Graduates’ Association.

The autumn meeting and dinner of this Association
will be held at the Hotel Cecil on Wednesday, Novem¬
ber 27th, at 7.30 p.m., when the special guests will be
Sir James Digges La Touche, K.C.S.I., and Sir Shirley
Foster Murphy.

Medical Sickness and Accident 8oclety.

The usual monthly meeting of the Executive Com¬
mittee of the Medical Sickness, Annuity, and Life
Assurance Society, was held in London on the 8th inst.,
Dr. de Havilland-Hall in the Chair. The accounts
presented showed that the business of the Society
continued in a very satisfactory condition. During
the summer months the sickness claims had been
somewhat in excess of the expectation, but during the
month of October they were few in number, and for
the most part of short duration. A small addition
has been made to the list of those permanently in¬
capacitated, and so drawing what are practically life
annuities, but not more than was expected from the
growing number and increased age of the members.
Prospectuses and all further particulars on application
to Mr. F. Addiscott, Secretary, Medical Sickness and
Accident Society, 33, Chancery Lane, London.

The opening meeting of the Dublin University Bio¬
logical Association w-ill be held to-morrow evening,
when the President, Dr. Robert J. Rowlett, will deliver
an address on “Biology and Therapeutics.” Among
the speakers will be Sir Arthur Chance, Drs. W. St. C.
Symmers, Walter G. Smith, and J. B. Coleman.

The Earl of Rosebery presided at a quarterly meet¬
ing of the trustees of the Hunterian collection, held at
the Royal College of Surgeons oi November 13th. Sir
Douglas Powell (President of the Royal College of
Physicians), Mr. Henry Morris (President of the
College), and Dr. David Ferrier, Dr. J. Mitchell Bruce,
and Professor G. Sims Woodhead were present at the
meeting. Sir John Tweedy was elected a trustee of the
collection in the vacancy occasioned by the decease of
Sir Joseph Fayrer. The trustees adopted a resolution
expressing regret at the death of Professor Stewart,
and recorded their appreciation of his services as con¬
servator of the museum.

Lord Balfour of Burleigh recently attended a
meeting at Birmingham in support of the scheme for
providing the Queen Alexandra Sanatorium at Davos.
His lordship said the object was to provide accommo¬
dation for English-speaking patients of small means
suffering from curable forms of pulmonary disease.
The site had been purchased, and a large sum raised,
but ^15,000 to £ 16,000 more were required. Sir
Oliver Lodge proposed a tesolution commending the
sanatorium to the sympathy and support of the public,
and it was decided to open a fund in the town.

PASS LISTS.

Royal College of .Surgeons

The following candidates, having passed the
lequired examinations and conformed to the bye-laws,
have been admitted members of the Royal College of
Surgeons of England :—

Wm. S. Alderson, M. Thos. Ascough, Wm. Thos.
Briscoe, B.A., Arthur Burrows, Martin Camacho,
Jas. R. C. Canney, B.A., J. A. Clark, Robt. M.
Coalbank, J. L. Cock, G. G. Collet, B.A., Wm. W.
Cook, Robt. Crawford, B.A., N. C. Davis, G. H.
Davy, B.A., E. J. de Verteuil, R. L. E. Downer,
G. W. Dryland, B.A., N. A. Eddlestone, E. P. Evans,

F. P. Fisher, A. E. Foerster, A. E. G. Fraser, T. R.
Glynn, B.A., P. H. G. Gosse, Morrice Greer, J. E.
Hailstone, M.A., J. I*. Hastings, H. J. Henderson,

E. B. Hinde, B.A., F. G. Hitch, E. Le R. Hodgkins,
M. J. Holgate, F. H. Holl, J. G. Ivers, W. M.
Jeffreys, B.A., Robt. Knowles, B.A., Percy Lang,
A. N. Leeming, K. A. Lees, B.A., W. H. Leigh,
R. McC. Linnell, B.A., H. N. Little, B.A., E. W.
Lowry, J. A. Master, W. L’Estrange Mathews,
M. H. E. R. Montesole, Benj. Moore, H. H. Moyle,
A. T. Nankivell, W. F. Neil, Donald North, E. E. T.
Nuthall, B. H. Palmer, B.A., John Parkinson, D. G.
Perry, C. H.. L. Petch, A. G. Peter, L. L. Phillips,
Montagu Phillips, B.A., E. S. Phipson, M. D. Price,
M. J. Rattray, Alfred Richardson, C. M. Rigby, C. F.
Robertson, L. P. Sanders, E. A. Saunders, S. MacK.
Saunders, G. B. Scott, R. B. S. Sewell, B.A., F. M.
Smith, P. L. Stallard, B.A., R. H. E. Stevens, K. H.
Stokes, H. D. Thomas, G. G. Timpson. S. N. Tiwary,

G. W. Trigg, B.A., R. W. S. Walker, B.A., C». D. H.
Wallace, A. L. Walters, W. W. White, Reg. Willan,
R. T. Williams, G. E. Wilson, A. L. Yates, and A. P.
Yonge, B.A.

A Diploma of Fellow has been granted to Lieut.
R. H. Bott, I.M.S., and Diplomas for Licence in
Dental Surgery to E. W. Cooke and D. B. Franks.
Royal College of Surgeons la Ireland—Dental Examination.

The following candidates have passed the necessary
examination for the Licence in Dental Surgery:—
P. J. Bermingham, T. J. K. Bradley, C. J. Hyland,

F. Leniham, M. S. Philson, and R. P. Thomson.

The following have passed the primary part of the

examination:—W. Bennett, N. A. Clarke, C. A.
Furness, and L. P Vernon.

Trinity College, Dublin.

The following candidates passed the Final Medical
Examination, Part II., Michaelmas, 1907 Medicine.
—William S. Thacker and George F. Graham (passed
on high marks) ; Frank R. Seymour, Bethel A. H.
Solomons, Edward C'. Stoney, Edward J. H. Garstin,
Julian B. Jones, Henry J. Keane, William H. Sutcliffe,
William Knapp, John H. Waterhouse, Albert E.
Wynne (satis respondit).

Digitized by LaOOQle

564 The Medical Press. NOTICES TO CORRESPONDENTS,

Nov. 20, 1907.

NOTICES TO
CORRESPONDENTS, ffc.

CoaaMPONDKXTB requiring a reply in this column are par-
tiouJarly requested to make use of a Distinctive Signature or
and to avoid the praotioe of signing: themselves
• Header, * “ Subscriber,” " Old Subscriber," eto. Uuob oon-
fusion will be spared by attention to this rule.
r , BUB SC &IPTION S.

Subscriptions may oommenoe at any date, but the two volumes
each year begin on January 1st and July 1st respectively. Terms
per annum, 21s.; post free at borne or abroad. Foreign sub¬
scriptions must be paid in advance For India, Messrs. Thacker,
Spink and Co., of Calcutta, are our offioially-appointed agent*.
Indian subscriptions are Rs. 15.12.

ADVJBRTIBBMBNTB.

Fob Onb InsertionW hole Page, £5; Half Page, £2 10s.:

Quarter Page, £1 5s.; One-eighth, 12s. 6d.

The following reductions are made for a seriesWhole Page, 13
insertions, at £3 10s.; 26 at £3 3s.; 52 insertions at £3, and

f ro rata for smaller spaces.

1 announcements of Praotioes, Assistances, Vacancies, Books,
Ac.—8even lines or under (70 words), 4s. 6d. per insertion:
6d. per line beyond.

R - 8.—The mortality, direct and indirect, of acquired
syphilis, when properly treated, is stated not to exceed 4 or 5
per cent. These figures apply to normal and otherwise healthy
individuals, of regular habits. In elderly, inebriate, and
exhausted subjects the proportion is probably tenfold. It is
obvious, in view of the difficulties inherent to such researches,
that the statistics can only be very approximative.

Metricus. It may Interest you to know that the English
penny piece weighs exactly ten grammes and the halfpenny five
grammes. Inasmuch as an ounce is approximately the equiva¬
lent of thirty grammes, three pennies may be taken to represent
one ounce and so on.

Minor.—W e should not recommend our correspondent to con¬
sent to the clause mentioned in the partnership deed.

Coma.—M any things have been tried, but we think the only
treatment for diabetic coma which has shown any particular
result is the administration of sodium bicarbonate. The drug
may bo given by mouth or by hypodermio injection, preferably the
latter. The theory on which it is given is that of excess of acid
(chiefly 0 -oxybutyric acid) in the blood.

W. R. M.—The statement you refer to is one of the standing
type that find their way into medical text-books, and then
become stereotyped by being adopted by one author after another.
No one quite knows how they arise. We should be very sorry to
defend it ourselves.

INCOME TAX REMISSION.

To the Editor of The Medical Press and Circular.

Sir, —By the Finance Act, 1907, passed in the last session of
Parliament, the 133rd 8ection of the Income Tax Aot, 5 and 6
Viet., 0 . 35 (whereby relief was granted whenever the profits of
the year of assessment fell below the average) was abolished. All
persons who shall receive a notice of charge for the current year
(1907-8) desiring to appeal against the same on the ground that
it is excessive, are required to give notice of appeal within the
time set out on such notice of charge, failing which the Com¬
missioners of Taxes will not at any time thereafter entertain any
application to have such assessment amended. Persons whose
profits for the year ended prior to the 6th day of April last fell
below the average should at once take the necessary steps to
claim repayment of any sum they are entitled to.

Yonrs, eto.,

The Income-Tax Adjustment Aoenct.

E. Montague,

London, E.C. Seo.

Jfttetinge of the ^odelieo, Xeetoreo, <&c.

Wednesday, November 20th

Rotal Microscopical Society (20 Hanover Square, W.).—
8 p.m.: Paper:—Mr. J. W. Gordon: Meroury Globules ns Test
Objects for the Miorosoope.

Royal Meteorological Society (Institute of Civil Engineers,
Great George Street, Westminster, S.W.).—7.30 p.m.: Papers.- —
The International Balloon Ascents, July 22nd to 27th, 1907.
Reports by Mr. W. H. DineB, Mr. J. E. Petavel, Mr. W. A. Har¬
wood, Capt. C. H. Ley, and Prof. W. E. Thrift. Discussion of
the Meteorological Observations made at the British Kite Stations,
1906-1907 (Miss M. White, Mr. T. V. Pring, and Mr. J. E. Petavel).

Societt of Arts (John 8treet, Adelphi, W.O.).—8 p m.:
Inaugural Address: Sir Steuart C. llaylev.

Medical Graduates’ College and Polyclinic (22 Chenies
Street, W.C.).—1 p.m.: Mr. R. Johnson: Clinique. (Surgioal.)
5.15 p.m.: Lecture: Mr. D. Armour: Head Injuries.

North-East London Post-Graduate College (Prince of
Wales's General Hospital, Tottenham, N.).—Cliniques: —

2.30 p.m.: Medical Out-patient (Dr. Whipham); Dermatologioal
(Dr. G. N. Meachen); Ophthalmological (Mr. R. P. Brooks).

Thursday, November 21st.

Medical Graduates’ College and Polyclinic (22 Chenies
Street, W.C.).—4 p.m.: Mr. Hutchinson: Clinique. (Surgical.)
5.15 p.m.: Lecture:—Mr. A. W. M. Robson: Pancrestio Catarrh
and Interstitial Panoreatitis in Relation to Catarrhal Jaundice
and also Glycosuria.

North-East London Post-Graduate College (Prince of
Wales's General Hospital, Tottenham, N.).—2.30 p.m.: Gyneco¬
logical Operations (Dr. Giles). Cliniques:—Medical Out-patient
(Dr. Whiting): Surgical Out-patient (Mr. Carson): X-Ray (Dr.
Pirie). 3 p.m.: Medical In-patient (Dr. G. P. Chappel).

4.30 p.m.: Throat Operations (Mr. Carson). 5 p.m.: Demon¬
stration at the Mount Vernon Hospital, Hampstead, N.W.:—Dr.
J. E. Squire: Selected Chest Cases.

St. John s Hospital for Diseases op the Skin (Leicester
8quare, W.C.).—8 p.m.: Chesterfield Lecture:—Dr. M. rockrell;
Aone Vulgaris in ita Three Stages: I., Comedo; II., iLdnr.ita;
III., Necrotioa.

Hospital for Sick Children (Gt. Ormond Street, W.C.).—
4 p.m.: Lecture:—Mr. Kellook: Tortioollis.

Friday, November 22nd.

Royal Society of Medicine (Epidemiological Section) (20
Hanover Souare, W.).—8.30 p.m.: Paper:—Dr. M. Ooplans: Medi¬
cal Inspection in Schools: The Gloucestershire Scheme.

Medical Graduates’ Colleoe and Polyclinic (22 Cbenies
Street, W.C.).—4 p.m.: Dr. H. Tilley: Clinique. (Far.)

5.15 p.m.: Lecture:—Dr. D. Ferrier: Atrophic Paralyses.

North-East London Post-Graduate College (Prince of
Wales’s General Hospital, Tottenham, N.).—10 a.m.: Clinique.—
Surgical Outpatient (Mr. H. Evans). 2.30 p.m.: Surgical Opera¬
tions (Mr. Edmunds). Cliniques:—Medical Out-patient (Dr.
Auld); Eye (Mr. Brooks). 3 p.m.: Medioal In-patient (Dr. M.
Leslie).

Central London Throat and Ear Hospital (Gray’s Inn
Road, W.C.).—3.45 p.m.: Demonstration:—Dr. W. Wingrave:
Clinical Pathology.

Tuesday, November 26th.

Royal Society of Medicine (Therapeutical and Pharmaco¬
logical 8ection) (Apothecaries' Hall, Blackfriars, E.C.).—
4.30 p.m.: Dr. James Cantlie, M.B., F.R.C.S.: Some Tropical
Diseases and the Remedies Required for their Treatment and
Prophylaxis; Dr. William Murray, F.R.C.P.: Therapeutics of
Indigestion.

JLppoitttmeme.

Evershed, A. R. F., M.R.C.S., L.R.C.P.Lond., Honorary Oph-
thalmio Surgeon to the Brixton Dispensary.

Holland, Eardley L., M.D. Lend., F.R.C.8.Eng., Obstetric Regi¬
strar and Tutor to King’s College Hospital.

Inner, John, M.B., C.M.Aberd., Medioal Officer to the Aberdeen

Dispensary-

M'Ewan, Thomas Duncan, M.B., Ch.B.Glasg., Junior Assistant
Physician to the Royal Asylum, Glasgow.

Read, A. W., M.R.C.S., L.R.C.P.Lond., Clinical Assistant to the
Chelsea Hospital for Women.

Shapland, John Dee, M.D.Durh., Honorary Medical Offioer to
the Brixton Dispensary.

Shaw, Charles John, M.D.Edin., Senior Assistant Physician to
the Royal Asylum, Glasgow.

laontcus.

Cornwall County Asylum, Bodmin.—Third Assistant Medioal
Officer. Salary, £140 a year, with board, lodging, etc. Appli¬
cations to Medical Superintendent.

Shanghai Municipal Council.—Assistant Medical Officer of Health.
Salary, £580 per annum. Applications to Messrs. John Pook
and Co., 63, Lesdenhall Street, London, E.C.

Windsor and Eton Royal Dispensary and Infirmary.—House Sur¬
geon. Salary, £110 per annum, with residence, board, laun¬
dry, and attendance. Applications to Geo. P Cart land,
Secretary.

West Riding Asylum, Wakefield.—Assistant Medical Officer.
Salary, £150 per annum, with apartments, board, washing,
and attendance. Applications to the Medical Director.

Royal National Hospital for Consumption for Ireland.—Resident
Medioal Offioer. Salary, £300 per annum, with house. Appli¬
cations to Hon. Secretary, 13, South Frederick Street, Dublin.

#irthe.

Jobson.—O n Nov. 11th, at Trelyon. Ilford, the wife of T. Bat-
tersby Jobson, M.D., of a daughter.

Somerset. —On Nov. 12th, at Stoueleigh, Mansfield Road, Reed¬
ing, the wife of Edward Somerset, M.R.C-S.Kng., L.R.C.P.
Lond., of a son.

Symons.—O n Nov. 14th, at Offloers' Quarters, Queen Alexandra
Military Hospital, Millbank, 8.W., the wife of Major F. A.
Svmons’, R.A.M.C., of a daughter.

Wise!—O n Nov. 14th, at 206, Burrage Road, Woolwich, the wife
of H. M. Wise, M.B., of a son.

JHamagw.

Dent—Lewis.— On Nov. 15th, at St Peter’s Collegiate Church,
Wolverhampton, Howard Henry Congreve Dent, F.R.C.S..
eldest Bon of the late Joseph Henry Dent and Mrs. Dent, of
Merivale, Edgbaston, to Olive Mary, daughter of Rowland
W. Lewis, J.P., of Penn Croft, near Wolverhampton.
Gibbinb—Dix.—O n Nov. 18, at St. James’s. Paddington, Kenneth
Mayoh Glbbins, M.B., B.8.Lond., M.R.C.S_ L.R.C.P., of Holm iale
Parkstone, Dorset, * eldest son of B. T. Glbbins, of Dkley and
Tunbridge Wells, to Anne Mary, daughter of the late Thomas
Tucker Dix, of Wells, Somerset. .....

Tooth— Chilver. —On Nov. 12th, at the Parish Church, Mid hurst.
Howard Henry Tooth, M.D., C.M G., of 3*. Harley Street.
London, to Helen Kathnrine, second daughter of the Rev.
Charles S. Chilver, of Gate House, Midhurst.

■Beaths.

Cookson.— On Nov. 12th, at St. Kitts. Carysfort Road, Boscombe,
Jane Grace, wife of Samuel Cookson, M.D., late of Stafford.
Hutchinson. —On Nov. 15th, in London, after a long illness. Sir
Charles Frederick, M.D., of Mayfield. Sussex, youngest son of
Dr. Hutchinson, of Nottingham and Scarborough, in his 58th
year.

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The Medical Press and Circular.

“SALUS POPULI SUPREMA LEX."

Vol. CXXXV. WEDNESDAY, NOV. 27. 1907. No. 22

Notes and Comments.

The news of the raid on the “ brown
The “ Brown dog ” memorial at Battersea by some
Dog ” and the University College and Middlesex
Students. Hospital students, and its disas¬
trous termination, is very poor read¬
ing* as likewise are the accounts of the
subsequent demonstrations and processions. It
.s of course not legal, and therefore not
politic, to smash property that does not belong to
one, however offensive such property may be. The
law will not even allow a sanitary authority to
break up ihe most pestilential doss-house without
full compensation to the ojwner out of the rate¬
payers’ pockets; it matters not that his property
has been a cause of sickness and death to dozens.
So, too, it is possible apparently to write on an erec¬
tion in a public place an insult to a learned cor¬
poration, calculated to bring it into disrepute and
contempt, and to enjoy the full protection of the
law. It is difficult to believe that the Council of
the University College have not taken legal advice
on the matter, and been advised to let it rest;
but we should have thought ourselves that taking
the words of the inscription and the action of the
erection of the memorial very good grounds for a
libel action are shown. The dog is alleged to
have been “done to death in the laboratories of
University College,” and though the phrase may
possibly not bear an exact legal interpretation, it is
always used as a svnonym for murder. Murder is
illegal killing, and whatever may be said about
the dog’s death it was destroyed in a perfectly legal
and regular manner. That, to our mind,’might
constitute one count in a libel action. The second
is like unto it. • It is said the dog “endured vivi¬
section extending over more than two months.”
The suggestio falsi is obvious enough. We should
go further and say that the ordinary interpretation
of the words would be that the animal was
operated on continuously for two months, which,
though absurd to instructed persons, would not be
to the folk likely to see most of the memorial.

Its Serious
Side.

It may be wise of University
College to take no action if not
assured of winning on legal grounds,
but it is impossible for the Council
to be surprised at its students feeling
and resenting the insult. They must also remember
that the London newspapers, which regard under¬
graduate “ rags ” at Oxford or Cambridge as par¬
donable youthful frolics, even if a policeman or two
be maimed seriojsly, always characterise in the
harshest terms any evidence of similar spirit in a
London 9tudent. The Battersea memorial is a
standing menace to the reputation for good conduct
• bat London medical students have earned for
themselves for the last twenty or thirty years, and

the point is one for the authorities fully to consider.
The whole “ brown dog ” incident constitutes one
of the most disgraceful pages in the anti¬
vivisection movement, and that we fear only be¬
cause it happened to be sifted in a court of law.
The story was a grave perversion of facts; it was
repeated to a large audience without inquiry or
confirmation, and was disproved before a jury.
Without one word of regret for the utter want of
truth and ingenuousness characterising the whole
affair, the anti-vivisectionists subscribed £2,000,
the amount of the damages rewarded for the libel,
to recompense the defendant, and actually proceeded
further to accentuate their w r ant of shame by erect¬
ing a memorial to commemorate the incident. It
is bad enough that a section of faddists should be¬
have thus, but that the official representatives of a
L .on don borough should receive the statue
especially bearing such an inscription is almost in¬
credible.

We wonder how the young men of
Battersea, who take a pride in their

Vice*versa. borough and their civic representa¬
tives would like it if (say) University
College erected in Gower Street a
monument to a bullock, with some such inscription
as the following :—

“ In memory of the dun bullock, which was
cruelly mutilated by being castrated, without any
anaesthetic, in order that his flesh might taste
better at the Mayoral dinner at Battersea in
November.

“Also in memory of 5,000 bullocks done to death
in Battersea every year for the gratification of man.”

We hope that they would have sufficient good
feeling not only to resent the insult, but to recog¬
nise that, whereas the barbarous operation was per¬
formed not only without anaesthetics hut for no
necessary purpose, that animal experimentation
provides the children of their borough with the
only means whereby they can efficiently be helped
to recover when attacked by diphtheria. At any
rate, we could hardly be astonished if demonstra¬
tions in force were made against such a memorial,
and we suspect that those journals who regarded
the suffragette riots with amiable tolerance, and
now denounce the students with corresponding
vigour, would find plenty of excuses in “ provoca¬
tion.”

Since the days of Madame Blavatsky
<> c if and Mr- Edmund Garnett’s revela-
n . ,, „ tions there has been a great slump

Protection. j n l n di an mysteries and cults, and
our American friends have taken the
opportunity to foist a little occidental philosophy
upon us in the shape of Christian Science. The
essence of both cults seems to be unlimited

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566 The Medical Press.

LEADING ARTICLES.

Nov. 37, 1907.

credulity, and (at least) a moderate income. The
poor, however little their education, curiously
enough are seldom effected by these typhoons of
ecstaticism, whether they blow from East or West.
But on the stage of esoteric things enters a fresh
•heroine, a Hindoo lady, bearing the very Eastern
name of Madame Cavalier, who seems destined to
win fame again to her neglected country. Recently
she gave a lecture on the very original title of
“ Self-protection from Adverse Suggestions.” From
the description of the lecture it seems that she
started away with the usual preamble about earth-
planes and spirit-spheres, but the cloven hoof soon
exhibited itself beneath the silk gown, and the full
tide of doctors not knowing their oyn business and
Madame Cavalier knowing a great deal about it,
was let loose. The adverse suggestians from which
people are to protect themselves, are not, apparently,
those thrown out by Madame Cavalier, but
diseases. It is true, says the prophetess, you suffer
pain—there, at least, she has the start of the
Christian Scientists, for people always like others
to know when they suffer—but yo\i can always get
rid of it by calling only on the “ leader.” The leader
may be Mahomet or Christ; it really does not
matter; they will be effectually protected by an
“electric band of light.” The room is said to have
been filled with devotees, and we shall probably soon
have a church, temple, or mosque erected for their
convenience.

It is a curious fact that it needed
the excited comments of the lay Press
ri° h ^ nd on tl "° cases hepatic cirrhosis in
Cirrhosis. children to stir the medical profes¬
sion to look up the evidence connect¬
ing that condition with alcoholic excess. At any
rate, the attention of the profession has been
seriously directed to a scientific question as the
result of outside agitation. Whatever may have
been in the minds of most, Dr. Welsh Branth-
waite’s intimation that among 8,000 drunkards
with whom he has been brought into contact during
the last five years, he has never come across one
case of cirrhosis, is a little disconcerting. Dr.
Branthwaite says he has seen congestive liver en¬
largement and functional disturbance after drinking
bouts, but they have always subsided under rest
and temperance. It is probably true that only a
small proportion of drinkers get cirrhosis, and that
cirrhosis is not only caused by alcohol, but it may
seriously be questioned whether it be actually
alcohol itself or some other constituent in intoxi¬
cating drink which causes the fibrosis. The atten¬
tion directed to the subject will do much good if it
result in clearing up the enigma, but as an instance
of the harm that the questioning of a belief like
this may do we may instance an article in the
Daily Telegraph of November 18th, in which the
writer uses the discussion to show that alcohol may
not be such a bad thing after all, and that it is un¬
reasonable to attempt to limit the supply of drink
<0 people till more is known about it. Happily,
even people who are not doctors recognise that
alcohol has some dangers, even if cirrhosis of the
liver is not the most prominent.

LEADING ARTICLES.

DO MEDICAL MEN ASSIST IN THE SALE
OF PROPRIETARY MEDICINES?

The mind of the medical profession, as a whole,
is sufficiently well made up on the point of the evil
of proprietary medicines to warrant some plain
speaking as to the matter. In approaching such a
subject it becomes at once apparent that many
•'■\rr-e interests are concerned, and that there are

manifold phases which demand careful investiga¬
tion in order to arrive at anything like a sound
perception of their relative meaning. The truth
of that proposition will be readily recognised after
a brief survey of the operations of the drug trade,
both wholesale' and retail, of the proprietary medi¬
cine trade, of the professional journals and publica¬
tions, of the newspapers and journals that profit by
advertisements, of all these as regards capitalists,
public and medical profession. The tangled issues
involved in that combination present a problem that
requires tact, knowledge, and a strongly judicial
spirit for its solution. Among these complexities
anises the question whether medical men do not in
some instances play into the hands of the pro¬
prietary system which they regard with so much
disfavour. This doubt has been sugested by an
important work recently issued by the Pharmaceu¬
tical Society of Great Britain, under the title of the
“ British Pharmaceutical Codex.” The scope of the
volume may perhaps best be conveyed to medical
readers by designating it as a kind of enlarged and
comprehensive extra-pharmacopceia. Its appear¬
ance has given rise to a vast deal of criticism in the
ranks of the pharmacists themselves. We are not
here concerned with the list of inaccuracies inevit¬
ably connected with a work of so great dimensions,
dealing as it does with a vast array of details. Nor
does there seem great pertinency in the complaint
that the volume in question to a great extent par¬
takes of the nature of a compilation. So far as the
medical profession is concerned one of its most
important features consists in the definition of a
great number of drugs or combinations of drugs
sold under fancy names, so that any practitioner
can, by reference to the Codex, see exactly what he
is ordering, and, if necessary, replace it by the cor¬
responding drug from the British Pharmacopoeia
To take an instance which is unlikely to injure deli¬
cate susceptibilities, it is well known that boracic
acid forms the basis of \arious dusting and face
powders, sold under a variety of catchpenny titles.
Let us for a moment assume that a medical man
entertained the unlikely intention of prescribing one
of those proprietary dusting powders. By turning
to the particular trade name in the Codex he would
at once learn that it consisted of, say, boracic acid,
starch, and oxide of zinc, whereupon he might
write his own formula. It may be argued that he
would be doing an injury thereby to the proprietor,
but it is difficult to understand what exclusive right
can be claimed in a combination of well-known
drugs, such as are ordered by medical men daily
throughout the length and breadth of the land. It
would be easy to multiply instances almost inde¬
finitely, but it will serve the purpose if readers are
asked to think for a moment of the various pro¬
prietary forms in which aloes, jalap, permanganate
of potash, cascara sagrada, the salicyl com¬
pounds, chloral and opium are sold to the public.
We suggest that medical practitioners who order
such compounds are playing into the hands of the
traders in proprietary medicines. The position of
the Pharmaceutical Society with regard to the
matter may be gathered from the following quota¬
tion, taken from the preface to the Codex.
“Special attention has been devoted to the
nomenclature of substances of definite composition
which are known under a variety of names, and it
has been considered desirable to describe such sub-

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Nov. 37, 1907.

CURRENT TOPICS.

stances under brief, more or less descriptive
names, which have, dn some instances, been
spe:ially devised for the purpose. Reference is
made to trade-protected names and other com¬
mercial designations of such substances in footnotes
to the respective monographs, though prescribes
will prefer to encourage the use of names which
everyone is free to use. Trade names, as a ru.e,
can only be legally applied to the products of firms
or individuals in whom proprietary rights in those
names are vested, and the attention of dispensers
is particularly directed to the fact that when a
medicament is ordered under a proprietary trade
name, it is not permissible to substitute a similar
product to which that trade-name does not legally
apply.” The subject is alive with possibilities, and
medical men will do well to inform themselves upon
the prescribing of simple drugs under fancy names
thus brought within the range of practical politics
by the issue of the Codex.

CLIFFORD v. TIMMS.

The last phase of Clifford v. Timms was com¬
pleted in the House of Lords last week, when the
Court, consisting of the Lord Chancellor, Lord
Halsbury, Lord Macnaghten, and Lord Atkinson,
gave judgment for the respondent without even call¬
ing on his course!. We can only say that if the
House of Peers gave equally convincing proof of its
business acumen in political matters, there would be
little demand for its reform from either party in the
State. To the non-legal mind it has always been a
marvel how any lawyer could have advised that
there was any ground for action, the breach of the
partnership agreement being so obvious and above
board. IJut the marvel was rendered still more
staggering when the case was heard before Mr.
Justice Warrington, and decided against the de¬
fendant. At the trial a gTeat deal was
done to “ side-track ” the issue by raising
the unnecessary question as to whether the
decisions of the General Medical Council
are binding on other statutory authorities, and it
must be confessed that it is a pity that the House
of Lords could not have settled the matter once for
all in giving their judgment. We have no reason¬
able doubt what the decision would have been after
the views that were expressed in the Court of Ap¬
peal, although Mr. Justice Warrington in the lower
court, in our opinion, erred strangely for a man of
his calibre. But although, as we say, we regret the
point was not settled by the House of Lords, we
commend heartily the broad outlook taken by their
lordships and the business-like way in which the;
refused to be drawn by the red herring dragged
across their path. The whole point of the case was
whether the action of Mr. Clifford, in starting an
institute of dentistry, worked by unregistered den¬
tists under the supervision of himself and his family,
who were registered dentists, and advertising the
institution by such methods as decrying the com¬
petency, and even making insinuations against the
characters of English dentists, was guilty of pro¬
fessional misconduct, because, if so, Mr. Timms was
at liberty to break his partnership deed. This ex¬
ceedingly simple issue led to all this litigation and
fuss, when to the ordinary man it must have I een
palpable that if professional misconduct, as apart
from private misconduct, means anything, it means
precisely conduct of the character perpetrated by the

The Medical Peess. 567

appellant. The Lord Chancellor, in giving judg¬
ment, in which all the members of the court con¬
curred, brushed aside the question of the statutory
authority of the decisions of the General Medical
Council as being a matter of indifference to the
issue, and merely said that it having been shown
that Mr. Clifford had sanctioned the form of the
advertisements, professional misconduct was ipso
faclo proved. We heartily congratulate Mr. Timms,
and trust that now he has severed himself from
these gentry, he will enjoy the pursuit of his art by
the regular methods which all that is best in the
spirit of dentistry seeks to establish in the practice
of that beneficent art.

CURRE NT T OPICS.

The Victory at Bristol.

The determined and united action of the Staff of
the Royal Infirmary at Bristol and the practitioners
of the neighbourhood has met with the success that
must always follow such action, namely, by the
withdrawal of the propositions of the other side.
We understand that the settlement has been arrived
at by a process of give and take, and the terms will
probably be announced in due time. But the matter
for rejoicing at the present moment is that it has
been demonstrated again that no town or country
can afford to flout medical opinion, and that if
medical men are firm, reasonable, and united they
cannot be overridden by any body in the land. The
victory is especially gratifying in that most of the
committee of the Royal Infirmary' are strong men
of much local prestige, and the issue was one which
effered considerable temptations to such medical
men as did not see eye to eye with their colleagues
in the matter. But in all these matters it must be
borne steadily in mind that the undermining of the
influence of a colleague or band of colleagues is a
dangerous policy which is sure sooner or later to
react on the interloper. Happily in the present in¬
stance there has been nothing but loyalty, and the
staff have vindicated their right to be regarded not
ns subordinates to the Committee of Management,
but as their colleagues and coadjutors. The staff
would not have dreamed of laying down how many
charitable committees members of the Board might
serve on; it was no less ridiculous for the Com¬
mittee to attempt to lay down a similar rule for the
staff.

The Memorandum of the Medical Depart¬
ment of the Board of Education.

The Board of Education, through the Medical
Department, have issued the promised memorandum
on the medical inspection of school children. As we
have indicated before, the policy of the Board as now-
more definitely declared, is to work the inspection
through the medical officer’s of health department,
and, according to the memorandum, he is to be the
chief executive officer, having such assistants and
subordinates as his authority thinks necessary. The
practical and economical convenience of this policy
is obvious; its dangers equally so. Let us hope
that in practice the latter will prove below expecta¬
tion. The words of the memorandum are brave
and, we are sure, sincere. “One of the objects of
the new legislation is to simulate a sense of duty
in matters affecting health in the homes of the
people; to enlist the best services and interest of the
parents ; and to educate their sense of responsibility
for the personal hygiene of their children. . . .

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5^8 The Medical Press.

CURRENT TOPICS.

Nov. 27, 1907.

It is in the home, in fact, that both the seed and
the fruit of public health are to be found.” All that
is as it should be, but if this process of enlistment
and stimulation is to be successful, it will require
an amount of patience and tact among the officers
appointed which are very personal to the individual.
The Board have decided to have but three inspec¬
tions of the children—namely, on joining, at about
the third year after joining, and at about the sixth
year after joining; and they hope that the parents
will be present at the first inspection. We fancy
that the last suggestion is one of the most salutary.

The Medical Student of To day.

Curiously enough, only a few days have elapsed
since the appearance in our columns of a com¬
ment upon the docile and exemplary conduct of the
medical student of to^lay. Within the past week
some extraordinary ebullitions have taken place in
London, arising out of a police-court prosecution
of certain medical students, the facts of which are
noted elsewhere. The demonstrations have been
of an innocent but somewhat tumultuous nature.
Members of various schools have rushed in shout¬
ing procession through the streets, bearing in one
instance the figure of the Highlander taking snuff,
which has appeared on previous occasions, and in
another instance carrying aloft an effigy of the
unpopular magistrate. Such conduct is indefen¬
sible, if only on the ground of the potential disorder
of a serious kind that is inseparable from emotional
outbreaks of this kind conducted coram publico. At
the same time it will hardly be denied by police and
public that some ground of provocation was
altogether wanting in the affair. Indeed, the
whole demonstration may be regarded as the harm¬
less protest of a number of high-spirited youths,
who imagined they were labouring under long¬
standing provocation. Their conduct was one of
righteous indignation rather than of the latent or
inherent rowdiness which some of the journai:
have rather ungenerously imputed to them.

Patent Medicines in the Antipodes.

The Commonwealth Government of Australasia
seem resolved to attack the evils of the patent
medicine trsde with stern determination. A short
Bill has been announced, to be introduced as a
supplementary measure to the Commerce Bill, in
order to confer greater powers of control over the
importation of those proprietary goods. The
advent of this Bill is announced in the Australasian
Mail of November 17th. It will enable the Minister
of Customs—directly, and without any loophole for
equivocation being given—to insist upon the labels
of the bottles of all imported medicines bearing such
indication as to the nature of the contents as the
Minister may deem necessary. The necessity of
supplementary legislation was forced upon Sir
\\ iilium Lyne, who had imagined that .sufficient
power was already conferred by the Commerce Act,
but he had subsequently been informed by the
Crown Law Officer that to remove all possibility
of disputes a special Bill was necessary. By this
step the stern rebuke is offered to the United
Kingdom, whose worthless and dangerous wares
are thereby excluded from Australasian shores.
The irony of the situation, interpolated as it is amid
an economical tariff strife, may be accepted as a

solid contribution to those who protest against the
patent medicine traffic an the United Kingdom.
I f the Colonies one and all reject these noxious im-
; ports from the Mother Country, they will inflict a
; deadly blow against a ruthless social monster.

Tradesmen’s Wrappers.

1 The pitfalls to health are so manifold and various
that our eyes must necessarily be shut to many of
them. At the same time there are a certain num¬
ber that can be dealt with summarily if once haled
before the bar of public opinion. Among these
minor dangers come the newspaper coverings often
1 used bv tradesmen to wrap up butter, cheese,
bacon, fish and other articles of food. It is simply
: appalling to reflect on the myriads of microbes that
must be adherent to the surface of an ordinary
newspaper that has been in the hands of readers
and in many strange places before being stored in
l the tradesman’s shop. One marvels that such a
practice should ever have been permitted by a long-
' suffering public to exist. It is tolerably certain that
when once recognised the dawn of better things will
] quickly arise in the shape of clean, white, prefer-
j ably sterilised wrappers around all articles from
J butterman, grocer, provision vendor, fishmonger
and other dealers in articles of food. Indeed, the
better class tradesman has already abandoned the
: filthy newspaper for the attractive white wrapper.

Sandow as Physician.

Let the cobbler stick to his last, and let the pro¬
fessional strong man attend to his own legitimate
business. Mr. Eugene Sandow was the first to
show what marvels could be accomplished by the
systematic cultivation of the human muscles. No
one can complain if he advocates his methods of
physical culture as conducive to health, and even
indirectly curative in various minor troubles, just
as golf, or rowing, or riding, or other exercise is
an aid to health. But when Sandow plays the
physician and claims to cure a long list of maladies,
including dyspepsia, nervous diseases, gout, rheu¬
matism, paralysis, heart, chest, lung and “various
other complaints,” then we see no particular reason
why he should not be classed with other quacks.
Presumably in all or nearly all cases he makes his
own diagnosis, a fact that at once vitiates hope¬
lessly his statistics iboth of the nature of

cases and of cures. How is a man to

distinguish between a trivial and a most
serious form of dyspepsia? In the latter event it
may be, of course, merely symptomatic of such
things as cancer, advanced disease of liver, heart
disease, or consumption. If Sandow claims to cure
“dyspepsia” with his exercises he is by inference
asserting his ability to deal with any of the causes
mentioned. This single instance suffices to show
the self-sufficient and unblushing temerity with
which the amateur and untrained physician is pre¬
pared to tackle any ill that human flesh is heir to.

Sarcoma and the Compensation Act.

The relation of malignant disease to industrial
occupation is likely to give rise to a goodly number
of keenly disputed cases under the new Workmen's
t Compensation Act. Already two cases in which
sarcoma was alleged to have followed injury have

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Nov. 27, 1907.

PERSONAL.

The Medical Press. 569

been decided in favour of the workmen. In one
instance the sarcoma affected the jaw, and was said
to have been the result of an accident. In the
second a leg was amputated for sarcoma in the
lower end of the femur, said to have resulted from
an injury some three months before the growth was
recognised. Curiously enough the majority of the
text books on surgery are silent as to the possible
or probable relation of sarcomatous growths to
traumatism. There are two notable exceptions,
however, in Bland Sutton’s book on “Tumours,"
and in Sir Frederick Treves’s “ System of Surgery,”
both of which accept the theory of traumatism as
a cause, at any rate, in periosteal and by implication
in endosteal forms of sarcoma. As other cases of
the kind are certain to occur from time to time, «t
is highly desirable that surgeons should endeavour
to formulate some fairly definite conclusions in this
interesting point of etiology. From the circum¬
stances of the case it is difficult to establish absolute
data, but with further extended and concentrate'!
observation it should not be impossible to arrive at
an authoritative verdict as to the balance of proba¬
bilities in this alleged relationship.

Property in Dead Bodies.

Arising out of our note on “Property in Museum
Specimens, ” in the issue of November 20th, in which
we said that “it might be possible to prosecute a
scientific enthusiast of such a kind [i.e., one who
stole museum specimens] for stealing the glass jar
and spirits, and even for damage to the jars,” a
correspondent reminds us of a curious incident. In
the days of body-snatching every “ sack-em-up ”
•was aware that his avocation, dangerous as it was,
was not illegal if he merely captured the naked
body, whereas removal of any of the grave-clothes
was punishable. In the latter half of the eighteenth
century, when Cornelius Magrath, the famous Irish
giant died, Robinson, the Professor of Anatomy
in Dublin, is reported to have said to his class :—
“Gentlemen, I have been told that some of
you in your zeal have contemplated carry¬
ing off the body. I must earnestly beg of you not
to think of such a thing: but if you should be so
carried away with your desire for knowledge that
■thus against my expressed wish you persist in
doing so, I would have you to remember that if
you take only the body, there is no law whereby
you can be touched, but if you take so much as a
rag or a stocking with it, it is a hanging matter "
(“James Macartney,” by Alex. Macalister. 1900.
p. 16-17). Needless to say that in a few days the
good professor himself dissected the body, and
Magrath’s skeleton still remains in the museum of
Trinity College.

Indian Methods for Delirious Patients.

Tiie sentence of death recently passed upon a
Cree medicine man, in the Keewatin territory,
reveals a curious practice in that remote tribe. The
trial, which was noticed in the Times of October
28th last, originally extended also to an old chief,
but the latter strangled himself while in custody.
The charge was that of having put a delirious
woman to death. One of the witnesses confessed
that another murder of the same kind had taken
place three weeks later, he himself helping to hold
down the victim—a sick man who had been
brought by his wife from another tribe simply to

be put out of the way. The medicine man was
condemned to death, but recommended to mercy
on account of his ignorance. Immediately after
the trial a party of mounted police set off on the
400-mile journey to Gurry Lake, in order to arrest
several Indians concerned in another murder of the
same kind, which is believed to have been the
twenty-sixth committed within the last twenty
years. The putting to death of delirious persons is
probably due to a belief in their demoniacal posses¬
sion. It is not so many generations ago that our
own treatment of lunatics was almost equally
primitive in practice. A plausible explanation of
the matter is that the natives desire to get rid of
helpless persons who consume their share of a
limited supply of food, although themselves un¬
productive. In certain savage tribes, as in Pata¬
gonia, it is a recognised custom to destroy the
aged and useless members of the community.

PERSONAL.

H.M. the King has sent his annual subscription of
£100 to the Middlesex Hospital.

Mr. R. A. Bickersteth was elected Surgeon to the
Liverpool Royal Infirmary on November 21st.

The Master of the Apothecaries’ Society, Dr.
George Wilks, took the chair at the Lord Mayor’s
Day dinner given by that company.

Dr. F. Henry was, on November 19th, at a meeting
of the Liverpool Select Vestry, appointed Medical
Superintendent of the Highfield Infirmary.

Sir R. Douglas Powell, President of the Royal
College of Physicians of London, opened the Tuber¬
culosis Exhibition in Belfast last Friday.

Dr. Sidney P. Phillips will take the chair at the
annual dinner of the Harveian Society at the Imperial
Restaurant to-morrow (Thursday) at 7.30 p.m.

Mr. Rockefeller has given £5 20,000 for the per¬
manent endowment of the Institute for Medical
Research which he founded at New York in. 1901.

Sir Alfred H. Keogh will hold conferences with
the medical profession at Exeter and Plymouth early
next month on the proposed medical service for the
Territorial Army.

Lady Theodora Guest has presented to the West¬
minster Hospital, at Shaftesbury, a fully equipped
operating room as a memorial to her mother, the late
Marchioness of Westminster.

Prince Ranjitsinji has given Rs. 1,000 to the
Jamsetjee Jeejeebhog Hospital at Bombay as a token
of the skill and devotion shown him during his late
illness by a nurse from that institution.

Sir William Bennett, K.C.V.O., Consulting Sur¬
geon to St. George’s Hospital, has been elected Presi¬
dent of the Incorporated Institute of Hygiene in place
of the late Sir William Broadbent, Bart.

The Faculty of Medicine of London University have
appointed Professor Ernest Henry Starling, M.D.,
B.S., F.R.C.P., F.R.S., to be their representative on
Senate for the remainder of the period 1905-9, vice Dr.
Lauriston E. Shaw resigned.

Dr. G. E. Cartwright W’ood, Bacteriologist to the
Laboratories of the Royal College of Physicians amt
Surgeons, London, has been appointed by the Metro¬
politan Asylums Board as Bacteriologist at their estab¬
lishment at Belmont, at a salary of ^600 a year.

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570 The Medical Press.

CLINICAL LECTURE.

Nov. 27, 1907.

A Clinical Lecture

ON

LINGERING LABOUR; ITS CAUSES AND TREATMENT, (a)

By JAMES MORRISON, MJXLond*

Hon. Physician Accoucheur Farringdon Dispensary and Lying-in Institution.

Gentlemen, —First of all, I want to show you this
Barnes-Galabin-Simpson variety of forceps, the only
forceps on the market which allows the manipulations
of two pairs of forceps in a single instrument.

In regard to our subject for this afternoon, lingering
labour, I would like to remind you of some of the
points, because I am constantly being called in to cases
of lingering labour in which there should be no diffi¬
culty. By “lingering labour” I mean labour where
there is no mechanical obstruction to the birth, both
passages and passenger being normal, and the cause
of such labour is some fault in the forces. In the
primipara the full time which should be taken for the
whole confinement is 24 hours, and in the multipara
12 hours. That, of course, is a very long time, par¬
ticularly in general practice, and therefore the second
stage in the multipara is often cut down to nil. You
may say that for the primipara the first stage is 16
hours, and the second 8 hours; and in the multipara
8 hours and 4 hours respectively. But you can never
do wrong by waiting in the case of the primipara. In
multipara you can cut it down to 4 hours justifiably
by putting on forceps. It is an unwritten rule at
Queen Charlotte’s to cut short the second stage in a
multipara after two hours by putting on forceps—
that is to say, lingering labour, where there is no
obstruction, but where the pains are wanting or are
insufficient, and so the labour is delayed over the
average time.

The causes of delay in lingering labour may be
classified as those due to the mother’s general condition,
causes in the uterus, and causes in the passages ; there
are also causes on the part of the child. If the child
is too large, the labour will be an obstructed one. All
sorts of debilitating diseases will ^essen the mother’s
expulsive force; anaemia, lung troubles, and the
wasting due to starvation are the common ones. I
do not propose to go into these to-day. You must
always be on the look-out for diverticula and pendu¬
lous belly. If you stand the patient up, you may find
that, instead of the child pointing downwards and
backwards towards the coccyx, the abdominal walls
are pendulous, and the child more or less looks up¬
wards and backwards. The absence of pains is due
to what is called primary uterine inertia. The tonic
contractions belong to obstructed labour, not to linger¬
ing labour. Primary inertia means that the pains are
weak from the beginning ; the woman has never had
pains strong enough to expel the child. That very
seldom occurs in the primipara, but in the multi para
it is common. In pendulous bellv there is a lack of
abdominal pressure owing to weakness of the recti.
Secondary uterine inertia means that the pains have
been strong, but that they have then got weaker and
gone off. The commonest causes of these are, 1st, that
the woman has not been properly taught how to bear
down ; 2nd, she is not we'll under the doctor’s control ;

(a) Delivered «t the Medical Graduates’ College and Polyollnlc,
Chenlet Street, W.C.,on Monday, July 8th, 1907.

Not*.— The Author’s corrected proof had not been received at the
time of going to Press.— Editor.

she is tossing about, and refuses to do anything she is
told, and when the pains come on she screams. She
does not make use of the pains, the child does not
advance, and after a time she naturally becomes
exhausted; then the pains get weaker, and pass ofl.
When this happens, many men, having watched the
case for several hours, bring up their forceps and put
them on. That is quite the wrong thing to do, for the
result is post-partum haemorrhage. They do not know
what to do, so they put on a binder, and hope for the
best. Many years ago, when I was a “locum,” I had
three or four of these cases in one week. The practi¬
tioner had come back to the surgery, and shortly after¬
wards received a message that the woman was bleeding.

He said he was too busy to go—would I mind? Some
of them were nearly moribund, and in each case he
had put on forceps because he could not wait. The
uterus is clogged, and you cannot get any stimulation
of it; so after the child is delivered you perhaps use
a hot uterine douche, but it will not contract. The
reason is that the nervous arc is broken at the nerve
end-plates, which are clogged up with the products of
the constant contractions. You can give smelling-salts,
put the child to the breast, apply cold water to the
abdomen, and give a uterine douche, but the placental
site will bleed because of this clogging with the pro¬
ducts of nervous waste due to the continual strong
pains. In those cases there is nothing to do but plug
the uterus.

In regard to the ovum itself, one very common cause
of lingering labour is premature rupture of the mem¬
branes ; perhaps it is the cause in nine cases out of
ten. In the posterior cases the lower uterine segment
is not properly filled by the head, the woman bears
down before the cervix is opened, and there is, there¬
fore, premature rupture of the membranes. And later
on, the head not being properly Hexed, the occiput
remains behind, and you have to put on forceps. I
want to devote a good deal of attention to-day to the
subject of the premature rupture of membranes. The
membranes may be too adherent round the internal
os, which you notice more in placenta praevia. Then
there is over-distention of the uterus, so that the uterus
cannot get a “purchase ” on the child. Other causes
are hydramnios and twins. In that the delay is in the
first stage ; everything goes right after the membranes
are ruptured. It is common for the first stage to be
delayed 24 or 36 hours, and I have seen cases in which
the pains have continued for three days, but were not
strong enough to open up the cervix.

Let us consider the commonest cause of lingering
labour—the premature rupture of membranes. The
treatment depends on the stage at which you meet with
it. If the membranes are ruptured with the cervix
half an inch or so thick, the treatment differs from
that where the cervix is open and the walls thin. If
you get the case early, and the cervix is still thick,
and is not fully dilated, do not put on the forceps.
Never put on forceps with an undilated cervix. Use
de Reeve’s (?) bag. Absolutely the best use of this
bag is in premature rupture of membranes. Before
the cervix is open, the uterus turns the dilating force
into an expulsive force, and the uterus pushes the child j

on to the cervix, the cervix gets emptied and closes up j

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Nov. 37, 1907.

CLINICAL LECTURE.

The Medical Press. 57 1

again, and there is a hard, rigid, contracted cervix,
with spasm. To prevent that, put in this bag and
replace the membranes. In that way you save hours,
because the labour now goes on in the normal way.
You can alter the tension of the bag by pulling on the
tube, and when the bag comes out, the os will be
sufficiently dilated for the bag to pass. If you have
not this bag, use an ordinary penny air-ball blown out
and tied on to a catheter, and an ordinary pair of
forceps will be sufficient for introducing the bag. This
bag can be introduced into a cervix which admits two
fingers; afterwards loosen your forceps and turn on
the tap. Blow it up with water, and as it fills see that
this is well inside the cervix, and afterwards extend
it up as far as it will go. Then take out the forceps,
which can be removed separately. If you have a diffi¬
culty in getting the bag inside, fix the anterior lip
with a volsella. With the Bame 3 bag it is necessary
to have a number of them, and therefore the risk of
sepsis is increased. You only want one such bag as I
show you ; it is easily sterilised. Sometimes these cases
of premature rupture come off without trouble, but the
majority of them cause delay; therefore do not wait
until you replace the bag of membranes. If you can¬
not introduce the bag because the cervix will not admit
two fingers, you must wait, and, while waiting, give
chloral, a i-drachm dose by the bowel. It is supposed
to have a specific action on the cervix, and I think it
has. I have given drachm doses hundreds of times,
and I have never had a bad result from it, though some
people say chloral is not a safe drug to use You can
repeat in ^-drachm doses. If you have a case in which
you have not put on your de Reeve’3 bag, and you are
sorry for it, and where labour has been going on
longer, and the uterus has emptied itself of its liquor
amnii, the cervix is still in front of the head, and very
often the anterior lip is nipped between the child's head
and the pubes, and therefore gets cedematous; the
pains are very great, causing the woman to shriek ;
those cases want treatment quite differently. You find
a thin os, and the child’s head will descend before
the osseous canal is open. It is of no use putting in
a bag, because if you begin to push up the child you
will risk rupturing the uterus. You give the woman
chloroform, and it acts like a charm—perhaps in ten
minutes the whole case is over. The head is rammed
down on the cervix, and causes it to be irritated and
go into spasm, arid that causes the painful contraction.
By giving chloroform you relieve the pressure, and
take the head off the cervix, and the cervix opens up.
You can either put on forceps or let it deliver
naturally, but the case is over. Chloroform acts better
and quicker in these cases than opium.

There is a similar condition, but not so marked,
where the pains are not so great and the descent is
greater. The cervix is not so thin, and the os more
open, but the swollen anterior lip protrudes from the
vulva. There is a plum-shaped ma 3 S. Do not cut it
off as a polypus. The treatment for that is, while the
pains are off, put your finger between the head and
the anterior lip, and try to stretch the cervix over the
child’s head. Between the pains there will be a
distinct relaxation of the uterus, and the woman will
allow you to press the anterior lip up.

Primary uterine inertia due to other causes must be
treated in the ordinary way. Several things are often
overlooked at confinements. The woman does not have
rest and food. In primiparae, very often two or three
days before labour commences she has not been eating
or sleeping. These two important points must be
looked to. If the pains are not strong, give her plenty
of liquid nourishing food and sedatives, opium being
the best. When she awakes the pains will be stronger,
and the birth will probably take place. The bowels
and the bladder must be seen to. A loaded rectum
was a common cause of lingering labour, but nowadays
the bowels are better looked to. Still, a loaded bladder
is a common cause, and later on it causes haemorrhage.
The doctor is continually in the room, and the woman
has had her pains to think about, and even if she has
thought about her bladder, she has not liked to say
she wanted to empty it. If after that there is nothing
in the way, the os is opened, and the labour is not
coming off, the question is—when are you to interfere
by putting on forceps? In a multipara, where there is

nothing wrong with the passage or with the passenger,
you are justified in putting on the forceps after two
hours. You do so, not to pull the child out, but to
help the pains. So you must pull with the pains, and
, relax between them. If the head is sticking in the
upper part of the pelvis, put on axis-traction forceps.
If the child is sticking in the lower part, put on the
ordinary ones. I advise you, for general practice, in
these high cases, to put on axis-traction bars. With
the ordinary forceps you are not pulling far enough
back, and that makes all the difference as to whether
the child comes down easily or not. Never put forceps
on a primipara, however many hours you may have to
wait. If you can get a woman through her first con¬
finement without a temperature and without cutting,
she will get through it without being a chronic invalid.
If the ordinary married woman has instruments at her
first confinement, she always seems to have something
wrong with her afterwards. There is only one justi¬
fiable exception to this, and that is when the head
sticks at the bony outlet, at the narrowest part of the
pelvis. If the head does not advance, you are justified
in putting on forceps. You pull the child’s head a
little bit past with one good tug, and immediately take
off your forceps ; don’t attempt to bring the head over
the perinaeum. In the primipara you wait half an hour
before putting on the forceps to see if the head
advances. When the head is once through the bony
outlet, it will never slip baok. Bathe the perinaeum
with hot fomentations. Some doctors say they do not
believe in fomenting the perinaeum, but others do.
Many of those who do not believe in it have applied a
little warm water by means of cotton wool once every
half-hour. That, of course, has no effect. You want
a big diaper or plug of cotton wool, the water as hot
as she can stand it, and soak the perinaeum and right
back on to the buttocks. If you look where the lines
of stretching took place after the child is born, you
find them on the buttocks and thighs, showing that
those parts ought to be softened. In carrying out your
softening, do it for half an hour, then give it ten
minutes rest, and then go on for another half-hour.
Let the head come forward and go back as often as
you like, but each time it will come a little further.
Whenever you get that backward and forward process
on the perinaeum, labour never stops, secondary uterine
inertia does not come on at that stage, and the more
often it does that the safer it is for the perinaeum.

With regard to unfavourable positions, of course
the great bugbear is the posterior case. You do not
diagnose the posterior position until the membranes
have been ruptured, and perhaps the head has
descended well into the pelvis. But if you diagnose
the posterior position only, before the rupture of the
membranes, or while the head is still at the brim, or
the cervix not fully dilated, it is justifiable to attempt
to rotate the posterior cases into anterior cases. And
I advise you to always give chloroform, and always
introduce the whole hand into the vagina, seize the
occiput, and pull it round to the front. You are
working above the brim, and therefore you can do it.
When you have got the occiput in front, keep it there.
With the other hand rotate the anterior shoulder to
the opposite side of the abdomen. If you do not do
that it will get into the same position again. When
the head is engaged in the pelvis, it will not move
again, but if you have not got the shoulders round,
the child will swing back again. The posterior fon-
tanelle should be much lower than the anterior. As
soon as you recognise that you have a posterior case,
therefore, you push up the forehead and carry out
what I have described.

Ordinary Unreduced Occiptio-Posterior Cases :—The
treatment for this condition is either to put on forceps
and pull the head down the perinaeum, with the occiput
behind, and then take off the forceps and allow the
occiput to rotate to the front, and again put on the
forceps in order to extract the head, or else put on the
forceps the wrong way up, and as you pull down allow
the forceps to rotate right round ; in other words,
anticipate the rotation of the occiput to the front. In
putting on the forceps, introduce the left blade with
the left hand, and with the edge of your finger on the
blade rotate it round. Do not do this by the handle
alone; you guard the blade from injuring the uterus by

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Nov. 37, 1907-

572 Th e Medical Press .__ OR IGINAL

means of the hand. Do similarly with the right blade. '
I remember particularly a case in which an attempt
had been made for several hours to deliver, and finally
the instruments were laid out in readiness to do cranio¬
tomy. But they had not tried what I am now
describing. I put the blade on in the way I have
mentioned, and, with moderate pulling, I got the head
down. It was a 12 lb. baby. I can assure you it is an
extremely good tip for those cases.

The only other point about lingering labour is breech
labour. In this kind there is nearly always a lingering
labour, because you have the child coming the wrong
way—that is, with the head and shoulders up above.
Most of the force of the uterus is exerted in squeezing,
like squeezing a pip between the fingers, but with the
larger part above ; the result of the snueezing is to
force the child upwards instead of downwards. In a
breech case leave the membranes intact as long; as
possible ; do not rupture them, even if they appear at
the vulva, because even when the breech has passed
through the cervix the cervix is not dilated enough to
allow the head to pass. Secondly, remember you have
to deliver the child artificially, so you must be pre¬
pared to deliver. And you ought to have a systematic
way of delivering the breech. When the breech comes
down to the umbilicus, you must yourself start to
deliver, because when the child has reached that spot
it has only four minutes to live, because the placenta
is beginning to be detached, and the child has half
left the uterus. First look for the arms, and always
be prepared to pull down the extended arms, the pos¬
terior arm first; then turn the child right round until
the anterior arm becomes the posterior. Next deliver
the head, and do not attempt to pull the head out '
until you have passed your hand in. Then put your
fingers into the mouth. The head must come down
transversely from the pelvis; pull it down from the
brim to the floor. Don’t attempt to rotate the child
until the head is on the floor. You must not turn the
back to the front immediately the shoulders are born,
though that is the usual thing one sees. All the time
you are delivering the breech you should either be
pushing on the uterus or getting someone else to push
down, because the more you pull from below the more
vou tend to extend the legs and arms. Deliver the
breech always with the woman lying in the dorsal
position across the bed. Secondly, always give chloro¬
form if you possibly can, because it is painful to pass
the hand in alongside the child’s body. Of course, if
more than four minutes have elapsed after the child
has reached the umbilicus, and before it is born, you
do not cease your efforts, but try to resuscitate the
child. I have seen a child pulled round when it has
been 20 minutes afterwards.

Note. —A Clinical Lecture by a well-known teacher
appear* «'» each number of this journal. The lecture for
newt week will be by R. W. Philip, M.A., M. D., F.R.C.P. f
F.R.C.8.E., Physician and Lecturer on Clinical Medicine,
Royal Infirmary, Edinburgh. Subject: “ Exophthalmic
Ooitre and Myxcedema."

ORIGINAL PAPERS.

TUBERCULOSIS IN CHILDHOOD
AND ITS RELATION TO MILK, (a)

By JOHN M'CAW, M.D., R.U.I., Etc.,

BeDlor PhysicUu to the Belfast Hospital for Hick Children.

During the past few years, and especially at the
present time, the tuberculosis question has engaged
and is engaging the attention of the medical profession
in all countries. A campaign is being carried on
against tuberculosis which has already resulted in
much benefit, and bids fair to eventually stamp out the
disease completely. Whether or not this highly
desirable result will be attained in our time is very
doubtful, but it is satisfactory to know that the means

(a) An nddreu delivered at the Opening Meeting of the Otter
Medical Society.

PAPERS.

by which the disease is generated and spread are well
known, and that prevention is not impossible.

The medical profession in Ireland have not been
behind-hand in this campaign. The large amount of
tuberculosis existing in Belfast has been very forcibly
brought out by means of letters in the local Press,
and especially by statistics submitted by the various
witnesses who appeared before the Health Com¬
mission. Further, the Registrar-General of Ire¬
land, in his annual report for the year 1906.
points out that out of a total of 74,417 deaths registered
no fewer than 11,756, or 15.8 per cent., were due to
tuberculous disease. Of the total number of 11,756
deaths, the number dying from phthisis (pulmonary
tuberculosis) was 8,933. Of this total, 1,072 died
between the age of 15 to 20 years; the deaths from
20 to 25 years numbered 1,444, an d from 35 to 45.
years they numbered 1,557. The report of the
Superintendent Medical Officer of Health of Belfast
shows that during the year 1906 1,015 deaths were
registered in Belfast as caused by phthisis, and 395
from other forms of tuberculous disease.

Finally, the Registrar-General for Ireland points
out that, while in England the death-rate for all
forms of tuberculous disease has declined from 3.3
per 1,000 in 1864 to 1.6 per 1,000 in 1905, and in
Scotland from 3.6 per 1,000 in 1864 to 2.1 per 1,000
in 1905, it has in Ireland risen from 2.4 per 1,000 in
1864 to 2.9 in 1904 and to 2.7 per 1,000 in 1905 and
1906. With these figures before me I think I am
justified in saying that in no country is it more
desirable to pursue a vigorous campaign against
tuberculosis than in Ireland, and in no city in the
United Kingdom is a better opportunity afforded for
studying and fighting the disease than in Belfast.
Our position, therefore, with regard to the large
amount of adult tuberculosis existing in Belfast, is
well known and assured, and to it I need not further
refer; but what about tuberculosis in childhoood?
As a separate enquiry this aspect of the question has
been but lightly touched upon, and I shall endeavour,
as far as possible in the time at my disposal, to
supply the omission in what follows.

My connection with the Belfast Hospital for Sick
Children for the past twenty years has given me
exceptional opportunities for studying the disease,
and I shall now place before you, as shortly as
possible, the main points with regard to tuberculosis
in childhood, and lay special emphasis upon the con¬
nection which exists between tuberculosis and cows’
milk. In order that my remarks may be quite clear
and readily followed, I shall discuss the subject under
the following heads:—(1.) What amount of tuber¬
culosis in children exists in Belfast? (2.) What types
of the disease are met with? (3.) What connection
exists between tuberculosis and cows’ milk? (4.) What
can be done to prevent or cure the disease?

1. What Amount of Tcbkrcui.osis in Children
Exists in Belfast? —In conversation with the
physicians and surgeons attached to children's
hospitals I find a general consensus of opinion that
tuberculous disease of one kind or another forms a
very considerable part of their work in these institu¬
tions, and Professor Holt states that autopsies on
children dying from all causes under 15 years of age.
show the presence of tuberculosis estimated by various
observers at from 14 to 40 per cent. I think the state¬
ment may safely be made that a large amount of
tuberculosis exists among children. That this opinion
is well founded, I shall now endeavour to support
by a few statistics. At the Children’s Hospital, in
Queen Street, during the quinquennial period 1903-06,
26,193 cases were treated, and tuberculous disease in
some form was met with in almost 20.0 per cent.—
to be accurate, in 19.99 per cent, of them. Of this
total, 4,049 were treated as in-patients in the wards,
and 28.52 per cent, of them were tuberculous, while
22,144 new cases were treated in the out-patient
department, and 18.26 per cent, suffered from tuber¬
culosis in some form.

The interesting question arises: How do we in
Belfast compare with other cities in regard to the
atj ionnt of tuberculosis met with in children? To

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Nov. 27, 1907.

ORIGINAL PAPERS.

The Medical Press. 573

arrive at an answer to this question I have examined,
on exactly the same basis, the returns of the cases
treated at various hospitals, as follows: —

Belfast Hospital for Blok Children—No. of Intern patients, 828 ;

No. tuberculous, 23*74 per oent.

Ulster do. do. do. —No. of intern patients, 247;

No. tuberculous, 30‘34 per oent.

■Great Ormond Street, London... —No. of Intern patients, 2,876 ;

No. tuberoulous, 27 per oent.
Boyal Edinburgh Hospital ... —No. of intern patients, 1,968 ;

No. tucerculous, 20 per cent.

Manchester Children’s Hospital —No. of Intern patients, 1 999 ;

No. tuberculous, 21‘3 per oent.

East London do. do.

—No. of Intern patients, 2,054 ;
No. tuberculous, 24*3 per cent.

Glasgow do. da

—No. of Intern patients, 1,177 ;

No. tuberoulous, 27*06 per cent.

This table shows a wonderful agreement amongst
the returns of these hospitals as to the amount of
tuberculosis met with. My firm conviction is that all
children’s hospitals meet with much the same amount
of tuberculosis, and that that amount is very large.

2. What Types of the Disease are Met With?—
A glance at the statistics which I have given will be
sufficient to demonstrate the fact that a certain number
of the cases of tuberculosis met with at the children’s
hospitals are deemed suitable for treatment in the
medical wards, while others are more properly sent
to the surgical side. From this, then, one might say
that there is a medical as distinguished from a surgical
form of tuberculosis ; and while this is true enough,
still it is not sufficient, nor does it satisfy the question.

One of the most noteworthy deductions from the
statistics is the preponderating amount of surgical
tuberculosis met with when compared with that seen
by the physician, and this point I wish very specially
to emphasise, as having a most important bearing on
causation and treatment. If the returns of the
hospitals mentioned be examined, it will be found that
the cases treated on the medical side consist of phthisis
and meningitis, spinal caries and general tubercu¬
losis ; while on the surgical side the surgeon is
deluged with chronic abscesses, tuberculous joints,
lymphadenitis, and chronic ulcers. But it should be
noted that many of the cases treated in the medical
wards would be more properly classified as surgical—
such, for instance, as lupus, spinal caries, etc.—which,
if added to the surgical figures, would still more
emphasise the preponderance of surgical over medical
tuberculosis. These facts suggest the question, is the
disease as seen by the physician only another form of
that met with by the surgeon, or are they different
types of the same disease, and caused by a bacillus of
a different species?

Recently the theory has been put forward that tuber¬
culous affections of the human body are divisible into
two types :— (a) a type caused by tubercle bacilli from
the human, and called the “typus huraanus ” ; and
(b) a type caused by tubercle bacilli from the cow,
and called the “typus bovinus.” These bacilli are
varieties of the same species, but they give rise to
quite distinct and different lesions, according to the
method of infection. In the first (or human) type,
the bacilli are inhaled in dust, and find a lodgment
in the apex of the lung. From this site of infection
the disease may spread and cause secondary infection
-of the intestines, or set up a tuberculous laryngitis.
In the second (or bovine) type, the disease is con¬
veyed indirectly by means of tubercle bacilli taken
into the body in raw milk, meat, etc. Here the
infection is carried to the intestines and mesenteric
glands, and gives rise to tabes mesenterica, tuber¬
culous peritonitis, tubercle of the pelvic organs, tuber¬
culous lymphatic glands, tuberculous bones and
joints, lupus, tuberculous meningitis, or acute miliary
tuberculosis. Much may be said in support of this
theory; and I will content myself at present by point¬
ing to the enormous amount of surgical tuberculosis
met with at an age when cow’s milk is largely availed
of—indeed, is the chief article of diet—as a circum¬
stance of the highest moment, and also to the follow¬
ing extracts from the report of the Royal Commission
on Human and Bovine Tuberculosis. In that report

(page ro) the effects of feeding calves with the bacillus
of bovine tuberculosis are set forth as follows: —In
each of six cows, whose udders had been made tuber
culous by intra-mammary injection, the calves were
allowed to suck for varying periods. In one case
only was general tuberculosis produced. In all the
other five calves killed, after being kept alive from
74 to 363 days, the tuberculosis was for the most part
limited to the intestines and mesenteric glands.
Fourteen calves were fed with tuberculous milk, the
number of bacilli ingested varying from one to ten
millions. None of these calves showed when killed
anything more than tuberculosis limited to the intestine
and to the mesenteric or ileo-colic glands; in one
case tuberculous lesions were found in the pharyngeal
glands. In other animals the results are no less
striking. Thus a quantity of milk from a tuberculous
udder produced in each of two pig9 tuberculous
disease of the mesenteric and ileo-colic glands. In
goats, feeding sometimes produced a generalised pro¬
gressive tuberculosis ; at other times the disease was
limited for the most part to the mesenteric and adjoin¬
ing glands. In anthropoid apes, a chimpanzee was
fed for a week with tuberculous milk, the number of
bacilli given being estimated roughly to be 100
millions. It was killed when very ill, 100 days later,
and showed generalised progressive tuberculosis ; the
intestines and associated glands were tuberculous,
and there were also tubercles in the lungs, thoracic
glands, spleen and kidneys. Another chimpanzee
received 10 million bacilli, tuberculous milk being the
medium. It died 144 days afterwards, with tubercu¬
lous ulceration of the intestines, and caseous or
caseo-calcareous lesions in the mesenteric and meso-
colic glands. The tuberculosis was, therefore,
limited. These experiments, then, in the anthropoid
ape, an animal so nearly related to man, are of the
highest importance, and point clearly to the fact that
when the dose of bovine tubercle bacilli taken into
the system is large, a generalised tuberculosis, start¬
ing from the intestines and mesenteric glands, is set
up ; whereas when the dose is moderate, the affection
may remain confined to the intestines and mesenteric
glands, which in time may extend to other glands and
bones and joints. Here, then, I submit is evidence
sufficient to support the contention that the large
percentage of tuberculosis met with in children is
bovine, and caused by the ingestion of bovine tubercle
bacilli in milk, meat, etc., and that this form of
tuberculosis is chiefly surgical. But this theory goes
a step further. It is affirmed by some that these two
types of the disease are more or less antagonistic, so
that a child when it becomes affected with bovine
tuberculosis absorbs an antitoxin, which protects it
against the human type of the disease, and similarly
the human type renders it either less liable to be
attacked by, or immune against, the bovine bacillus.
In support of this contention the rarity of pulmonary
tuberculosis in association with tuberculous glands,
or joints, or bone disease is pointed to; and the
further fact is relied upon, namely, that the vast
amount of tuberculosis met with in the child is
surgical, the result of infection with bovine bacilli,
and also that the adult or human type of the disease
is quite rarely met with at an early age.

To carry this argument to a logical conclusion : if
this theory be correct, then human serum, or tuber¬
culin R., should be beneficial when used for surgical
or bovine tuberculosis; and, vice versa, bovine serum
should be beneficial in tuberculosis of human type.
Much evidence could be adduced in support of this
contention, and my experience, but more especially
the experience of surgeons, is, that in limited tuber¬
culous lesions of a surgical nature the injection of
tuberculin R. is followed by favourable results. Dr.
Nathan Raw, of Liverpool, whose work in this con¬
nection has been very extensive, writes me to say
that he has obtained the most gratifying results from
the use of these serums, and, after long observation
of clinical cases, and extensive laboratory work, he is
convinced the theory is sound. I cannot, however,
now wait to discuss this point further, but I should
like to make the suggestion that during the session
an evening might be very profitably devoted to a dis-

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ORIGINAL PAPERS.

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cussion of this subject. The third question to be
answered is:—

3. What Connection Exists Between Tubercu¬
losis in Children and Cows’ Milk? —As I consider
this to be a very important part of my subject, I
should like to emphasise its importance as much as
possible, for two reasons— first, because the con¬
nection is a very close and" vital one, as I shall
endeavour to prove; and, secondly, because no serious
attempt has yet been made by the authorities to
determine the amount of tuberculosis existing among
dairy cattle, much less to adopt such measures as are
necessary to stamp out bovine tuberculosis. In what
has gone before, I have shown that a large amount
of tuberculous disease exists amongst children. Let
me now draw your attention to the fact that the
disease appears at a time of life when cows’ milk is
the main, or almost the main, article of diet. These
two statements taken together are sufficient to
establish a firima facie case against cows’ milk.
Further, I have shown that tuberculosis in children is
very largely of the surgical type—that is, it is chiefly
glandular, and almost certainly due to the bacillus
of bovine tuberculosis which has been taken into the
system in food. In support of this the following
definite pronouncement of the Royal Commission is
of the highest moment. On page 36, paragraph 66,
of their report is the following:—“There can be no
doubt but that in a certain number of cases the
tuberculosis occurring in the human subject, especially
in children, is the direct result of the introduction
into the human body of the bacillus of bovine tuber¬
culosis ; and there can also be no doubt that in the
majority at least of these cases the bacillus is intro¬
duced through cows’ milk. Cows’ milk containing
bovine tubercle bacilli is clearly a cause of tubercu¬
losis, and of fatal tuberculosis, in man. Of the 60
cases of human tuberculosis investigated by us, 14 of
the viruses contained the bovine bacillus. If, instead
of taking all these 60 cases, we confine ourselves to
cases of tuberculosis in which the bacilli were
apparently introduced into the body by way of the
alimentary canal, the proportion of cases of bovine
infection becomes very much larger. Of the 60 cases
investigated by us, 28 possessed clinical histories
indicating that in them the bacillus was introduced
through the alimentary canal. Of these, 13 contained
the bovine bacillus. Of 9 cases in which the cervical
glands were studied by us, 3, and of the 19 cases in
which the lesions of abdominal tuberculosis were
studied by us, 10, contained the bovine bacillus. These
facts indicate that a very large proportion of tuber¬
culosis contracted by ingestion is due to tubercle
baciUi of bovine source. A very considerable amount
of disease and loss of life, especially among the young,
must be attributed to the consumption of cows’ milk
containing tubercle bacilli, ... for the bacillus of
bovine tuberculosis can readily, by feeding as well as
by subcutaneous injection, give 'rise to generalised
tuberculosis in the anthropoid ape, so nearly related
to man, and, indeed, seems to produce this result
more readily than in the bovine body itself.” After
these weighty words it is quite unnecessary for me
to labour the point further, and, indeed, it would be
a waste of your time were I to do so. This pro¬
nouncement of the Royal Commission establishes a
close and clear connection between cows’ milk and
tuberculosis in children, and must be considered
final.

4. Finally, What Can be Done to Prevent or
Cure the Disease? —With regard to the first part of
the question—how can we prevent tuberculosis in
childhood ? I think I may safely say a general opinion
exists that our best hopes for eradicating the disease
lie in the direction of preventing it, and accordingly
measures adopted for prevention must be energetically
pursued. Two eminent opinions have been expressed
on this point from which we may obtain guidance,
namely, that of Professor Koch, who lays stress upon
the transmission of the disease by contagion, especially
by means of the respiratory organs; and that of
Professor Von Behring, who is of opinion that tuber-
culosis in children is principally disseminated through

the alimentary canal, and he sees a fruitful source of
danger to children in the tuberculous nature of much
of our milk supply. I think both these pronounce¬
ments are true, but I hold strongly that the latter
• theory is the more important one as regards children.
Acting upon Koch’s opinion it is necessary that
children be kept apart from those suffering from
pulmonary tuberculosis, whose breath and sputa are
loaded with infectious germs. This has been recognised
in Germany, where visits are made to the houses of
consumptives, children are removed, when this is
possible, from such surroundings, directions are given
and patients are taught the most efficient means of
disinfecting and disposing of their sputa, and the
necessity for keeping their clothes, beds, furniture, and
floors clean. Such means as these constitute a power¬
ful factor in limiting the area of the disease and
diminishing its virulence. Then much good has
resulted from convalescent homes in the country,
holiday camps, and forest schools. The country homes
are simple but suitable buildings put up somewhere
in the woods to which children may be taken and kept
for the entire day. At these homes everything is con¬
ducted upon strictly hygienic lines, from the proper
cleansing of the children to the furnishing of a suit¬
able dietary, and the enforcement of physical exercise.

Coming now to Von Behring’s view that tuberculosis
in children is principally disseminated through the
alimentary canal, I believe we have here the most
important factor in the tuberculosis of children. Many
eminent authorities in this country adhere to this
view, and have given expression to the opinion that
the bacilli found in these cases are most commonly of
the bovine type, and gain entrance into the system bv
means of the milk of infected cows. It may here be
asked, what amount of bovine tuberculosis exists?
The report of the Royal Commission on Tuberculosis
states that “of all animals slaughtered for food in
Great Britain and Ireland those of the bovine race
seem to be more largely affected with tuberculosis than
any other.” In the absence of statistical information
as regards our own country, the report proceeds to
show that, in Leipzig, of 9,303 cows slaughtered,
4,048, or 43.51 per cent., were tuberculous. The pro¬
portion of such diseased cattle in English cow-hou9es.
which has been publicly and authoritatively stated
to be about 30 per cent, by the late Professor
MacFadyean, is, therefore, probably not excessive. In
the year 1901 there were 1,887,414 milch cows in Eng¬
land, and 4,102,061 in the United Kingdom. Thirty
per cent, of these means upwards of 560,000 tubercu¬
lous cows for England alone, and nearly millions
for the United Kingdom. If 5 quarts of milk be
allowed as a fair average yield per day for each cow,
then 6,250,000 quarts of milk, the daily yield of
tuberculous cows, are consumed each year in the
United Kingdom. Again, it has been calculated, and
is admitted, that tuberculosis of the udder exists in
2 per cent, of dairy cows in the United Kingdom;
this means that some 20,000 cows with active tuber¬
culosis of the udder are to-day contributing to our
milk supply, and some 100,000 quarts of milk teeming
with virulent bovine tubercle bacilli are consumed
each day in the United Kingdom.

When it is remembered that even one diseased
udder is capable of disseminating a huge number of
tubercle bacilli, the bare idea of the amount of possible
human tuberculosis from the milk of so immense a
number of diseased cows is appalling. I regret I am
unable to place before you any statistics bearing upon
the prevalence of tuberculosis in cattle supplying milk
to Belfast, but the following figures, taken from the
report of the Medical Officer of Health of Manchester
Dr. Nevin, are interesting in this connection . —During
the year 1904, 432 samples of milk were examined, the
number of farmers represented in the total being 318
Of these 318 farmers, 188 reside in Cheshire, and 21
of them (or 11.17 P*r cent.) sent tuberculous milk -
83 live in Derbyshire, and 5 of them (6.02 per cent >
sent tuberculous milk; 14 reside in Lancashire, and
1 of them (7.14 per cent.) sent tuberculous milk;

8 reside in Yorkshire, and 2 of them (25.00 per cent \
sent tuberculous milk. Are we in Belfast any better
off in regard to the number of diseased cows supplv-

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ORIGINAL PAPERS.

The Medical Press. 575

ing milk than Manchester? My firm belief is we are
not. I am confirmed in this opinion from what I
have seen when visiting some of the dairies within
the city, and that much tuberculous milk is purveyed
in our midst I think admits of no doubt. It is clear,
therefore, that a large amount of tuberculosis in cattle
exists, and the connection between the disease in
cattle and tuberculosis in childhood having been
established, it follows, if we would prevent the disease
in children, the first and most important step is to
stamp it out in cattle. In considering how this may
be done it is necessary to remember that in tubercu¬
losis, before the formation of tubercles in any part of
the body, there is a stage of the disease of unknown
duration during which the bacilli multiply and
circulate throughout the body. To regard the disease
as beginning with and being localised in tubercular
formations is to fail to recognise the bacillary stage
of the disease, and is therefore wrong. This pre-
tubercular stage can only be detected by means of the
tuberculin test; therefore, it becomes imperative that
this test be applied to all dairy cattle, and that every
cow reacting to this test be withdrawn and the carcass
destroyed. To ensure success, however, compulsory
and universal application of the principle is necessary.
Fair compensation for the loss to the stock-owner
should be granted ; and, probably, the sum of money
that would be required for this purpose is the main
objection to the enforcement of the measure by the
Government. In the year 1865-66 an outbreak of
cattle-plague occurred in this country, which involved
the death of 233,000 head of stock. And what took
place? The first consideration was the stamping-out
of the disease as quickly as possible, and at any cost.
But tuberculosis in animals is more widespread than
cattle-plague has ever been : it is always present in
our herds, whereas outbreaks of plague are few and
far between ; and, what is worst of all, tuberculosis
causes a vast amount of sickness and suffering and
death and despair, which cattle-plague does not do.
Surely this most astounding condition of things will
not be permitted to continue much longer. The
public—and, more especially, we members of the
medical profession—should now and at once insist,
both on hygienic and economic grounds, that it is
urgently necessary to stamp out this awful disease of
tuberculosis in cattle. It is estimated that the disease
in animals may be eliminated in a single year, and,
if so, what a year of triumph that would be!

To protect children from the ravages of tubercu¬
losis, the following rules may be formulated: —

1. The Notification of ail Births Within
Twenty-Four Hours. —This would enable health
visitors to examine into the state of the child's sur¬
roundings ; to have the child removed, or precau¬
tions taken, should any case of tuberculosis exist in
the house; and to give suitable directions for the
care of the child, and especially to encourage breast¬
feeding.

2. Complete Control of the Milk Supply by the
State. —This should include the application of the
tuberculin test to dairy cattle , and the removal of all
such as react to this test; cleanliness in the collection
of all milk, and in the transmission of it from the
dairy to the consumer; the removal of dairies from
the centre of large town and cities.

3. Medical Inspection of School Children and
School Premises. —First, to detect and remove
children who are actually ill or unfit to attend
school; and, secondly, to ensure proper ventilation
and sanitary arrangements in the schools, and to
prevent overcrowding. The elementary principles of
hygiene should be taught to even young children ; to
older children the principles of domestic hygiene and
economy should be added.

4. Dwelling-houses in the poorer districts should be
made more sanitary, especially with regard to the free
access to them of sunlight and fresh air. Ireland is
behindhand in this respect—a circumstance which
may, in part, account for its high death-rate from
phthisis. A levelling-up of the social and domestic
conditions of the poor is urgently required; for of
the 1,200,000 children born each year in the United

Kingdom, fully one-fourth to one-third of them are
born to want and squalor.

5. All advanced cases of phthisis should be segre¬
gated as far as practicable and treated in special
institutions set apart for that purpose. Children who
are allowed to live in the house with a consumptive
are exposed to serious risk.

6. Notification of the disease should be com¬
pulsory. By this means health officers would know
where the disease existed, and it would enable them
to take suitable precautions against the spread of the
disease by disinfection and other means.

With the second part of the question —What can be
done to cure the disease ?—I need not detain you long.
I have said that the large proportion of tuberculosis
in childhood comes within the purview of the surgeons,
and with them the treatment may safely be left; for
Belfast is fortunate in having a band of gentlemen
second to none in the kingdom for operative skill and
surgical acumen.

With regard to the use of tuberculin, the scientific
investigations concerning it have placed in our hands
a remedy of the greatest value. Unfortunately, the
profession still feel a want of confidence in it, or a
dread of its reaction, but it should be remembered
that the use of tuberculin at the present time is very
different from what it was when first introduced.
Formerly tuberculin was administered by rule of
thumb, and often with disastrous results ; now, thanks
to the brilliant researches of Sir A. E. Wright, and
the discovery by him of the opsonic index, the dose
of tuberculin, its effects, and the most suitable times
for injection, can be regulated with scientific pre¬
cision.

This discovery has in fact brought treatment with
tuberculin within the realm of safe therapeutics, and
the clinical success which has attended the employ¬
ment of this treatment has firmly established its
position as a remedial agent of the first importance.
In addition to the use of tuberculin, our efforts to
cure tuberculosis, or stay its progress, must include
good and wholesome food, healthy hygienic surround¬
ings, an abundance of pure air, and such drugs as
cod liver oil in combination with the hypophosphites.

THE ABORTIVE TREATMENT OF
SYPHILIS BY THE INTENSIVE
METHOD.

By Prof. R. DUHOT, M.D.,

Director of the Dcrmo-Syphllljrruphlcal Department at the Central
Polyclinic, Brussels.

[Specially Reported for this Journal.]

The possibility of definitively cutting short an attack
of syphilis by early intensive treatment has not so far
been admitted. Perhaps it would be well for me to
commence by putting in plain words what I really
intend to convey by this term in order to avoid con¬
fusion. The word “abortive” in this connection must
not be understood in the sense in which it might be
interpreted after eradication of the chancre supposing,
for the sake of argument, that this procedure really
held out hope of attaining its object. Surgical treat¬
ment which would at the same time remove the cause
and obviate the effects would indeed have been ideal,
but unfortunately such is not the case.

The abortive treatment of syphilis in the sense I
intend must be interpreted with a much wider scope,
in fact, we must allow the term a certain elasticity.
It consists of medical treatment which by energetic and
rapid mercurialisation from the very onset prevents the
generalisation of the spirochaste in the organism,
shuts up the infection in loco , and restricts it to the
chancre with limited glandular enlargement, sub¬
sequently weakening the infection until ultimate extinc¬
tion in such wise that no secondary manifestation
makes its appearance in spite of the closest search and
observation.

In patients thus treated, therefore, we never get any
roseola or general glandular enlargement, or alopecia,
or mucous patches, or leucoderma, in short, none of
the clinical symptoms by which we are enabled

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ORIGINAL PAPERS.

Nov. 27, 1907.

to diagnose the generalisation of the disease in the
economy. Lymphocytosis in the cerebro-spinal fluid
has also been absent in the cases that nave been
observed. It is indeed the curative and preventive
properties of mercury pushed to their uttermost degree.
It appears to me that the term “ abortive ” is justified
by contrast with the other methods which admit re¬
currence as a general rule.

I have subjected altogether 134 patients to this mode
of treatment, 120 men and 14 women, their ages vary¬
ing from 16 to 36 years. Among these 134 cases sir
were doubtful, presenting certain ill-defined throat
symptoms. The conditions of success of the abortive
treatment are the following : —

(1) The treatment must be commenced before the
twelfth day following the appearance of the chancre.

(2) The treatment entails the employment of injec¬
tions of insoluble salts, or calomel, or what is more
practical, grey oil, in intensive doses.

(3) The first course of treatment should be pushed
to the utmost degree compatible with the resistance
of the organism, and continued for not less than four
months.

(4) The subsequent courses of treatment comprise
shorter periods, on the lines of the chronic inter¬
mittent treatment of syphilis.

*•—The Treatment to be Commenced before the
Twelfth Day.

Experience seemed to indicate the twelfth day as the
limit for the certain, abortive treatment of syphilis,
nevertheless I have myself successfully carried out the
treatment in a case of chancre of 17 days’ standing.
That is a matter of judgment, and there is consider¬
able difficulty in exactly establishing the extreme limit
for the success of the treatment, and it is quite con¬
ceivable that other observers may find it feasible to
extend this period. In any case the limit cannot
possibly be the same in all patients, for no one will
contest that the generalisation of the spirochaete takes
place with very variable rapidity in different subjects,
and that the conditions of microbial virulence and
organic resistance must influence the duration of the
period of generalisation.

The necessity for prompt treatment and the value of
the preventive action of mercury, still questioned by
some observers, are amply confirmed by the results of
Uie abortive treatment. By pills and inunctions given
from the onset we can at most hope to delay and
mitigate the roseola, reducing it maybe to a few scant
manifestations, whereas by a more energetic treatment,
such as the abortive method, we may obviate it
altogether. It must, however, be borne in mind that
*f instead of inaugurating immediate treatment we
await the appearance of the roseola the same treat¬
ment, although applied with the same energy, will not
succeed in jugulating the attack, and this fact, better
than all the heresies put together, illustrates the
capital importance of the epoch at which the treat-
m ® nt , IS , gun> . . The possibility of cutting short an
attack of syphilis had already been foreseen by my
inend and master, Prof. Jullien, who has published
several observations of the kind. All I have done has
been to systematise his ideas, and I flatter myself that
my efforts in that direction have been successful.

In early mercurial treatment there is one great rock
ahead, viz., error of diagnosis. I believe, however,
without arrogating to them the gift of infallibility,
that svphiligraphers upon whom long experience has
conferred the tactus eruditus, who scan with every care
the incubation period and the appearances, have an
immense superiority over the ordinary practitioner,
and experience no hesitation under circumstances
where others would be greatly embarrassed. In a
really doubtful case I should be the first to hold my
hand and await the appearance of the roseola. Of
late, however, such cases have been getting rarer and
rarer, and the chances of error have greatly diminished
now that the recognition of the spirochaete affords us
a new and unquestionable basis of diagnosis.

2.—Method of Application and Doses.

If I early made up my mind only to use insoluble
«alts for injection in carrying out the abortive treat¬

ment, it was because experience had shown me that
in practice this method alone possessed the qualities
indispensable for the success of the treatment. I do
not pretend that, theoretically, at any rate, inunctions
and soluble injections might not attain the same end.
But inunctions present certain drawbacks and short¬
comings. They do not display the same activity in all
subjects, and are open to various objections which it
would be tedious to enumerate here. Daily injections
of soluble salts become so irksome for the patient,
and are often so painful in intensive doses, that these
two methods can but rarely be found suitable in daily
practice; moreover, they only imperfectly realise the
abortive treatment. Soluble salts, moreover, present
the very great disadvantage that they are too rapidly
eliminated without having liberated their mercury
constituent, and without having adequately permeated
the cells of the organism. Indeed, for the results
of the two to be made comparable, we should have to
employ a method of uniform activity which would
not be liable to numerous sources of error. Although
the injection of insoluble salts is itself by no means
exempt from drawbacks, it does assure the regularity
of therapeutical effects as witnessed daily in our
clinic which it will not occur to anyone to question
at the present time.

The best method, then, is by the injection of in¬
soluble salts, which enable us to obtain the desired
results by methodical and scientific mercurialisation,
without interfering with the patient’s social and family
I life. Inasmuch as the abortive treatment ought not
to be reserved for exceptional cases, but, on the con¬
trary, should be employed whenever the oppor¬
tunity presents itself, the therapeutical agent
we make use of must be one readily accepted
by the patient. The preparation that best
fulfils this condition from every point of view
is grey oil. It is, indeed, the preparation that
appears to be most popular with syphiligraphers, who
are in favour of insoluble injections, and their prefer¬
ence is justified by the fact that this preparation yields
the best possible results, and has enabled me to carry
out the abortive treatment in 134 instances, with only
six doubtful cases.

3.—The Maximum Intensity of the First Course
of Treatment.

Then, too, the method of insoluble injections realises
better than any other the possibility of intensive
treatment which is indispensable to its success. It is
just when the virus is beginning to multiply that it
behoves us to attack it with the greatest possible
energy, and on the intensity of the first course of
treatment will depend the ultimate course of the dis¬
ease. It may be that in the subsequent courses of
treatment less energetic means can be employed, and
that inunctions and soluble injections may suffice to
annul the virus once it has been mastered by the first
course.

But for this first attack of the diathesis the applica¬
tion of mercurialisation must not be in the least
attenuated. It must be pushed to the limit of organic
resistance, and my experience has satisfied me that it
is always necessary to give not less than 15 or 20
injections, entailing a course of about four months.
The first three injections must be made at intervals
of five days, the next three every six days, and the
remainder at intervals of eight days. Each of these
injections comprises a Barthelemy syringeful of grey
oil at 40 per cent., which is equivalent to 0.14 centi¬
gramme of metallic mercury. These doses are cal¬
culated for adults of an average weight of 65 kilo¬
grammes.

4 -—Treatment to be Continued on the Lines of
the Chronic Intermittent Treatment of Syphilis.

During the two years following, I give ten or twelve
weekly injections at intervals of two months. During
the third and fourth years I give eight or ten injections
at intervals of three months, but, as I shall explain
later, I am by no means convinced of the necessity of
treatment during the third, and especially during the
fourth year, and if I have hitherto adhered to this
plan it was merely in order to leave nothing to
chance.

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The Medical Press. 577

Nov. 27, 1907.

It may be objected by timid practitioners that there
is more danger in pushing mercury in intensive doses
than in allowing the development of a slight roseola;
they may suggest that it would be safer to proceed with
less haste rather than run the risk of mercurial intoxi¬
cation. As a matter of fact, no such intoxication takes
place provided one is careful to make sure of the
integrity of the emunctories, and those who have
visited my clinic have been able to satisfy themselves
of the perfect tolerance of my method. Not are we
justified in employing this big word intoxication
merely because there happens to be some slight dis¬
comfort, any more than we have the right to ascribe
any lassitude and pallor exclusively to the influence
of the treatment.

It may be conceded that mercury can never be a
food, but neither will syphilis ever become a welcome
disease, and assuredly we are more interested in
ridding the organism definitely of such an enemy than
in taking precautions lest the mercury should determine
sundry slight inconveniences, which, moreover, are
easily remedied. We see our patients during the inter¬
vals of the intensive treatment not only make good
the weight they have lost, when there has been any
loss, but even put on more flesh. This clearly proves
that if there be any intoxication it is less than would
•be provoked by the generalisation of the virus of
syphilis, so anaemiating in its nature, and of two evils
it behoves us to choose the lesser.

Moreover, it would be absurd in the extreme to look
at the matter from such a narrow point of view, and
to overlook the fact that the roseola, as well as the
local lesion, though admittedly of trifling gravity, is
at the same time an unquestionable sign of constitu¬
tional infection. To allow the syphilis to run its
■course, says Jullien, when it is within your power to
stop it, is to adopt an attitude of abnegation which
nothing in therapeutics can justify, and the conse¬
quences whereof will weigh heavily on the whole sub¬
sequent course of the disease.

If the toxins of syphilis really play the part with
which they are credited, would it not be supremely
illogical to permit the development of these poison-
-producing agents of whose deleterious effects we are
-still imperfectly cognizant. The slight importance
that used to be attached to the roseola has imbued
many practitioners with another false idea, viz., that
of making it a sort of criterium of the virulence of
the attack and of regulating the energy of the treat-
-ment thereby.

Another very erroneous conception in respect of the
syphilitic exanthem, which may explain the slight
concern with which many regard it, is that syphilis at
the secondary period is a purely cutaneous disease,
oblivious of the fact that there may be many graver
■exanthemata than the one which is visible to the eye.

We know since Ravaut’s works that roseola is not
infrequently associated with cerebro-spinal lympho-
•cytosis, and we are also aware of the refractoriness of
syphilitic affections of the nervous system to medica¬
tion. Can it therefore be a matter of indifference to
allow the spirochaete, at the period of its first
-virulence, to attack the meninges and the cerebro¬
spinal centres the absolute integrity whereof is in¬
dispensable to the harmonious working of all the
•organs?

Lumbar puncture will render it possible for us to
^recognise the fact that the meninges are being involved,
-and if we are fortunate enough to have made the
puncture early, we may be able to cut the pro¬
cess short. Moreover, it would be contrary to all
clinical principles to allow an infective malady like
syphilis to develop in the organism, and the routine
practice of waiting for the appearance of the roseola
before commencing treatment ought to be abandoned
once and for all. It has, indeed, always been based
on errors of observation. Lumbar puncture carried
out on ten patients who had followed the abortive
treatment only revealed physiological lymphocytosis,
showing that the meninges had escaped injury.

In another patient who had had the roseola, puncture
was made after his first intensive course of treatment,
and microscopical examination revealed the past exist¬
ence of lymphocytosis, characterised by the presence

of degenerated deformed elements the nuclei whereof
took the stain imperfectly. I am absolutely convinced
that patients whose cerebro-spinal centres have been
protected against the initial development of the dia¬
thesis will be less liable than others to subsequent
syphilitic affections of the nervous system.

The abortive treatment should be employed at every
opportunity, just as, speaking generally, the intensive
treatment is applied to all syphilitics who are in a
condition to support it. Not, however, that I wish to
question the existence of benign forms of syphilis—
benign, that is, either by reason of the diminished
virulence of the organism or the enhanced resistance
of the subject, but what I do deny absolutely is that
there is any possible means of identifying these forms
beforehand.

We may be asked whether the abortive treatment of
syphilis will enable us to shorten the duration of the
treatment. It is only logical to suppose that such is
the case, although we are at present unable to bring
any clinical proofs thereof. There are several patients
whose treatment was abandoned after the second year,
but as the problem is difficult and its solution wholly
empirical, time alone will enable us to obtain the
data on which to base a trustworthy conclusion.

If the old-fashioned methods of treatment, applied
methodically during a period of four years, succeeded,
in spite of many shortcomings, in reducing the pro¬
portion of tertiary patients in Professor Fournier’s
hands to 3 per cent., it is only logical to suppose that,
as this result was attained in cases of syphilis in
which constitutional infection had been shown by
roseola and subsequent outbreaks, common sense
would tfell us that we can cure syphilis at less cost
when it has, so to speak, been circumscribed from the
commencement, and has been energetically fought
throughout.

But the question acquires special interest, and
demonstrates all the advantages of the intensive treat¬
ment, if we bear in mind that at least 25 par cent, of
the patients treated by the old-fashioned methods give
up treatment after the second year, in spite of our
warnings, and that under these conditions the pro¬
portion of tertiaries is no longer 3 per cent., but,
according to the same statistics, rises to 17 per cent.

A very important question arises at this juncture,
viz., whether in the doses indicated the method is prac¬
tically applicable—in other words, does it not entail
drawbacks which more than compensate for its advan¬
tages as just described? Here are my figures. In my
clinic about 15 per cent, of the patients cannot tolerate
it, but in private practice only about 5 per cent, are
unable to carry it through. The method, it may be
urged, is painful; well, there may be some pain on the
third day, but it is usually quite bearable and in most
instances it is nil or merely trifling. A French
physician once asserted that it was the puncture that
should be painless rather than the salt injected, and it
is for the practitioner to train his hand and acquire
the necessary dexterity, for it must be admitted that
but too frequently the injections are badly done, and
that the pain as often as not is the fault of the
operator.

It may be followed by abscess. Grey oil but rarely
gives rise to abscess formation, but the practitioner not
infrequently does for want of antiseptic precautions
and suitable instruments, and I have on various
occasions carried out without a hitch, to the patient’s
great surprise, a course of treatment which had been
inaugurated by several abscesses.

During the last twelve yeaTS I have made consider¬
ably more than 10,000 injections, and I have only had
four aseptic abscesses with calomel and four following
grey oil. Embolism can never take place with a
properly-applied method if we are careful to wait
twenty or thirty seconds before making the injection in
order to make sure that no blood trickles out of the
needle.

As to symptoms of poisoning I have never met with
anything at all serious. It is by no means rare for
some discomfort to be complained of at the end of the
course, but the symptoms soon clear up.

Stomatitis exists whatever method be employed, and
it is very important to attend to the state of the mouth

Google

THE OUT-PATIENT’S ROOM.

Nov. 37, 1907.

57 ® The Medical Press.

in every instance in which mercurial treatment is
adopted. The dose of 0.14 centigramme of mercury
for a person of average weight need not excite any
alarm and it is well borne. This ought to be the
average dose, for in the past we have always been
giving far too little mercury to our patients.

I have shown before various Belgian societies
extensive series of patients who had gone through the
course of 15 or 20 injections of 0.14 eg. of mercury
whose general health was excellent, who did not
present any nodules in the gluteal region and whose
mouths were free from the slightest trace of stomatitis.
It is obvious, however, and this condition is indis¬
pensable to the success of the abortive treatment, that
the method infers the absolute functional integrity of
the principal viscera , of the liver and, more par¬
ticularly, of the kidneys. In every instance the urine
must be examined before each injection.

This method is formally contra-indicated in the aged,
the cachectic, chronic alcoholics with renal insufficiency,
in arteriosclerosis and the subjects of plumbism and
gout, in the tuberculous, and in pregnant women with
albuminuria. Children bear the treatment well, the
doses of course being proportionately reduced.

The abortive method, apart from the advantages
which it presents in respect of the individual whose
diathesis is thus sterilised, also constitutes a very
advantageous method for the protection of society
since, by obviating all contagious manifestation, it
realises better than any other measure the prophylaxis
of syphilis.

OUT-PATIENTS’ ROOM.

METROPOLITAN HOSPITAL.

Minor Degrees of Shock.

By Leonard Williams, M.D., M.R.C.P.,

A»«UUnt Physician to the Hospital, Physician to the French
Hospital in London.

This young man, whose age is 20, comes here com¬
plaining of the vague subjective sensations which are
so commonly labelled neurotic or hysterical. He has
nothing more definite to tell us than that he is “not
sure of himself,” “is afraid to go out,” “feels all of
a shake.” When questioned, he says that he has no
appetite and that he is sleepless. Further cross-
examination elicits that these discomforts all came on
suddenly three days ago, after he had had a fright.
The fright was a serious one. It was caused by his
elder brother, who had come home from an asylum,
suddenly becoming acutely insane and escaping from
home.

In the out-patient room we are rather too apt to be
incredulous of the reality of the vague subjective sen¬
sations of which we hear so much from women ; and
the case of this young man is a good instance of the
injustice we sometimes do when we dismiss these com¬
plaints as fanciful and unworthy of serious attention.
It also illustrates the value of inquiring for a history
in every case, however unimportant it may seem. The
events which preceded this youth’s neurotic attack
were sufficiently alarming. They were, indeed, such
as might easily upset people of the most robust
organisation. His subjective sensations are evidently
very real, for he is suffering from a perceptible degree
of what is called shock. Physical examination does
not tell us very much. He has dilated pupils, it is
true, but they are equal, and react to light and accom¬
modation. His deep reflexes are, no doubt, exag¬
gerated, but there is no evidence of any organic disease
in his nervous system. I did not expect to find any,
but inasmuch as a great many organic nervous dis¬
eases show themselves by very typical “ functional ”
manifestations, it is never safe to take for granted that
physical signs are absent. More especially is it neces¬
sary to be careful in patients of this young man’s age,
because, of all organic nervous affections, that which
is most commonly diagnosed as functional is dis¬
seminated sclerosis, and this youth is just at the age
when this disease would be most likely to show the
first evidence of its presence.

Now what do we mean when we speak of shock?
The term shock, used surgically, conveys a very definite
picture to those of us who have witnessed severe
degrees of it; but used medically, and especially used
socially, its significance is of the vaguest. I think,
in reality—that is, pathologically—the term as thus
variously applied means the same thing, only in
different degrees. The essential condition in surgical
shock is a generalised dilatation of the arteries. The
muscular coats are no longer in the state of partial
contraction which is called “tone ”—the state in which
they are on the qui irive, so to speak, to obey an order
either for contraction or dilatation. They are flaccid
and inert, with the result that the pressure of the fluid
within the vessels becomes very much lowered, and
the blood stream dangerously sluggish. It is the
medulla which keeps the arteries in tone, so that if
tone is absent, we must suppose the medulla to be
either asleep or unduly exhausted. The medulla never
sleeps, any more than the heart does, but it is often
exhausted. Over-stimulation exhausts it, as in severe
abdominal operations and other conditions in which
the sensory nerves have been placed strongly on the
rack for a long period. For the first effect of irri¬
tating a sensory nerve is to stimulate the medulla, and
this produces constriction of the arteries. If the irri¬
tation of the nerve is prolonged, the medullary stimu¬
lation is also prolonged, and may be prolonged to the
point of exhaustion. When this happens, the medulla
is no longer able to maintain the tone of the arteries,
and the vessels relax. If they relax to their fullest
extent and remain so for any length of time, the blood
stream becomes so sluggish that the blood does not
reach the brain in sufficient quantities, and the patient
dies. Fortunately, this does not often happen, but it
is no uncommon thing for lesser degrees of medullary
exhaustion to take place. Perhaps we ought to confine
the word exhaustion to extreme degrees, and speak of
the lesser degrees as ijiedullary fatigue. Such a term
does not, however, convey at all accurately what has
happened in this young man's case. Here the medulla
has had a “ shake ” ; it has been subjected to a sudden
violent storm, with the result that it is neither ex¬
hausted nor in reality fatigued, but its equilibrium
is upset. It is still capable of reacting, but its re¬
actions, instead of being measured, controlled, and
smooth, are violent, spasmodic and jerky.

Thus it is that an estimation of this lad's blood-
pressure showed a figure (120 mm. Hg.) which is
normal, and when we counted his pulse in the upright
and recumbent postures we failed to find the very
decided increase in rate on standing which we should
expect to find in a case where the medulla was really
fatigued and the blood-vessels consequently in a state
of undue dilatation. The medulla is always in this
irritable state in hysterical or neurotic people, whose
blood-pressures, therefore, present the most extra¬
ordinary vagaries. The mere fact that the patient is
being examined by two or three doctors is sufficient to
elevate it unduly. If we could only catch these case-'
when they were “themselves,” uninfluenced by mental
stimulation, we should find the pressure low—some¬
times very low. It is then that, like Iphigenia, they
deplore their fate ; but let there come a stimulus, and
up mounts their blood-pressure, filling them with in¬
tense ambitions to Teform the world and all its con¬
tains, except, of course, themselves, who, in their owa
view, require no reforming. This eccentricity of blood-
pressure never occurs in the condition which is so
frequently confused with hysteria—namely, neuras¬
thenia. In neurasthenia the pressure is uniformly and
consistently low, and is conspicuously unresponsive
to ordinary stimulation. True neurasthenia is, in
point of fact, a species of “ shock ” in which the
medulla is fatigued indeed, but not primarily, as in
ordinary shock. In neurasthenia the medullary
fatigue is secondary to fatigue of some of the other
cerebral centres.

To confirm the suspicion that, except when subjected
to the stimulus of being examined, this lad’s arteries
are in a state of dilation, I examined his urine, :n
which, as vou saw, there was a distinct cloud of
albumen. Dilatation of the arteries causes the blood
to stagnate in the splanchnic area, and this gives rise
to a passive renal congestion which, in its turn, will

itized by G00gle

Nov. 27, 1907.

OPERATING THEATRES.

The Medical Press. 579

produce an albuminuria. Such, as I have often ex¬
plained, is the train of events which is responsible
for cyclical or postural albuminuria. The presence of
albumen in this lad’s urine is therefore strongly con¬
firmatory of the view that, in spite of the verdict of
the manometer, his arteries are unduly dilated.

The treatment of these cases is simple enough. We
will take this patient into the wards, and in a few days
his medulla will have recovered from its shake and
will once more be working smoothly. If we are to
treat him with drugs, these must be of the sedative
type. Bromide of potassium and valerian will do
him good by helping him to re-establish his medullary
equilibrium. Tonics he does not require ; they would,
indeed, do him harm. More especially ought we in
these cases to avoid strychnine. Strychnine acts by
stimulating the medulla, so that it is obviously pecu¬
liarly ill-adapted to the treatment of a case in which
the medulla is already in a state of undue irritability.
If he were a rich man instead of a poor one, it would
be well to send this patient to some spa or institution
where he would, in practised hands, be treated by cold
water baths and douches. In chronic neurotic cases,
more especially, these baths do an enormous amount
of good, and the place at which they are best adminis¬
tered is Divonne, close to the Lake of Geneva. It is
as well to remember in connection with this place that
it is a summer resort. I have known people sent there
in mid-winter with results not altogether favourable

OPERATING THEATRES.

HOSPITAL FOR SICK CHILDREN, GREAT
ORMOND STREET.

Case for Diagnosis.—Suprapubic Cystotomy.—
Mr. Edred Corner operated on a little girl, set. 10,
who had been admitted suffering from symptoms which
pointed to disease of the bladder. The history of her
illness dated from the time when she was three years
of age. During this period of seven years she had
been seen by many doctors, and treated as an in¬
patient at many hospitals throughout the Thames
Valley. Briefly, Mr. Comer said her symptoms were :
pain and frequency of micturition, aggravated by exer¬
cise and improving whilst lying up. On several occa¬
sions she had passed blood in her urine, but this was
most frequent at the commencement of her illness,
and had not occurred during ihe last two years ; the
urine, on examination, contained pus and albumen.
The diagnosis made previous to her admission to
Great Ormond Street was tuberculous disease of the
bladder, which diagnosis was arrived at rather by a
process of exclusion than on account of any positive
evidence being found in its favour; no tubercle bacilli
had been discovered in the urine. The child was
taken to the operating theatre and examined under an
ansesthetic. The bladder was first washed out, and
then examined with the stone sound. The end of the
sound in the bladder could be felt to impinge upon
some resistance, which did not give either the sensa¬
tion or the sound which a stone usually does ; yet,
whilst washing out the bladder, that organ had been
easily distended, so that it was impossible that the
resistance felt could have been due to the sound
meeting the bladder wall. The bladder was again washed
out, and the cystoscope passed, when the walls of the
viscus were seen to be much trabeculated. A little
further examination revealed the presence of a large
stone free in the bladder, its surface being thickly
covered with phosphatic deposit. It was impossible to
gauge the exact size of the stone, because only a small
portion of it could be seen at one time in the field
of the cystoscope. This stone was evidently the ex¬
planation of the long history of vesical symptoms. It
was thought that the stone was too large to be crushed
with the lithotrite, so the bladder was again distended

and a vertical incision made in the middle line just
above the pubes, the anterior sheath of the rectus
muscle opened, the recti abdominis muscles separated,
the peritoneal pouch in front of the bladder carefully
drawn upwards, and the bladder wall exposed. The
bladder is, Mr. Corner pointed out, easily recognised
by its colour and the tortuous veins which run on its
surface more or less parallel to the incision. It is often
easy to expose the bladder suprapubically in children,
as in them that viscus is placed higher and more in
the abdomen than it is in adults. Two guide stitches
were passed through the bladder wall, which was in¬
cised betw ?en them; a finger was passed through the
opening, and the large stone immediately felt. The
next step in the operation was technically the most
difficult of the whole proceeding; it was to grasp the
right diameter of the stone in forceps and deliver the
calculus from the bladder. This, Mr. Corner said, is
easy when the stone is small, but may take some time
when the stone is very large. The incision in the
bladder was not closed, but each side was attached to
the corresponding rectus muscle with a catgut stitch.
Mr. Corner remarked that it is advisable to do this
when the opening in the bladder is merely for tem¬
porary purposes ; if the opening is to be for some time,
then the bladder had better be sewn to the anterior
rectus sheath or to the skin. A rubber tube was placed
in the bladder through the lower part of the incision,
and the catgut stitches tied together, so as to close
the opening in the bladder wall round the tube. The
anterior rectus sheath in the upper part of the wound
was brought together with a few catgut stitches, as
was also the skin. A gauze plug was placed in the
lower part of the wound round the tube in the bladder.
By this means, Mr. Corner said, the bladder would
be drained by syphonage for three days, when the
rubber tube would be taken out. Mr. Corner re¬
marked that it seemed inconceivable that this stone
could have been free in the bladder for the seven years
during which the child had had vesical symptoms,
and that it could have been unrecognised by so many
medical men. Her pain and misery had reduced the
girl, who was fair, to that thin and delicate condition
so often associated with advanced tuberculosis. Her
appearance, and the inability to ascertain definitely
the cause of her illness, had led the diagnosis of
tuberculosis of the bladder to be made; and he would
suggest that this stone must have been hidden in a
pouch of the bladdeT during the greater part of the
period of her long illness; hence its presence could
not be ascertained with a sound. There were three
important lessons to be learnt from consideration of
this case: first, the sound may be an uncertain in¬
strument to depend upon for the diagnosis of s^one
in the bladder ; secondly, the cystoscope may be»of
the greatest use in arriving at a correct diagnosis;
thirdly, and from the point of view of the surgeon
dealing with cases in children, a skiagraph should
have been taken. The omission to take this step
(almost invariably omitted by students in examina¬
tions), which must have demonstrated indisputably the
presence of this huge calculus, would have saved the
patient from the loss of health, education and vigour
such as resulted from the last six years of her illness.

Medical Agreement.

At Pwllheli Board of Guardians meeting on Novem¬
ber 20th, a letter was read from the six public vacci¬
nators offering finally to settle the dispute as to the
vaccination fees, and they agreed to accept 5s. per case,
plus is. registration fee; but in the Aberdaron district,
which is the remotest part of Lleyn Peninsula, a fee
of 6s. was asked for, plus is. for registration. The
board’s offer was 5s. 6d. inclusive, and this they de¬
cided to adhere to. Failing acquiescence by the next
meeting, the board will take steps to fill up the places.

zed by Google

Nov. 27, 1907.

580 The Medical Press. TRANSACTIONS OF SOCIETIES.

TRANSACTIONS OF SOCIETIES.

ROYAL SOCIETY OF MEDICINE.

Obstetrical and Gynecological Section.

Meeting held Thursday, November 14TH, 1907.
The President, Dr. Herbert Spencer, in the Chair.

Dr. Thomas Wilson read a paper on
pubiotomy,

with notes of an illustrative case. The paper was
published in our last week’s impression. In the dis-
cussion that followed,

The President said he had no personal experience
of pubiotomy or of symphysiotomy, preferring the
alternative operations of induction of labour and
Caesarean section. The operation of pubiotomy had
been rarely performed in Britain, but Dr. Wilson had
omitted two cases operated on by Dr. Wallace, whose
opinion of the operation was “not an entirely favour¬
able one.” The President thought that Dr. Wilson
had not sufficiently emphasised the dangers of the
operation. Baumm’s two cases terminated fatally, and
Robert Mann had published a case of hernia through
the gap in the bone. Injuries of the bladder and
vagina and thrombosis were not uncommon accom¬
paniments of the operation, and, if not fatal, involved
considerable Tisk. He did not think a rest of 16 days
in bed was sufficient for the proper consolidation of
the bone. Dr. Wilson’s case occurred in a patient
with a pelvis of almost normal size, and though he
did not question the justifiability of the operation in
this case, the special dangers of laceration of the
vagina would be much greater when the pelvis was
considerably contracted. Operators seemed to be
divided in opinion upon the question of immediate
or deferred delivery ; but he thought it would be un¬
justifiable to submit a patient to the pains of labour
after the bone had been divided unless she were kept
continuously under an anassthetic, which itself involved
risk. Although the mortality of pubiotomy was not
high, it probably was at least as high as induction of
labour and Caesarean section, and involved dangers
which appeared to be unavoidable, and disabilities to
the mother, which were not met with in the alternative
operations. With regard to Pinard’s views on the
treatment of contracted pelvis, he would say something
on another occasion. Meantime, his recollection was
that Pinard had with symphysiotomy lost 12 per cent,
of the mothers and children. Pinard’s latest statistics,
mentioned by Dr. Hubert Roberts, showed a maternal
mortality in symphysiotomy of over 11 per cent., and
an infantile mortality of 14 per cent. They also
showed a growing faith in conservative Caesarean
section and a lessening faith in symphysiotomy.

Dr. Macnaughton-Jones said that, like ihe Presi¬
dent, he had never had recourse to symphysiotcmy.
At Heidelberg Prof. v. Rosthorn had given him the
details of a case in which uncontrollable and fatal
haemorrhage had occurred after pubiotomy. When he
was in Freiburg in 1906, Prof. v. KrOnig had per¬
formed' 30 cases without a death, and had lost two
children. On the other hand, Franque, up to March,
1905, had operated 43 times, with 12 deaths and the
loss of three children. Schauta, in his recent work,
seemed to favour pubiotomy. The higher the head,
KrOnig had pointed out, the greater the danger to the
bladder. The advantages over symphysiotomy seemed
mainly to be the avoidance of hasmorrhage and of
injury to the structures in the median line, as the
clitoris and urethra; but Zweifel and others con¬
sidered that the permanent effect, so far as pelvic uni¬
formity and general gain of increase in diameter are
concerned, was better in symphysiotomy than in
pubiotomy.

Dr. Griffith referred to the great difficulty there
is in discussing and comparing records of the opera¬
tions of pubiotomy and symphysiotomy, owing to the
different views held by different operators as to the
condition which justified the operation. His own ex¬
perience was confined to symphysiotomy, and he was

of opinion that pubiotomy presented no real advan¬
tages, while symphysiotomy was simple, and required
no special instruments. The difficulties, in his opinion,
were not in the operation but in the proper choice of
cases for which it was suitable. Those operators who,
like the late Dr. Varnier, declined to use forceps,
premature induction of labour, and any other means
than symphysiotomy for every case of even slight
difficulty, obtained a large number of good results
both as regards mothers and infants, but this was a
line of practice that does not appeal to English
obstetricians. He hoped the time would come when it
would be generally recognised that the treatment
necessary in cases of obstruction at the brim was not
to be determined by the length of the conjugate unless
in extreme degree of contraction. In these cases
Caesarean section was the only method, but in all the
common, slight, and moderate degrees of contraction,
the length of the conjugate, while a very important
factor, was never the determining factor. It was no
uncommon experience to see a woman spontaneously
delivered with a conjugate of about 3J inches, with¬
out danger to herself or her baby, while in other cases,
with a conjugate half an inch longer, the difficulty
and danger may be great, this depending first on the
size of the child’s head, a favourable position of the
head in relation to the obstruction, the mouldability
of the head, and the power of the uterus ; and it is
in the correct judgment of these difficulties that the
obstetrician of experience will be able to differentiate
and select those few cases to which, in his opinion, the
operation should be confined.

Dr. C. Hubert Roberts wished to add his testi¬
mony to that of Dr. Griffith with regard to the im¬
portance of endeavouring to estimate the s ; ze of the
foetal head in contracted pelvis, and not merely de¬
pending on the actual bony measurements of the pelvis
itself. As to pubiotomy and symphysiotomy, Dr.
Roberts thought that possibly these operations had
sprung into favour abroad largely on account of the
falling birth rate. The latest statistics of Pinard, in
the “Annales de Gynecologie et d’Obstetrique, ” for
September, 1907, showed this very forcibly, and in
France, at all events, it would seem that the induction
of abortion and premature labour in contracted pelvis
had been given up. Hence the frequent performance
abroad of such operations as pubiotomy and sym¬
physiotomy, especially the latter. Dr. Roberts had
performed subcutaneous symphysiotomy once at
Queen Charlotte’s Hospital, with good results to
mother and child. He had no experience of pubio¬
tomy.

Dr. Thomas Wilson, in reply, thanked the President
for referring him to Wallace’s two additional cases,
which brought the total number of pubiotomip per¬
formed in this country to ten. Where, after dividing
the bone, the labour is left to the natural efforts, it
does not appear to be necessary to keep the patient
anaesthetised. The pain following operation in Dr.
Wilson’s case was moderate, and this appeirs to be
the rule. Time must show whether symphysiotomy or
pubiotomy is the better operation. The latter appears
to possess over the former the advantages of being
less liable to cause severe bleeding, of endangering
the bladder to a less, and the urethra to a much less,
degree. It is remarkable that no discussion on pubio¬
tomy had previously taken place in London, and that
no one in this city appears to have put the operation
to a practical test.

The following specimens were shown :—

Dr. Herbert Spencer : Squamous carcinoma of the
cervix in a patient, a=t. 26. High amputation with
cautery. Patient shows no recurrence six and a-half
years after.

Mr. Alban Doran : Ovarian dermoid retained two
years in the pelvis after obstructing labour.

Dr. Fairbairn: Fatal rupture of an early tubal
pregnancy.

Dr. Macnaughton-Jones : An improved demonstra¬
tion pelvis.

Dr. Thomas Wilson: Unilateral haematom-;tra
recently acquired bv operation.

Dr. C. E. Parslow : Pregnant uterus with fibroid,

I the latter in a state of red degeneration.

Nov. 27, 1907.

TRANSACTIONS OF SOCIETIES. The Medical Press

ROYAL ACADEMY OF MEDICINE IN IRELAND.

Section of Medicine.

Meeting held Friday, November 8th, 1907.

The President, J. M. Redmond, in the Chair.

FUNCTIONAL SPASTIC PARAPLEGIA.

Dr. Craig exhibited a coachman, jet. twenty-three,
•who had been admitted to the Meath Hospital in
March, 1906, complaining of pain, coldness, and a
dead feeling in his left leg. He attributed his condi¬
tion to a wetting, received a year before, when he
■wore a broken boot. A sensation of “pins and
needles” in his left foot and leg followed. Subse¬
quently cold sweats occurred in the leg accompanied
by pain which passed up his side into his left arm.
Later the pain again attacked and settled in the calf
of his left leg, while from the hip down the limb
was cold and numb. Tremors then appeared in the
leg, so that on attempting to walk he staggered like
a drunken man ; spasm of the muscles in the leg and
extension of the tremors to the other leg and to the
arms followed. Examination revealed increased knee
jerks, some attempt at ankle clonus in the left leg,
slight nystagmoid movements of the eyeballs, no
slurring of speech, rhythmical tremors appear in the
limbs on using them. He was thought to have
disseminated sclerosis, and left hospital in about six
weeks without any change in his condition. He
weighed lost. 2lbs. on leaving hospital in April, 1906.
The patient came into hospital again about a month
ago, this time under Dr. Craig’s care. He now
attributes the onset of his illness to his having slept
on a mattress on a stable floor while nursing a sick
horse. He says his legs and left arm are weak, and
that he has shooting pains which run up his legs,
along his sides, across his chest and down again.
In the left arm he has shooting pains which escape
by the tips of his fingers. He is now only 8st. 7lbs.,
and appears to be wasted, but the wasting is quite
general. He is unable to stand with his eyes closed,
and staggers considerably when walking, knee jerks
are increased, there is no ankle clonus, but on the
left side a few spasms of rectus clonus are elicited
which give him pain. There is a flexor plantar reflex.
Hypersesthesia to touch, pain and heat is universal.
He has a fairly coarse tremor, seen well in his arm
when he places a forefinger on the tip of his nose.
He has very slight nystagmoid twitches on extreme
lateral movement of the eyeballs. Sir Henry Swanzy
reported that otherwise his eyes are perfectly normal
in every respect. There is no trouble connected with
either bladder or rectum. During his previous stay
in hospital the diagnosis of disseminated sclerosis
was undoubtedly made on the weakness of the legs
with increased knee jerks, the tremor and the
nystagmoid twitchings. The case is, however, a
functional one. The pain and numbness complained
of early in 1905 were probably due to sciatica. When
he came into hospital on the present occasion ataxia
was the most prominent feature of the case—to-night
he is free from ataxia. The knee jerks are also less
responsive, and even the tremor is not so marked.
This morning it was quite absent from both arms.
When now examined he exhibits to-night, for the first
time, a spurious clonus in the right leg. It is due
to spasm of the thigh muscles; the ankle is quite
unmoved. On rubbing his forehead with a forefinger
or on gently pulling the hairs of his legs he complains
of pain. The hyperaesthesia is quite general. The
points, however, upon which Dr. Craig most con¬
fidently relied in pronouncing against the existence
of an organic lesion in the brain and cord are—(1)
absence of ocular signs, such as optic nerve atrophy,
contraction of the field of vision, limitation of
muscular movements; (2) absence of any involvement
of the bladder and rectum ; (3) absence of true ankle
clonus and toe-extension phenomenon. Hypersesthesia
is less common in purely hysterical cases than
anaesthesia, but taking this symptom of general
hyperaesthesia with the loss of flesh and the general
aspect of the patient, Dr. Craig regarded his condi¬

tion as neurasthenic rather than hysterical—in fact
the case presents that alluring symptom group which
is so frequently found in people who have Teoeived
an injury for which compensation is expected. The
patient was exhibited to-night in order to draw atten¬
tion to the importance of making an accurate diagnosis
m cases exhibiting nervous disturbances, because of
the important differences in the prognosis between an
hysterical or functional paraplegia like the present
one and a case of, say, disseminated sclerosis. The
man has been taking valerianates for the past ten
days. Dr. Craig had told the patient that he will get
well, and already he was much impressed with the
improvement that has taken place, and which he
confidently expects will be continued.

Sir Christopher Nixon said it would be difficult
to conceive that a case which presented such varied
disturbances from the normal could be regarded as
simply functional in character. He thought the term
functional paraplegia was open to grave objection. It
did not explain in any way the multitude of symptoms
in the case. At first it undoubtedly showed the
ordinary symptoms of disseminated sclerosis. There
was more about the man than simple functional dis¬
turbance ; and, while he had the greatest respect for
Dr. Craig’s acumen in diagnosis, he claimed that there
was always room for latitude in nervous diseases, and
expressed the opinion that the case was one of
disseminated sclerosis undergoing a period of re¬
mission.

Dr. Drury said he had seen the case before, and
could bear out Dr. Craig’s statement that the
symptoms were different then from ten days previously.
He did not think, however, that they could altogether
depend on the absence of bladder symptoms as neces¬
sary early in diagnosis. In nearly all chronic nervous
cases very marked functional manifestations appeared.
He did not think that any of them could either con¬
demn the patient as being a case of organic disease
or buoy him up with the idea that it was merely
functional unless they had gone into the case with
greater fulness, and they might depend on the diagnosis
of Dr. Craig, who had studied the case.

Dr. Travers Smith said that if he had to give a
working opinion of the case he would give the same
as Dr. Craig, and he believed the patient would get
well. By that he would imply the loss of function
of some portion of the nervous apparatus, without
any discoverable anatomical change to account for it
He did not think they need be afraid of diagnosing
functional disturbance while still keeping their minds
open to the possibility of its being only preliminary to
permanent disturbance. He thought that the very
rapidity of the changes that had occurred in the case
as well as present symptoms, were all in favour of
functional disease.

Dr. Walter Smith said that in their present hazv
state of knowledge of many aspects of nervous disease',
he would hesitate to pronounce a definite opinion as
to the exact state of the case, but he shared Sir
C hristopher Nixon’s objections to the use of the word
functional, which, he hoped, before long would vanish
from medical nomenclature. If a term must be used
he would prefer the word hysterical, which connoted
a state of things better than functional. Stress had
been laid on the point that if the patient got well
the diagnosis of functional disease would thereby be
substantiated, which was as much as saying that if
the patient had organic disease he could not get well,
and therefore recovery would make a different
diagnosis—a line of argument which was quite un¬
warrantable. The recent demonstration that the
nerve-supply of the bladder and rectum was not
derived from the lumbar region should modify their
consideration of the matter, and he would hesitate to
accept Dr. Craig’s diagnosis as absolutely correct.

Dr. Moorhead said he had seen the casi previously
and had disagreed with Dr. Craig’s diagnosis, but
he had since come to think that the disease was
functional.

Dr. Purser discussed the site of functional degrada¬
tion in this case.

Dr. Craig, in reply, said he did not regard the

zed by GoOgle

Nov. 27, 1907.

582 The Medical Press. TRANSACTIONS OF SOCIETIES.

absence of bladder symptoms as of vital importance,
but in nearly every case of disseminated sclerosis with
pronounced symptoms bladder symptoms were present.
He only dwelt on the absence of such symptoms
because it was in combination with the absence of
ocular phenomena and ankle clonus.

EXHIBITS.

Dr. Winter showed a case of amyotrophic lateral
sclerosis. The patient was a coachman, aet. thirty-
eight, who, about six months before he first saw him,
noticed that he was wasting between the thumb and
first finger of the right hand; he did not then notice
any wetness. Since that time atrophy of the muscles
has proceeded rather rapidly, the muscles chiefly
involved being those of the right hand, the extensor
of the right wrist, and the deltoid and triceps, but
there is also some wasting of the muscles of the left
hand. A very well-marked feature of the case was
the fibrillary contraction of the muscles, which was
present in the muscles of both arms, and also both
pectorals and the scapular muscles. There were no
bulbar symptoms. In addition to his muscular atrophy
the patient showed exaggerated knee jerks and some¬
times ankle clonus, the reflexes in his arms being
also exaggerated, but beyond the facts elicited by
examination the patient showed no spastic symptoms,
and although at first sight the case looked like one
of progressive muscular atrophy Dr. Winter thought
that the name under which he had exhibited the case
gave a better idea of the conditions that were found,
and, in his opinion, the case tended to confirm the
view that the two conditions were identical.

Dr. Travers Smith showed cases of (1) progressive
muscular dystrophy, (a) paroxysmal tachycardia, (3) a
man who exhibited symptoms of a combination of
locomotor ataxia and multiple neuritis.

These were discussed by Drs. Little, Craig, and
Moorhead.

SOCIETY FOR THE STUDY OF DISEASE IN
CHILDREN.

Meeting held Friday, November 15TH, 1907,

Dr. George Carpenter in the chair.

Dr. G. H. Lock read a paper on a case of
rheumatic hyperpyrexia

in a child of six, who a year previously had had an
attack of chorea On September 10th, 1907, she had
left lobar pneumonia, which terminated by crisis on
the fifth day; two days after the crisis the choreiform
movements returned.

On September 20th there was pain in the left hip,
and the temperature rose to 100 deg. F. Subsequently
other joints became involved, and the case was a
typical one of acute rheumatism with chorea. On the
third day the temperature rose to 107 deg. F. In spite
of treatment by ice pack and graduated bath, death
occurred on the fifth day, the temperature just before
death being no deg. F. The severe choreic move¬
ments ceased only with death.

Dr. Eldon Pratt lead the notes of a case of (1)
fractured lower jaw in a child of four. The child
had been kicked by a horse, and the fracture was
vertically through the symphysis. It was treated by a
dental splint. Union was firm at the end of fifteen
days, and a perfect result was obtained, there being
complete absence of any deformity.

(2) Notes on a case of vaccinia. The patient was a
baby who was vaccinated when six days old in four
places on the left arm. Six days later all four places
had taken well; ten days later there was extensive
ulceration over the arm, measuring 3$ inches by 4I
inches, the surrounding skin was much inflamed, and
there were pocks of auto-inoculation near the left
axilla and over the right ribs. The whole of the body,
face, and limbs was covered with a diffuse papular
rash. The condition rapidly subsided under boracic
fomentations.

Dr. George Carpenter showed a boy of 11, with a
“Tuberculous Tumour of the Pons,” verified by Cal¬
mette’s ophthalmo-reaction. Subjective symptoms

commenced in August; optic neuritis and ophthalmo¬
plegia externa appeared the end of September. He
was now leading a fatuous existence, and had con¬
tinuous incontinence of urine and faeces. He could
answer questions rationally, and called out if he
wanted anything. Headache was now rarely com¬
plained of, sickness had disappeared, the knee jerks
were absent, he lay curled up in bed, and although
blind from choked discs wa3 contented.

Dr. Carpenter was not in favour of trephining for
the relief of optic neuritis; he thougnt the drawback
of a hernia cerebri, the improbability of ameliorating
the local condition, and the possibility of bringing the
child back to even a temporary recognition of its
unhappy state, contra-indicated any surgical inter¬
ference.

Dr. Poynton showed a case of oedema persisting
since birth. Child set. two years, male. Swelling of the
feet had been noticed since birth, varying in amount;
eyelids had been swollen in the mornings; there was
well marked swelling on the dorsum of each foot, with
slight pitting on hard pressure. Urine normal quan¬
tity, faint trace of albumen, and a few degenerative
cells with scattered leucocytes ; no casts or crystals.
He thought that there was some renal fault of con¬
genital origin.

Dr. G. A. Sutherland showed a female child of
seven months. The feet had been swollen since birth,
the sole of each foot being tense and hard, while the
dorsum was soft and pitted on pressure. Marked
blueness of the foot followed exposure to cold. The
child had suffered for some weeks from lichen urti¬
catus, with very large wheals on the head. There was
no evidence of renal or cardiac disease. The hands
were not oedematous, but became blue on exposure to
cold.

Mr. Russell Howard showed a case of precocious
development of the obese type in a girl. He could
find no evidence of any disease of the ductless glands,
or the accessory genital organs.

Dr. Porter Parkinson showed a case of (1) facial
paralysis in a girl, set. 3$, with some weakness of the
leg, apparently due to encephalitis. (2) A case of
lymphadenoma affecting the cervical glands in a boy,
set. six.

Mr. R. Warren showed a case of congenital dis¬
location of the hip joint in a girl of 5 years. Skia¬
grams showed that the femur had a very small neck
and no head.

Mr. Hugh Lett showed a case of acute arthritis of
the hip joint in a boy of 11 ; treated by irrigation and
drainage. The patient had recovered with perfect
movement in the joint.

Dr. Clutterbuck showed a case of intention tremor
in a child of 5! years. Labour was tedious, and com¬
pleted with instruments. No history or evidence of
syphilis The child never had convulsions. She is
rather backward mentally, and did not walk until she
was three years old. There was coarse intention
tremor of the hands, and marked inco-ordination and
spasticity of the lower limbs. The knee-jerks were
increased, and Babinski’s sign was present. No
changes in the fundi.

NORTH OF ENGLAND OBSTETRICAL AND
GYNAECOLOGICAL SOCIETY.

Meeting held at Sheffield, November 15TH, 1907.
The President, Dr. E. O. Croft (Leeds), in the Chair.

Mr. R. Favell (Sheffield) exhibited two specimens
of {( Fibro-myoma Uteri,” one undergoing calcareous,
the other cystic degeneration. (2) An ovarian cyst, in
which axial rotation of the pedicle had occurred.
(3) Syphilitic hypertrophic enlargement of the labia
majora in a patient, ret. 28, who had one child nine
years ago. There had been no abortions. She gave a
history of a lump in the external genitals for the last
eight years. Soon after her confinement, a year pre¬
viously, she had noticed some small hard lumps about
the anus which never quite disappeared. Five years
ago one of these tumours was the size of a hen’s egg,
and within the last six months others had appeared.
The largest growth, the size of a small cocoanut, was

i by Google

Digitize!

Nov. 27, 1907.

CORRESPONDENCE.

The Medical Press. 583

in the left labium majus. Both labia were excised,
and microscopic examination showed a loosely-woven
fibrous tissue structure, with inflammatory reaction,
especially around the vessels.

Mr. Archibald Cvff (Sheffield) showed calculi
removed per vaginam from the left ureter of a patient
who suffered from symptoms of stone in the kidney.
A radiograph located them 2 inches above the entrance
of the ureter into the bladder.

Dr. Miles H. Phillips (Sheffield) exhibited the
uterus containing a submucous fibroid undergoing
sarcomatous change. It was removed by abdominal
section from a nulliparous patient, set. 50, in whom
menorrhagia had been present for nine years. There
had been inter-menstrual bleeding and an offensive
purulent discharge for 14 months. On admission the
temperature was 101, and small sloughs were detected
in the vaginal discharge. The cervix uteri was patu¬
lous, and the uterus was the size of a four-months’
pregnancy. Exploration of its cavity revealed a
friable growth which microscopically proved to be
sarcomatous. The cervix was therefore stitched, and
removal of the uterus and appendages carried out by
abdominal section. Five weeks after the operation
the patient died suddenly from pulmonary embolism,
and the autopsy revealed septic thrombi in the internal
iliac veins and an embolus in a branch of the right
pulmonary artery; there was no peritonitis. The
microscopic sections demonstrated a mixed-cell sar¬
coma originating from the muscular fibres, submucous
fibromyoma, and invading the uterine wall.

Dr. Percival E. Barber (Sheffield) mentioned the
case of a woman, aet. 34, who had had one child three
years ago. Two weeks after an abortion bleeding
began, and was accompanied by a febrile condition.
"The uterus was enlarged and the cervix patulous.
Suspecting chorion-epithelioma, a scraping removed by
the blunt curette was examined microscopically, but
did not confirm suspicion. As the patient was be¬
coming progressively worse, abdominal section was
performed, but her condition did not justify an attempt
at the removal of ihe uterus being carried out. Re¬
covery, however, gradually took place, and the patient
became perfectly well.

Dr. W. E. Fothergill (Manchester) mentioned two
cases illustrating the value of Schuchardt’s para¬
vaginal incision. In the case of a single woman, set. 38,
-with a large submucous fibroid, the uterus extending
to the umbilicus, abdominal section was contra¬
indicated on account of an extremely offensive dis¬
charge in a debilitated patient. The removal of the
tumour was rendered possible per vaginam by an in¬
cision into the left ischio-rectal fossa, and extending
backwards to a point half an inch behind the anus.
In the second instance, also in a single woman, with
a very narrow vagina, hysterectomy for a myomatous
uterus was performed after a preliminary incision.

Mr. R. Favell also reported four cases of ectopic
gestation. Case I.—A woman, set. 27, who had one
child 12 months ago; had menstruated regularly 3/28
days. Her last period began a month ago, and con¬
tinued for a week. It was followed by a severe peri¬
toneal crisis. On admission there was marked tender¬
ness in the right flank, and a soft swelling could be
felt behind the uterus. Abdominal section performed
forthwith revealed free blood in the peritoneal cavity,
and clots in the pouch of Douglas. One inch from
the uterine attachment of the right Fallopian tube
there was a swelling the size of a filbert nut, on the
posterior aspect of which a rent had occurred. The
tube was removed, and recovery was uninterrupted.
Case 2 was of a full-term ectopic gestation, in a
woman, ®t. 30, 10 years married, with one child nine
years old. Menstruation was in abeyance from Novem¬
ber, 1906, until July, 1907, when she had a red vaginal
discharge for a week. At this time she felt movements
in the abdomen. She had become progressively stouter,
and thought herself pregnant, but as labour did not
come on, she sought advice a fortnight since. The
abdominal tumour resembled the full-term uterus, but
no foetal parts could be felt, and no heart-sounds or
souffle heard. At the upper limit of the tumour there
was something like a softened foetal head. Bimanually
the cervix was hard and closed, and the uterus lay
between the tumour and the symphysis pubis. The

sound passed 5 inches. Abdominal section showed the
gestation sac to be adherent to the parietes and
omentum, and to be intimately connected with the left
appendage. The uterus lay in front and to the right.
The sac and its contents were removed intact, and
although there was considerable shock following the
operation, the patient was making a good recovery.
The specimen was being investigated. In the other two
cases there was disease of the opposite appendage,
which was also removed, and in one case the uterus
was also removed, as the sac was intimately adherent
to it.

CORRESPONDENCE.

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

TarM. Nov. 24 tta, 1907 .

Treatment of Gastric Ulcer

At the ninth session of the Congrfcs de Medecine held
last month in Paris, three questions were treated :
Hemophilia, ulcer of the stomach, and exophthalmic
goitre. M. Linossier read a paper on the treatment of
gastric ulcer, of which the following is a summary : —

Dietetic Treatment. —Theoretically, absolute suppres¬
sion of all gastric activity, complete rest of the organ
until complete cicatrisation of the ulcer would be the
ideal treatment, but in practice, the danger of inani¬
tion is an obstacle to this desideratum.

Was it not possible to introduce, otherwise than by
the mouth, alimentary substances into the organism
so as to realise rest of the stomach without the incon¬
venience and dangers of inanition? To meet this end
four different methods have been tried; subcutaneous,
peritoneal, jejunal, rectal.

As to the value of nutritive enemas, it is impossible
to arrive at a formula applicable to every case. In
certain subjects, absorption is almost nil, while in
others, these enemas seem to almost suffice for the needs
of the organism. However, the psychic action of this
treatment must not be lost sight of; the patient is con¬
vinced he is nourished and for that reason supports
inanition.

Where the suppression of all liquid or solid food,
although momentarily, is considered impracticable, the
diet allowed should fulfil four conditions; not to
provoke any irritation of the gastric walls, that is to
say, the food should be liquid or slightly thickened,
neither too hot nor too cold; to sojourn as little time
as possible in the stomach; to stimulate as little as
possible the gastric secretion ; to protect, if possible,
the ulcer from the digestive action of the gastric juice.

Medical Treatment .—Absolute rest in bed and the ice
bag to the epigastrium. Although its action on the
hematemesis is doubtful, it is a good means of keeping
the patient quiet. After a few days, the ice can be
replaced by a simple warm compress, protected against
evaporation and refrigeration by means of oil silk or
some other impermeable tissue. The patient must be
well covered in bed, and hot bottles placed to his feet,
as any lowering of his temperature is very prejudicial.

If the subject is sufficiently vigorous, total suppres¬
sion of solids or liquids by the mouth might be pre¬
scribed, and towards the second or third day sub¬
cutaneous injections of artificial serum might be given.

Nutritive enemas will be prescribed as soon as the
patient can support them. Each morning an
evacuating enema will be given first and after its
operation, a nutritive enema, which can be repeated
twice during the day.

Egg, one.

Dextrin, 2 dr.

Phosphate of soda, 15 gr.

Bicarb, of soda, 15 g'r.

Laudanum, 6 drops.

Water, 10 oz.

If these enemas are well tolerated, they might be
increased in nutritive value.

zed by GoOgle

584 The Medical Press.

CORRESPONDENCE.

Nov. 27, 1907^

Eggs, 2 or 3.

Dextrin, 4 dr.

Bicarb, of soda, 15 gr.

Beef tea (without salt), 10 oz.

If well tolerated, this treatment might be continued
a week, when a little sweetened water may be given by
the mouth, and on the following day milk. The
quantity of milk given the first day should not exceed
ten ounces, when it may be gradually increased to a
quart and a half. If the patient complains of burn-
ing in the stomach (due to a too free secretion of
H Cl ), the hyper-acidity might be corrected by a
little bicarbonate of soda, but in such cases only.
While undergoing this first period of nutritive regime,
the stomach of the patient should be carefully
examined by percussion and palpation so as to
ascertain that it has not become distended for '.'-ant ot
tone, and that the evacuation of the contents is not
abnormally prolonged. In such a case the quantity
of milk must be diminished, but its nutritive qualities
may be increased by the addition of milk powder,
lactose, cream, rice, tapioca, or casein. Where pain
persists in spite of this more nutritious regime, bicar¬
bonate of soda or subnitrate of bismuth might be pre¬
scribed in large doses. If no relief comes from this
treatment, the question of operating might suggest
itself (gastro-enterostomy).

Constipation is best treated by enemas of olive
oil, and anemia by subcutaneous injections of
cacodylate of soda.

Such is the treatment of a typical case of gastric
ulcer, and if properly conducted, the symptoms dis¬
appear, but frequently the cure is only apparent and
momentary, and the patient is always exposed to a
relapse.

Treatment of Hemoptysis

The first thing to be done and before all other
treatment is to inject 4 drachms of a solution of gela¬
tine into the cellular tissue of the abdominal wall.

Gelatine, 2 dr.

Chloride of sodium, 1 dr.

Water, 1 pint.

The solution should be sterilised. The injection
should be repeated each day or twice a day if neces¬
sary.

Internally: —

Ergotine (Bonjean), 1 dr.

Gallic acid, 10 gr.

Syrup of turpentine, 1 oz.

Water, 4 oz.

Chloride of calcium, 1 dr.

Ext. of opium, ii gr.

Syrup of peppermint, 1 oz.

Water, 4 oz.

A tablespoonful of these two mixtures to be given
alternately every hour.

If the haemoptysis does not yield to this treatment,
an acid mixture might be tried.

Aromatic sulphuric acid, 4 dr.

Water, 1 quart.

A wineglassful every two hours.

Or,

Digitalis powder, \

Hippo, powder, * ®

For one pill.

Five to six daily, until nausea sets in.

GERMANY.

Berlin. Nov. 24th. 1907.

At the Verein fur Innere Medizin, Hr. E. Klebs dis¬
cussed the subject of

Immunisation in Tuberculosis.

He said that in civilised lands the majority of the
population had suffered at one time or other from
tuberculosis, the traces of which were recognisable.
Naegele’s assumption that 90 per cent, had thus
suffered was not far wrong. From the speaker’s own
investigations he would say that the percentage of
people who had been attacked by the disease and had
recovered more or less of themselves was 65.' These

recovered by self-immunisation, for self-recovery and
immunisation were the same thing. But this self-
healing was, in consequence of self-infection, very
frail. The phthisical patient who expectorated tubercle
bacilli up to his old age, and was therefore a danger
to those around him, was himself immune, until he
succumbed to a relapse If these senile tuberculous
patients had no cavities, they died of repeated catarrhs,
which were not recognised as tuberculous. Such cases
were extraordinarily frequent. Even in middle life
such conditions were by no means unknown.

It might, perhaps, be objected that such a partial
immunisation did not deserve its name; but it hap¬
pened everywhere, and in all diseases ; there was every¬
where a partial and relative immunity. The histories,
of small-pox, and the plague, of cholera and diph¬
theria showed this.

Now arose the question that could only be settled
experimentally: How did immunity arise in tubercu¬
losis? It was undeniable that self-healing took place
in a few cases, and our endeavour must be to bring
about this result at pleasure. These experiments in
immunisation could be carried out in two directions,,
either by procuring mitigated bacilli, as was done by
Pasteur, and after him by Chauveau in the seventies,
or by searching for immune bodies in tubercle cul¬
tures.

The speaker had become acquainted with two facts
that struck out a more accurate way of reaching
immunity. The first was that in the recovery of
guinea-pigs from tuberculosis the active principle lay
in the substances passing over in the glycerine extract
of tubercle bacilli. He further found in his experi¬
ments with injection of tubercle bacilli, where the
injections were successful, the wandering cell became
active, and led the tubercle bacilli to the nearest lymph
glands. In the blood, on the other hand, the tubercle
bacilli were mostly quickly destroyed. In inhalation
experiments he found that when tubercle bacilli
reached the lungs in small quantity, the lungs soon got
free of them, under normal circumstances, as the
wandering cells took up the tubercle bacilli and with¬
out exception carried them to the bronchial glands.
The tubercle “ sozine ” prepared from the glycerine
extract of tubercle bacilli favoured this action, and
might lead to recovery. After showing some tables
relating to his experiments and preparations, the
speaker said that we here saw a genetic connection
between scrofula and tubercle. The scrofulous new
growth was in the first place the result of hyperleuco-
cytosis caused by tubercle bacilli products ; the dead
tubercle bacilli were found in large-celled lympho¬
cytes in the scrofulous glands. This hyperleucocy-
tosis was also demonstrable in the blood. Whilst the
normal for guinea-pigs was 10,000 leucocytes, with
5-6 to 5-7 millions of erythrocytes, the number mounted
in animals that had been treated with tubercle-sozine
to 18,000 to 20,000.

Whence these tuberculophile wandering cells came
was not clear. They were mostly thought to come
from bone marrow, but his cases rather pointed to the
spleen. It was a fact that these disturbances that were
not wanting in human tuberculosis always began with
swelling of the spleen, and belonged 10 the most
typical form of pseudo- or true leucaemia. At any
rate, they always led to splenomegaly. As a second
organ the liver became diseased, so that properly all
these cases were examples of the so-called Banti’s dis¬
ease—splenomegaly with cirrhosis of the liver. Death
took place when the like process finally took place in
the lungs. The speaker would trace back the whole
group of lymphomata and lymphosarcomata to such
latent tuberculosis. In these cases these tuberculo¬
phile wandering cells did not die, but lived on inde¬
pendently in the organs into which they had wan¬
dered. This new growth, therefore, resting on a patho¬
logical basis, was originally a natural process of cure
which only did harm when it was in excess. Lympho¬
matosis and leucaemia stood near together genetic¬
ally, and probably to be ranked with them was Hirsch-
feld’s erythraemia with splenomegaly. Naturally other
things might set up a similar process—for example*
feeding with carcinoma.

This specific artificially induced leucocytosis had
still another aim—it always reduced the temperature-

Digitized by LaOOQle

Nov. 27, 1 907.

CORRESPONDENCE.

The Medical Press. 5&5

for the reason, according to the speaker’s opinion, that
the tubercle bacilli that led to fever through their dis¬
semination in the blood were conducted to the lvmph
glands and there taken up.

Investigations were in progress for the purpose of
showing how far this inoculation would remove a
fresh infection, or carry an existing one to recovery.
Of course, the usual bactericide substances would still
be employed in all cases of serious tuberculous
infection.

AUSTRIA.

Vienna, Nov. 24th, 1907.

Multiple Sclerosis and Urinary Trouble.

Hochwart presented a patient, aet. 16, to »he

Gesellschaft fur Innere Medicin ” with a persistent
desire to micturate, evidently due to a nervous origin.
1 he bulbar shaking in the extremities and eyes was
unusually slight. The urine was normal. A few
months before this examination the patient was
troubled with retention, followed by a dribbling, un¬
comfortable condition. Then commenced nystagmus,
increased patellar tendon reflex, more sensitive in the
left than the right, slight ataxia in the left extremity,
and hyper-hemi-algesia in the left side. All the
phenomena of multiple sclerosis were present.

Optic Aphasia.

Stejskal next exhibited a case from the Second
Medical Clinic which he diagnosed as optic aphasia
after a severe attack of meningitis. When received
into hospital the patient was stupid or benumbed men¬
tally, neck stiff, pupillary reaction in left eye quite
gone, but the right responded slightly. The abdomen
was distended; taches cerebrales and Kernig’s
symptom— i.e., loss of contraction in the lower ex¬
tremities by passive movement. There was also
bradycardia = 64, with elevated temperature, con¬
firming the symptoms of meningitis. Later bilateral
neuritis optica set in, with right hemi-anopsia, right
facial paresis, with a slight deviation of the tongue
towards the right when put out of the mouth. Three
weeks later the patient improved in every one of the
symptoms, but a pronounced sensorial aphasia set in,
which also improved after a time. Repeated aspira¬
tions in the lumbar region were performed, giving on
every occasion a haemorrhagic fluid rich in leucocytes
and rods with capsules which gave a negative result
with the Gram method. Prof. Ghon said these
bacilli belonged to the capsule group, and in shape
resembled Friedlander’s bacilli. Many cultivations in
opposition to expectoration proved it invulnerable to
this mode of treatment, as the capsuled bacilli are
usually easily cultivated.

Hypoplasia of the Aortic System.

Hans Politzer brought in a case from the Second
Clinic with a defective aortic system and hypertrophy,
with dilatation of the heart. The apex beat was in
the fifth intercostal space two finger-breadths outside
the mammillary line, with every sign of hypertrophy
and dilatation. Auscultation gave a systolic murmur
loudest over the pulmonalis, where a second pul¬
monary sound was heard. The heart’s rhythm was
regular, pulse 88 to 92, no pulsation in the cervical
veins, but the carotid was small, with a very weak
pulse. There was no sub-clavian or jugular pulse even
when the diaphragm was highly elevated. The radial
and crural arteries were very small, while no pulsation
could be found in the dorsalis pedis.

From this he concluded there was hypoplasia of the
aortic system, with hypertrophy and dilatation of the
cardiac. The patient was pale, with 6.5 millions of
erythrocytes and 16.6 per cent, of haemoglobin.

ClRRHOSE BRONZEE.

Falta exhibited a case of cirrhosis from the First
Clinic. The case was received into hospital with
alcoholic polyneuritis, enlargement of liver and spleen,
ascites, and a mulatto bronzing of the skin over the
whole body. When the neuritis subsided the bronzing
of the skin became much less, showing a direct con¬
nection with the neuritis.

Cirrhose bronzee, cirrhose hypertrophique pigmen-
taire, or cirrhose avec Melanodermie, are all charac¬
teristic of alcoholic excess, which seems to produce a
hasmo-chromatic substance in the large organs of the

body, lymphatic glands, skin, lungs, bone, marrow,
etc. This condition seems to have a close affinity to
the diab&te bronze, Cachexie bronzee, dans le diabfete
sucr£, and may be the origin of the hasmo-chromatosis.
This substance is found as fine granules in the basal
cells of the Malpighian layer.

Cardiac Insufficiency.

Eppinger gave a description of his experiments on
animals to test the efficacy of undsr-feeding or hunger¬
ing would have on a hypertrophic heart. His results
clearly show that after five days the animal is unable
to bear insufficiency or the sinking blood pressure,
but if intravenous injections of dextrose, levulose and
glycogen be given, the pressure rises and the animal
is quickly restored.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

Women Graduates and the University Franchise.
—A further stage in the action brought by some of the
women graduates against the Universities of Edin¬
burgh and St. Andrews was reached on Saturday, the
16th, when the judgment of the Lord Ordinary was
upheld by the Extra Division of the Court of Session.
The action was raised in order to compel the Univer¬
sity to send voting papers to the female graduates, and
for declarator that women are entitled to vote at the
election of a member of Parliament for the Univer¬
sities. The decision of the Lord Ordinary was against
the women graduates, and against this decision they
re-claimed. Lord Maclaren, in giving the judgment,
said that it was a principle of the unwritten Constitu¬
tional law of the country lhat men only were entitled
to vote. Ambiguous expressions in Acts of Parliament
must be construed in the light of Constitutional prin¬
ciples. If it was intended to subvert a Constitutional
principle, it must be done by the Act in the plainest
language. At the time the Act was framed it was not
necessary expressly to exclude women, because women
could not then be legally on the register. The argu¬
ment was that a franchise originally conferred on
graduates who were necessarily men had been ex¬
tended to women, not by a direct enactment, but by
the indirect effect of an Act of Parliament which was
concerned only with academic functions, and in the
interests of the higher education of women authorised
their admission to a degree. It was difficult to con¬
ceive that the Legislature should have devolved the
power of conferring the franchise, a power which it
had always kept in its own hands. The Lord Ordi¬
nary’s judgment was therefore affirmed, and the re¬
claiming note refused.

Glasgow Medical Officer and the Plague.—
Dr. Chalmers states that towards the middle of
October a case of plague was admitted to hospital.
The boy is now free from infection, and is progressing
favourably. When this case occurred it was also
established that a death in August last had been due
to a like cause. Both were removed from the same
district of the city. According to Article 7 of the
Paris Convention, the occurrence of such an isolated
case does not constitute an infected area, rnd the
measures prescribed by the Convention for infectious
areas are not put into operation. Article 9 provides
that any area which may have been declared infected
ceases to be so five days after the death or isolation
of the last case in hospital.

Tuberculosis and the Glasgow Milk Supply.—
Dr. Chalmers states that in consequence of the de¬
tection of tubercle bacilli in samples of milk taken at
a railway station, the public authorities of the district
whence the milk came arranged to inspect all the dairy
animals. This led to the discovery of two cows with
tuberculous udders. As a further result of the inquiry.
Dr. Buchanan reports two additional infected samples
of cream from another county, and inquiry at the
! farms there has revealed the existence of cows with
I udder disease. In 77 samples of cream, three have
1 been found capable of transmitting tuberculosis. The
question cannot remain long unsettled as to the course
, a consuming authority may adopt when tuberculous

Digitized by GoOgle

CORRESPONDENCE.

Nov. 27, 1907-

586 T he Medical Press.

milk is on sale within its area, along with milk pro¬
duced at its own byxes under conditions which render
tuberculosis improbable. It might be desirable to
secure Parliamentary power to prohibit the sale within
their own boundary of milk from districts where re¬
peated evidence of tuberculosis among milch cows had
been obtained. .

Woodilee Asylum: Annual Report.— During the
year there were 1,271 patients under treatment; 177
males and 159 females were admitted, and 75 men and
80 women were discharged. The deaths numbered 123
—males 58, women 65. The rise in the admission rate
was 71 as compared with last year; this is due to the
reception of imbeciles from the Larbert and other
institutions, and to the admission of 9enile cases. On
this account the recovery rate is also unusually low—
27.79 per cent, as compared with 37.9 in the preceding
year. A system of electric baths has been installed in
the men’s asylum.

BELFAST.

The Irish University Problem.— Mr. Birrell in a
speech delivered at Belfast during the past week added
a little to our knowledge of his proposed solution of
the Irish University question. In the first place he
told his audience that all the surmises which had
recently appeared in the newspapers was “all un¬
authorised and almost wholly false.” He then added
that “we cannot expect to attain what we want without
a considerable amount of unanimity,” and he rejoiced
to say he was receiving a “considerable amount of
support even from quarters where he did not expect
it.” He told his audience that “the question was a
very difficult one,” and that rightly or wrongly he
believed he had “the opinion of the best people in
Ireland, irrespective of party, behind him.” He then
added : “We know that seats of learning in these days
must be entirely unsectarian. They must be free, they
must be on their emoluments, in their fellowships, in
everything pertaining to them free and open to all the
world, irrespective of religious opinion.” The Bryce
scheme is dead. A bond fide Catholic University
scheme is apparently equally dead—though of that
there was never any doubt, and everything points
towards the fulfilment of the recommendations of the
Robertson Commission, as we have already pointed
out in our last issue. Whether this scheme is to be
modified by the establishment of a University in Bel¬
fast will probably not be definitely known for some
time, but in view of Mr. Birrell’s statement regarding
the accuracy of newspapers, a Belfast independent
University does not seem to be likely. But for that
statement, there are many indications that such a
scheme is in the air.

The Registrar-General and Registration Dis¬
tricts. —At a meeting of the Lisburn Board of
Guardians last week an interesting discussion took
place on the reading of a letter from the Registrar-
General, refusing to constitute the Purdysburn In¬
fectious Diseases Hospital into a separate registration
district, as he had been requested to do. He replied
that in no case, so far as he was aware, had any public
institution in the United Kingdom been made a
separate district for registration purposes, but, as Dr.
Orr pointed out, there is probably no other instance
in the United Kingdom of a large city “dumping the
physical and mental wreckage of the city ” into an
unoffending country district. It must be remembered
that not only is the Infectious Diseasep Hospital for
Belfast situated at Purdysburn, but also the District
Asylum. It certainly seems Tather hard on the
registrar for the district that all the extra registration
work which this involves should fall upon his
shoulders; work which really belongs to the City of
Belfast, and not to the Lurgan Union.

Proposed Inebriate Home for the North of
Ireland. —An informal meeting was held last week
in the Medical Institute, Belfast, to discuss the pro¬
posal to open an inebriate reformatory somewhere in
the North, the suggested site being the disused County
Gaol at Downpatrick. The meeting was convened by
Dr. Norman Barnett, the honorary secretary of the

local branch of the British Medical Temperance
Association, and was presided over by Dr. Calwell, the
president of the same body, but the attendance was
not limited to medical men, a number of clergymen
of all denominations and several laymen being
present. There is no such reformatory in Ulster, or
indeed north of Dublin, and the meeting was generally
agreed that it was quite time to start one, on the
broadest possible foundations, and a committee was
formed with this object in view.

Health of School Children. —At a meeting of the
Public Health Committee held last week a report on
the International Congress of School Hygiene was pre¬
sented by Dr. Henry O’Neill and another member, and
a series of recommendations were made. These, if
adopted, would revolutionise education in the city, for
they advise the Corporation to take over the control
of secular education in both primary and secondary
schools, providing and maintaining new primary
schools where necessary, and to appoint a special
medical officer, under the Medical Officer of Health, to
supervise school hygiene in the city. Dr. O’Neill is
a barrister as well as a medical man, so he has pre¬
sumably considered the legal aspects of his recom¬
mendations, but they strike one as fairly courageous
and sweeping!

Tuberculosis. —Belfast is revelling in an orgy of
popular medicine at present, the Tuberculosis Exhibi¬
tion being in full swing. It was opened on Friday,
22nd, with an address by Sir Douglas Powell, who
created a little breeze in medical circles by expressing
his disapproval of compulsory notification to which
the Ulster Medical Society, like most other medical
bodies in Ireland, is committed. It is said that we may
comfort ourselves with the knowledge that another
London consultant placed our Dublin colleagues in a
similar predicament by pronouncing tuberculosis non-
contagious. As far as one can judge from the opening
days, the exhibition promises to be a great success, and
the programme of lectures by medical men is an
excellent one. The Corporation proposed a little time
ago to open a dispensary for the out-patient treatment
of tuberculosis, but the Local Government Board hare
refused to sanction the scheme, saying that there is no
power under any Act of Parliament for such a expendi¬
ture.

LETTERS TO THE EDITOR.

THE LATEST PHASE OF THE TRYPSIN'
TREATMENT OF CANCER.

To the Editor of The Medical Press and Circular

Sir, —My attention has teen drawn to a book pub¬
lished by Dr. C. W. Saleeby entitled “The Conquest
of Cancer.”

I feel bound to take some notice of this publication
by reason of the fact that certain misrepresentations
distributed throughout the book have been made in
regard to my introduction of the method of treatment
of inoperable cancer by trypsin, and the consider*-
tions which led me to it.

This is a book which purports to inform the public
respecting the views now held by the scientific workers
of the profession as to the present position of the
cancer question, and the method adopted by the author
of carrying out this design is that or abusing everyone
who does not happen to agree with himself or Dr
Beard.

I do not deem it necessary to re-discuss the question
of priority so far as the introduction of the trypsin
treatment of cancer is concerned, inasmuch as my
claims have been recognised by independent observers
in the scientific Press of this country (vide Natnn,
January 10th, 1907).

But Dr. Saleeby would have his readers believe that
Dr. Beard first suggested the treatment, and that I only
employed or advocated it. After referring to a paper
read by the latter in Edinburgh on December 13th.
1904, an abstract of which v'as printed in the
of February 4th, 1905, he goes on to say:—“Only a
few weeks after Dr. Beard’s lecture, Dr. Shaw-
Mackenzie began the hypodermic use of trypsin in
cancer, and to him undoubtedly must be awarded the

loogle

Nov. 27, 1907.

CORRESPONDENCE.

credit of being the first physician to employ the new
treatment. . . . My purpose is to illustrate the
conditions under which discoveries are made, and I
will here quote from a private letter of Dr. Beard to
myself:— 1 At once, December 8th, 1904, I got all my
critical period preparations . . . and saw at once
that I had neglected to lay stress as a character of the
critical period on the commencing functional activities
of the pancreas gland. So the problem was solved so
far. The other thing is a later story. At once I saw
there must be an antithesis of ferments, but was not
aware whether any ferment had been described in the
cancers. . . . January 18th, 1905. . . . Then
it was you might have heard my heart thump. All was
exactly as I had foreseen. . . .’ This letter was
not sent for publication, but I have taken the liberty
of putting it on record for its personal and general
interest. ”

It was on December 8th, 1904, as published by me
in the Lancet , February nth, 1905, I commenced in¬
vestigations into the action of pancreatic and other
ferments on glycogen. The considerations which led
me to this were known to many, and published in a
pamphlet nf mine in October, 1904, in the British
Medical Journal, January 7th, 1905, and the Lancet,
January 14th, 1905; but I will here take the liberty of
quoting from a letter of Dt. Beard to myself dated
December 7th, 1905:—“When you get this letter on
December 8th, it is a year exactly since you and I
independently arrived at the trypsin idea. . . .”

The strenuousness of the efforts displayed by Dr.
Saleeby in the lay Press, no less than in his book on
behalf of the claim of another, must clearly demon¬
strate to any impartial person the weakness of his
cause. If anything more was required it is the attempt
to submit my work to destructive criticism. It is re¬
peatedly reiterated that trypsin has no action on gly¬
cogen. “There is no ferment,” he says, “which affects
both protcids and carbohydrates, such as glycogen.”
This is simply begging the question. Observers of old
regarded glycogen as starch in proteid combination,
and the purest glycogen obtainable still contains
nitrogen. Moreover, the action of the proteolytic fer¬
ment rather than the amylolytic was and is supported
by the fact recently and independently testified to that
glycogen exists in the living tissues as pTOteid-glycogen.
Dr. Saleeby mentions Dr. Odier’s work. He does not
mention that in growths treated with a mixture of
pancreas, liver and muscle extracts, coincident with
atrophy of cells, histological examination has shown
them to be deprived of glycogen. Drs. Saleeby and
Beard attribute any action on glycogen to the leuco¬
cytes, forgetful that the digestive properties of these
are attributed to a proteolytic ferment apparently iden¬
tical with trypsin. This additional aid of the leuco¬
cytes and increase has long been recognised, and
found expression in hypodermic injections of chian
turpentine introduced by Col. T. Ligertwood, C.B.,
M.D., and myself three years ago. Most suggestive
of the action on glycogen at the present time is that
the pancreas produces an “activator substance for a
glycolitic enzyme contained in other tissues.” What¬
ever the explanation, it is obvious the glycogenic nutri¬
tion of cancer may be interfered with, whatever the
precise nature of the cell proliferation, be it epithelial
or “ trophoblastic.”

Again, while my theory of cancer by analogy with
diabetes is noted, no mention is made of the clinical
fact of alternation of diabetes and cancer in different
members of the same family, which directly led me
to the inference that if, as is well known in certain
cases, diabetes is a pancreatic disease with defective
ferment action, so also might carcinoma be. He notes
my suggestion of premature ageing of the pancreas,
only to reject it, and to advance on his own account
a shortage of trypsin from “whatever cause.” In
this respect readers of my work will know that, in
referring to the age incidence of cancer, I suggested
also congenital imperfections, and in referring to cases
of spontaneous cure I suggested the removal of inhi¬
bitory— e.g., mental, nervous, trophic or chemical
causes temporarily interfering with either the general
or local supply of the proteolytic ferments.

I pass on to chapters on the preparations of the fer¬
ments and the details of treatment. Is there anything

The Medical Press 5 ^7

here which is not known or indicated in my book?
Injections of trypsin were first prepared by Mr. F. W.
Gamble, for me. Of early cases treated, two at the
present time are apparently in good general health,
2J and 2 years, whether it is due to treatment or not.
The injections were sent to Dr. Beard, at my request,
by Messrs. Allen and Hanburys for the purposes of
Dr. Beard’s experiments on mice, and full information
and composition were given by me. As for technique
and details of treatment—“ nypodermal, oral, and.
local ”—these were fully published by me (a), and
Dr. Saleeby’s recommendations are, so far as I can
see, for the most part adopted from my work without
acknowledgment. He differs essentially in the im¬
portance he attaches to amylopsin and in the addi¬
tional recommendation of amylopsin injections.

I imagine that most persons will find the most effec¬
tive commentary upon this and upon questions of the
strength of trypsin solutions discussed by Dr. Saleeby,
in a paper by Dr. Hald, of Copenhagen, published in
the Lancet, November 16th, 1907, (£) in which the
author shows that the so-called solutions of amylopsin
actually contain an abundance of proteolytic ferment,
and in which paper also the author independently
establishes the potency of British tryptic preparations.

Yours faithfully,

J. A. Shaw-Mackenzie, M.D.Lond.

[We have already accepted the evidence in favour
of Dr. Shaw-Mackenzie’s priority of claim to the
trypsin treatment of cancer as established. Dr. Saleeby
has not favoured us with a copy of his book for
review.— Ed. M. P. and C.]

DISEASES OF TWINS.

To the Editor of The Medical Press and Circular.

Sir,—A s father of twin boys I am able to add a
small contribution to the inquiry which Mr. J. Lionel
Tayler makes in your columns. My boys have just
entered upon their nineteenth year. For the first
twelve years of their lives their physical characteristics
as to 'height, weight, and measurements remained
closely alike; but they were always markedly different
in feature and in mental characteristics. They have
since varied in physical development, and have shown
more marked mental and intellectual differences.
They are well formed, uncommonly good-looking
bovs, but not very powerful. Their permanent teeth
are' without blemish. Their temporary sets were of
very good quality. The firstborn seems to have
stopped growing at 5ft. 6in., and has the mental
qualities of a superior man of business ; the second
born, still apparently growing at about the same
stature as his brother, is mentally up to the level of
an average “ scholarship ” boy at a public school, and
is thinking (somewhat to my discomfort), in the pre¬
sent deplorable position of the profession, of being
a doctor. At four years of age they had influenza
together, and with the rest of the household. At
fifteen, at a public school, they both became affected
with the mild variety of purulent ophthalmia, which
sometimes becomes epidemic in schools. At sixteen,
at a public school, they had measles, one a fortnight
after the other, and, later, German measles. Later
again they had whooping cough at the same interval.
This is their complete record of disease.

Yours, etc.,

Paterfamilias Medicus.

November 23rd, 1907.

A ROYAL COMMISSION ON QUACKERY.

To the Editor of The Medical Press and Circular.

Sir, —You ask for outspoken views on this most
important and practical of professional topics. Here
are mine. I fully believe in the practicability and
hopefulness of a Royal Commission as explained dur¬
ing late years in your correspondence and editorial
columns, and I agree as to the flimsiness of the objec¬
tions to it, provided always that the profession will

(а) “The Nature and Treatment of Cancer ” (Fourth Edition). By
J. A Shaw-Maokenxie, M.D.Lond. London: BaMlIere. Tindall A Cox.

(б) Comparative Researches on the Tryptlo Strength of Different
Trypsin Preparations, and on Their Action on the Human Body." By
P. Tetens Hald, M.D.

zcdb,Cr.ooole

3 O

588 The Medical Press.

Nov. 27, 1907.

SPECIAL ARTICLES.

unit© to carry the thing through. I view as either
hypocrisy or twaddle the suggestion that the profession
ought not to defend the simple public, and at the
same time themselves, against the injuries of quackery,
because the sole part of the profession is to succour
the suffering and to work at science. This view has
been put forth by members of the British Medical
Association. The profession is the most altruistic
existing, and its unselfishness would not be lessened if
it boasted of as much consideration from the State
as is accorded to veterinary surgeons and solicitors.
The profession has always included in its ranks great
numbers of men devoted to science; and through
their discoveries and the work of medical men in pro¬
moting national sanitation, a great part of their sources
of income has been done away with. This renders
the obligation of the State to them all the greater.
General practitioners, the bulk of the profession, are
largely prevented from joining in scientific work
under present conditions. Many of them are too
badly off and dispirited, whilst those practising among
the poorer classes are perforce dragged down to the
intellectual level of their customers. The average
general practitioner rarely has a chance of making a
diagnosis in a case worth observation. The patient,
fortified by a study of quack literature, makes his own
diagnosis. He has headache, rheumatism, or
“liver,” as the case may be, and comes to the prac¬
titioner for “something to do him good”—something
better than the quack nostrums with which he has
been dosing himself. The practitioner knows that if
he attempts to make a scientific diagnosis when this is
necessary, he will not, in the majority of instances, be
able to get any adequate payment for his trouble,
even in the rare cases in which the patient will sub¬
mit. So cases of incipient malignant disease and of
all sorts of organic pathological activity go on from
bad to worse, with no other treatment than useless
or harmful drugging. My final view (for the present)
is that if the coarser kinds of fraudulent quackery
which appeal to the poor and ignorant were put an
end to, not only would the mass of preventable
human misery be at once largely diminished, but the
general practitioner would be placed in a position in
which he could act truly as a professional man, in¬
stead of as a tradesman, and his earnings would be
increased to a degree raising him at least to a bit
above the often degrading condition of hopeless
shabby gentility in which he is at present forced
frequently to remain.

I am, etc.,

An Obscure Practitioner.

November 21st, 1907.

WHY LET SCARLET FEVER SPREAD?

To the Editor of The Medical Press and Circular.

Sir,—I am not surprised to see it stated in the Press
that London suffers from an epidemic of scarlet fever.
It does not take the right way to prevent it—viz., to
bring the earliest cases under medical inspection and
care. This can be done by means of the Guardians
of the Poor freely offering “medical relief” to all
sick children whose parents are unable to pay tor a
doctor. Parents cannot tell whether a child’s symptoms
are those of scarlet fever or not, and they will not,
under present circumstances, call in the Poor-law
doctor if they can possibly helo it, even though they
cannot pay for one themselves. If they do apply to
the Guardians, too often they are worried to repay the
cost of medical relief, or made to come, like sup¬
pliants, before the board or the committee. They are
treated like “paupers.” A Medical Officer of Health
once told me that “the poor did not mind having
scarlet fever in their homes, but they did mind having
the Poor-law doctor.” This was not dislike of the
Poor-law doctor, who was a kind and popular man,
but they objected to the degradation and disagreeables
connected with the Poor-law as it is administered by
the Guardians and relieving officers. Now the receipt
of medical relief does not disenfranchise, and the
sooner the Guardians make it understood that those
unable to pay for a doctor can have this help without
difficulty or degradation, the better for the public
health.

Of course the children have a legal right to medical
relief, but Guardians can, and I fear often do, prac¬
tically deprive them of it by discouraging applications
in various ways. This, again, is partly due to the old-
fashioned political economy, and to the Local Govern¬
ment Board inspectors, who think more about tbe
diminution of “pauperism” than of the diminution of
disease and death-rate. If the Local Government
Board would issue a circular as to medical relief on
the same excellent lines as the recent one as to mid¬
wives, much good would be done. Many of the poor,
and many also of the Guardians, do not understand
there is a legal right, and many of the poor do not
know how practically to obtain it. The circular would
be useful to all parties.

Yours, etc.,

J. Theodore Dodd, M.A.

Oxford, November 18th, 1907.

OBITUARY.

ROBERT J. PATON, M.D., C.M.F.din.

We regret to record the death of Dr. Robert John
Paton, who died on November 16th from blood-poison¬
ing, resulting on a slight scratch caused whilst con¬
ducting an operation. Dr. Paton, who was 45 years of
age, and honorary surgeon to the Newport and County
Hospital, five weeks ago, whilst performing an opera¬
tion for appendicitis on a patient at the hospital,
pricked his hand. Inoclation was succeeded by blood-
poisoning. Dr. Paton was born in India, his father
being Military Chaplain to the 72nd Highlanders. He
received his early education at Dumfries, and subse¬
quently at the Edinburgh University. For some time
he was medical officer at the Crighton Lunatic Asy¬
lum, Dumfries, but about 16 years ago he went into
practice at Newport. He obtained his M.B. at Edin¬
burgh in 1886, and M.D. Edinburgh in 1899. Shortly
after coming to Newport he joined the 2nd Y.B. South
Wales Borderers, and at the time of his death was
surgeon-major of the battalion. He also took ar.
active part in ambulance work, and was once tutor of
the local railwaymen, and some of the Volunteer Am¬
bulance Corps he trained saw active service in the
South African war. His principal work at Newport,
however, was as hon. surgeon to the Newport Hospital.
He was also medical officer for the St. Woollos district
of the Newport Union. He leaves a widow and one
daughter.

SPECIAL ARTICLES.

ROYAL COLLEGE OF SURGEONS OF
ENGLAND—ANNUAL MEETING OF FEL¬
LOWS AND MEMBERS.

The twenty-third annual meeting of fellows a v.i
members which took place at the Royal College 0;
Surgeons on Thursday last was the best attended
meeting for many years, nineteen fellows and 69 mem¬
bers being present. This was doubtless due to the
fact that since the last annual meeting both the
Society of Members and the Council of the College
had been received at the Privy Council by the Lori
President on the question of direct representation c:
members on the college council, the society having
previously presented a memorial on the subject to lb*
Prime Minister. The President of the College, Mi-
Henry Morris, presided at the meeting, and opened
the proceedings with a statement regarding the
principal items included in the report of the council,
which was laid before the meeting.

The President said that, with regard to the admission
of women to the college diplomas, the council had
passed a resolution in favour of such admission, and
that if the Royal College of Physicians were favour¬
able to the scheme a vote would then be taken of the
fellows and members erf the college. The council had
decided that it was not desirable for the college to
grant a Diploma in Tropical Medicine, but in order ic
give a cachet to successful students, they had decided
i to appoint assessors to be empowered to endorse the

Nov. 27, 1907.

MEDICAL NEWS IN BRIEF.

The Medical Press. 589 j

certificates in tropical medicine gained by the holders
of the college’s diplomas. With regard to the muni¬
ficent gift of Mr. and Mrs. Bischoffsheim of ^40,000
to the Imperial Cancer Research Fund, to celebrate
the event of their golden wedding, the President made
the interesting statement that, if happily the cancer
research came to a successful termination, the interest
on this sum would still be available for research into
other diseases. As regards the council declining to
take any action in the question of the representation of
members on the college council, the President assured
the meeting that the council was not actuated by any
hostility or opposition to the members, but by the feel¬
ing that the suggested innovation was not in the nature
of a desirable reform.

The resolutions, which were included in the last
issue of the Medical Press and Circular, were all
carried unanimously. Mr. F. W. Collingwood’s resolu¬
tion regarding the recognition of members of the
college for becoming candidates for hospital appoint¬
ments was seconded by Mr. H. Elliot-Blake; Mr.
Joseph Smith’s resolution re-affirming the desirability
of admitting members to direct representation on the
council was seconded by Mr. Brindley James, and a
long debate followed on the question. Dr. W. G.
Dickinson’s resolution, in which he expressed regret
that the report did not contain the reply of the Lord
President of the Privy Council to the deputation of
members of the college council, was seconded by Mr.
S. C. Lawrence. Dr. Dickinson suggested that the
advice given on behalf of the Government was that the
council should obtain a new Charter, and that the
action with reference to the admission of women to the
examinations of the college was with the object of
evading the necessity of getting a new Charter, because
if a new Charter were granted for the admission of
women to the examinations, it would have to include
the admission of members to the council. The two
resolutions standing in Mr. H. Elliot-Blake’s name
suggesting that the college and its work should join
with the University of London so as to form an
Imperial University of London, and that a hood should
be added to the gowns worn by fellows and members,
were seconded by Mr. Brindley James.

A vote of thanks to the President for presiding at
the meeting concluded the proceedings.

Medical News in Brief

Royal Army Medical Corpa.

Captain H. R. Bateman has been appointed for
special duty at the Royal Army Medical College.—
Major S. F. St. D. Green has been appointed to the
medical charge of the Louise Margaret Hospital for
Women and Children, Aldershot.—Lieut. H. E.
Gotelee, who has been doing duty at the Cambridge
Hospital, has left Aldershot for Ceylon.—<?apt. S. G.
Butler, surgeon-in-charge of the Cambridge Hospital,
Aldershot, has been ordered to embark for India. The
November issue of the Journal of the Royal Army
Medical Corps contains an important article by Sur-
eon-Lieut. E. L. Moss, who states that the rough
annel shirt issued to soldiers is responsible for some
affections of the skin. He says: “As medical officer
to the 2nd Battalion Royal Welsh Fusiliers, I have
been greatly impressed by the number of men tem¬
porarily inefficient and requiring admission to hos¬
pital on account of boils and pustular skin infections,
the result of scratching or chafing prickly heat. I
have strong reasons for believing that the regulation
flannel shirt is largely responsible for the condition.”
Battersea "BrownOar"Memorial

Ten students from Middlesex and University College
Hospitals were charged on November 21st at the
South-Western Police Court with causing wilful
damage to the “Brown Dog” memorial at Latchmere
Recreation Ground, Battersea, and after being sharply
reprimanded and warned by Mr. Paul Taylor, they
were fined ^5 each. The “Brown Dog” statue was
presented to Battersea by the International Anti-Vivi¬
section Council, and was unveiled by the Mayor of
Battersea in 1906- The inscription on it is in these

I terms :—“ In memory of the brown terrier dog done
to death in the laboratories of University College in
February, after having endured vivisection extending
over more than two months, and having been handed
over from one vivisector to another till death came to
his release. Also in memory of the 232 dogs vivi¬
sected in the same place during the year 1902.” The
dog is seated above a drinking fountain, at the base
of which are the words: “ Men and Women of Eng¬
land ! How long shall these things be?” Mr. Paul
Taylor said the erection of the momerial was per¬
fectly legitimate, and the defendants should remem¬
ber that there was another side to the question which
they regarded as personal to themselves. He could
not rega.'d anything as more serious than the assem¬
bling of 500 students, for such conduct was calculated
to lead to a public riot. He warned defendants if
such conduct was repeated the offending persons would
go to prison for two months without the option of a
fine.

Assault 00 a Medical Man.

Mr. E. C. Hughes, of Guy’s Hospital, was the sub¬
ject of a seiious assault in Soho on November 22nd.
His assailant was a smartly dressed young woman,
who went up to him as he left a hospital in Dean
Street. She was carrying an innocent-looking brown
paper parcel. There was an altercation between the
two, which was cut short by Mr. Hughes saying, “If
you follow, I shall give you in charge.” Thereupon
the woman struck him a blow on the side of the head
with the parcel, which contained a heavy iron hammer.
Mr. Hughes reeled and blood flowed from 1 is head ;
he was only saved from falling by an onlooker. The
woman was arrested and taken to Marlborough Street
Police Station. Mr. Hughes went in a cab to Guy’s
Hospital, where it was stated last night he was suffer¬
ing from a severe scalp wound.

p e°r Law Medical Officers and the 3apply of Expensive
Medicines.

Recently, in approving the appointment of a Dis-
tnct Medical Officer in the St. Germans Union, the
Local Government Board informed the Guardians that
they were of opinion that it was desirable that ex¬
pensive medicines should be supplied to the sick poor
at the cost of Boards of Guardians, and not at that of
the Medical Officer, and requested the Guardians to
take this opportunity of considering the matter with a
view to the adoption of such an agreement. The
Guardians decided to reply to the effect that it was
not their custom to do as suggested. They had con¬
fidence in their medical officers to give the best medi¬
cines where needed, and that if the Local Government
Board insisted on their suggestion being carried out
in this case they would have to consider the position
of the whole of the medical officers, f’o far no com¬
plaints had been received.

The Asylums Board and Bacteriology.

The Local Government Board having expressed their
willingness to assent to a proposal to erect bacterio¬
logical and anti-toxin laboratories at Belmont, and the
anti-toxin stables recently erected there being in work¬
ing order, the Hospitals Committee of the Metro¬
politan Asylums Board have now decided to recom¬
mend the Board to appoint Dr. C. E. Cartwright Wood
as bacteriologist at their establishment at a salary of
£fooo per annum, with an assistant at a salary of /■300
per annum.

Trinity College, Dublin

The following candidates have passed the Final
Medical Examination (Part II.), Michaelmas Term,
1907 Surgery: George F. Graham (Passed on High
Marks), Robert A. Askins, Wilfred J. Dunn, Julian B.
Jones, Bethel A. H. Solomons, Thomas P. S Eves
Henry D. Woodroffe, Francis O’B. Kennedy,' James
D. K. Roche, Wilfred L. Hogan, Henry J. Keane,
Archibald L. Robinson, James R. Yourell, Joseph H
Elliott, James G. M. Moloney.

Society of Apothecaries of London.

The following candidates having passed the usual
examinations, have received the L.S.A. Diploma of
the Society entitling them to practise Medicine Sur¬
gery and MidwiferyM. F. Emrys-Jones B S
Matthews, J. F. McQueen, G. H. Rodolph, and A L
Walters.

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590

The Medical Press

WEEKLY SUMMARY.

Nov. 37, 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specialty compiled for Thb Medical Press and Circular.

RECENT PATHOLOGICAL LITERATURE.

Toxicity of Therapeutic Sera. —Besredka points out
that most therapeutic anti-sera possess [Annales de
L'Instit. Pasteur., No. 10, 1907), in addition to their
anti-toxic properties, a certain amount of toxicity,
which may show itself by the occasional manifestation
of unpleasant symptoms following the therapeutic
application of these sera. He has been able to esti¬
mate the degree of this toxicity by subdural injections
of the sera into healthy guinea-pigs, and has been able
to demonstrate certain facts thereby. The more im¬
portant are as follows:—(1) The sera of horses living
under similar conditions aTe of the same degree of
toxicity ; individual differences are rare and of little
importance; (2) the variable toxicity of sera appears
to depend partly on their age and partly on their
origin ; (3) all sera are very toxic on the day of the
bleeding, but they lose their toxicity gradually in
keeping. No therapeutic serum, however, should be
used within two months of the date of bleeding. (4)
Any serum which produces toxic symptoms in guinea-
pigs in doses of 1-16 to 1-20 c.c. should be regarded
as too toxic for use. M.

Immunisation Against Inoculated Cancer. —Bridre
( Annal. de L'Instit. Pasteur., No. 10, Oct. 25th, 1907)
has carried out experiments with the object of estab¬
lishing, if possible, a condition of immunity or in¬
creased resistance in mice to inoculable tumours. As
a subject for experiment he chose a tumour of an
adeno-carcinomatous type, which gave from 30 to 40
per cent, of successful results when injected subcu¬
taneously He found, in the first place, that mice
which failed to develop the tumour on a first inocula¬
tion very often developed it on a second occasion, and
did not appear to have acquired any degree of im¬
munity from the first injection. Those, however, who
received two,inoculations without developing a tumour
remained immune as a rule when subsequent injections
were given. Injections of fresh cancerous tissue were
found in all cases to be more valuable than similar
injections of desiccated cancerous material. It was
found, however, that injection of normal tissues of a
mouse also conferred a heightened lesistance, and
from this he concluded that the immunity could not
be specific. The increase in resistance in all cases was
proportional to the amount of tissue injected. M.

Surra in Indo-Chlna. —Schein has studied exhaustively
the diseases caused by trypanosomes in cattle in Indo-
China, and to which the general term of surra is
applied (Annales de L'Institut. Pasteur, September,
1907). He has come to the conclusion that although
marked variations are noted in the course of various
epidemics, still all the epidemics are due to the
same trypanosome. The variations he attributes to
what he terms the genealogy of the particular parasite
in any casd. He finds also that the buffalo is not pro¬
tected after a single attack of surra, and that it can
in many cases be the carrier of virulent parasites with¬
out itself showing any symptoms. Infected cattle,
moreover, may be found outside the area of the epi¬
demic regions. As aids to the extermination of the
disease he recommends drainage and clearing of the
country, filling up of stagnant pools, careful choice
of pasture lands, careful segregation of diseased
animals, and occasional systematic examination of
healthy animals. M.

Staphylococcal Vaccines In the Treatment of Furun¬
culosis. —Hartwell and Lee ( Boston Med and Surg.
Journal , October 17th, 1907) report the result of their
observations on 100 cases of staphylococcal infections
treated by Wright’s methods. They have found that it
is unnecessary in such cases to make use of a vaccine

prepared from the actual organism that is causing the
individual lesion, but that a stock vaccine of any
staphylococcus aureus will do. In their earlier work
the opsonic index was taken regularly, but later thev
found that equally good results could be obtained
without the index by giving routine doses every four
days of from 300,000,000 to 600,000,000 micro-
organisms. The inoculations are made subcutaneously
and at a fresh site on each occasion. They summarise
their conclusions as follows:—(i) The vaccine treat¬
ment is the most effectual of all treatments for boils
and carbuncles; (2) although this treatment does not
prevent recurrence, cases of chronic furunculosis can
be absolutely controlled by occasional inoculations;
(3) the determination of the opsonic index is quite
unnecessary, and the treatment can be carried out
without special technical training. M.

ram ana »iooa-Fre«sure.-Auschmann has carried
out a series of experiments with the object of deter-

3J2II5 j nfl M/ en i e P ain u P° n blood-pressure
Woc J l -j October, 1907), and records his
, H. 13 “ethod consisted of applying painful

ri™* ^ St r ul i*° Y anous groups of individuals, and
recording the blood-pressure before and after the
application. Twenty individuals with normal sensi¬
bility were so tested, and in 18 there was a rise of from
8-10 m.m. of mercury. In persons with a neurotic
temperament and a high preliminary blood-pressure
the elevation produced was still greater. If the sensi¬
bility is disturbed in any way, either as the result of
functional or organic disease, the rise in pressure does
not take place.

«nh; P l d , en,IC ^ Pne "“ 0,,,a — Fab y an on the above

subject, and points out that while many writers have
att ention to cases of pneumonia occurring in
groups, the actual occurrence of such cases is com¬
paratively rare. He himself has lately observed such
a group, which he now reports (Johns Hopkins Host

I9< L 7) ‘ The e P id emic occurred in a
family of ten members, nine of whom were living in
the same house. Out of these nine, six members de¬
veloped acute pneumonia within a period of ten davs.
K,7 ( l°^ eT . memb f r ? developed an illness characterised
by headache and fever, and abdominal pain, within
the same period, but no physical signs were found in
2 gS ' * °" e , case P roved fatal, and the necropsv
a typical croupous pneumonia, of a pseudo-
Icbar type, while from the same individual during life
pneumococci were obtained on culture from the cir¬
culating blood. It was noted that where two of the
patients slept together, the second infection followed
the first in each instance in from six to nine days.

M.

The Metabolism in Leukaemia Treated by X-Rays.-

hinne reports the results of his investigations in four
cases of myelogenous leukaemia treated by daily ex¬
posure of the splenic region to the X-ray emanation;
for a period of about 20 minutes (Pus si sc he. Med.
Rundschau Heft. 8, 1907). During the treatment
frequent blood examinations were made, including
counts of the red and white cedis, haemoglobin estima¬
tion, and a differential white cell count. At the same
time the nitrogenous urinary output was determined,
and a quantitative estimation made of the purin sub-
!L ai l C ?f uric ** id «creted. The writer concludes
that the X-rays give much better results than can be
obtained by any other treatment, and that in most
cases all leukasmic symptoms disappear, so that a
complete cure results, at any rate for the time being.

I he best results are obtained in the myelogenous form
of the disease, and they do not appear suddenly, bnt

Digitized

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Nov. 27, 1907.

WEEKLY SUMMARY.

The Medical Press. 59 1

gradually develop. Apparently the rays influence the
disease process itself, but since the etiology is un¬
known, nothing definite can be stated on this point.
The diminution in number of the leucocytes seems to
be due to the fact that they are produced in smaller
numbers, inasmuch as their diminution goes hand-in-
hand with a lessening of the output of purin todies
and uric acid. At the commencement of treatment a
decrease in the output of these substances took place,
and continued till the leucocytes had fallen to about
the normal number. If the exposures were continued
after that time, the excretion of purin bodies again
increased, apparently due to the destructive effect of
the rays on tissue cells of the body. M.

Amaurotic Family Idiocy. —Cohen and Dixon report
a case of this disease in which the eyes were enucleated
for examination within three hours after death (Jour.
Amer. Med. Assoc., May, 1907). The histological
changes detected were, swelling of the multipolar
ganglion cells, displacement of their nuclei, retraction
of cell reticulum, diminution in number of ganglion
cells, and disappearance of Nissl’s granules. By
Weigert’s stain, dark granules were found in all the
ganglion cells, and it was found that at the macula
lutea there were several layers of multipolar cells,
while beginning simple atrophy of the optic nerve was
also noted. They think it likely that the primary
change in the disease is an arrested development, fol¬
lowed by degeneration caused by toxins, the result of
defective metabolism. M.

Blood Pressure in Tuberculosis.— Stanton has made
a study of the blood pressure in over 200 cases of
tuberculosis by means of a modified Riva-Rocci
instrument ( Internal. Clinics, Vol. III., 1907), and has
come to the following conclusions:—(1) The blood
pressure, both systolic and diastolic, is generally low
in tuberculosis, and, as in normal cases, is lower in
women than in men; (2) the pressure is higher in
improving cases and lower in progressing and un¬
favourable cases ; (3) haemoptysis is not accompanied
by any change in the pressure ; (4) the nephritis of
tuberculosis apparently does not increase the blood
pressure ; (5) time of day, presence of fever, degree
of involvement, have no influence on the blood pres¬
sure of tuberculosis. M.

Diagnosis of Typhoid Fever by the Conjunctival
Reaction. —Chantemesse has been experimenting with
typhoid fever patients in the hope of discovering an
ophthalmic reaction in them similar to what Calmette
has described in tuberculous patients when tuberculin
is dropped on to the surface of the conjunctiva. He
has carried out his observations (Deuisch. Med. Woch.,
1907, No. 39) on 120 patients altogether, out of whom
50 were healthy, and 70 were ill with enteric fever.
The healthy individuals in all cases failed to react,
while a reaction was obtained in all the others, and
this reaction was often obtained earlier than the Widal
reaction, and was often less equivocal. The writer
believes that the reaction gives a new aid to diagnosis,
which may be employed and relied on almost as soon
as the earliest clinical symptoms are developed.

M.

Vaccine Treatment and Diagnosis.— Wright and his
colleagues in the Laboratory of St. Mary’s Hospital
publish (Lancet, November 2nd, 1907) “a collection of
some of the more interesting” of their records in
regard to therapeutic immunisation. The points
touched on are very numerous, and we regret that we
cannot give a detailed analysis of the paper, which,
however, should be read in full. The authors show
that auto-inoculation is not infrequent in the begin¬
ning of tuberculous infection, and that it is a regular
accompaniment of the hectic fever of advanced
phthisis. In reference to a case of gonococcal arthritis
they show that there is an intimate relation between
auto-inoculation and auto-immunisation on the one
hand, and the clinical symptoms of the patient on the
v Cr ’ re R ar d to generalised bacterial infections,

they show that spontaneous auto-inoculations and
immunising responses are a characteristic feature in
anthrax septicemia as seen in rabbits. The history

of their vaccine work in regard to streptococcal and
staphylococcal septicaemias is set out in some detail.
The authors conclude the first part of their paper by
considering the effect of massage and of active mus¬
cular movements, the effect of operative interference
with the foci of disease, and the effect of active and
passive hyperasmia, in producing auto-inoculation and
auto-immunisation. In the second part of their paper
the authors bring forward evidence to show that in
the induction of an auto-inoculation, when this is pre¬
ceded and followed up by a series of measurements
of the opsonic index, there is at hand a method which
will aid in some of the diagnostic and therapeutic
problems which present themselves for solution in
connection with localised infections which are not
accessible to direct bacteriological examination. The
records and chart contained in the paper are certainly
interesting, some of them dramatically so. Particu¬
larly are to be noticed certain charts showing a very
remarkable parallelism between the opsonic power and
the temperature, and between the opsonic power and the
symptoms, in various cases. The table of thirty cases
where some important question of diagnosis or treat¬
ment was answered by the results of auto-inoculation,
gives examples of a great variety of cases, and of the
dogmatic answers which the authors think were justi¬
fied. The paper, as a whole, is of great interest, but
we are among those who think that selected cases, no
matter how striking, do not give a just view of the
results of a method of treatment or diagnosis. Vaccine
treatment has justified itself, not only in the hands of
Wright, but of his disciples all over the world. The
necessity for opsonic control is, however, not yet
established, and it cannot be so long as Wright pub¬
lishes only selected cases. Until a full account of the
work at St. Mary’s is published, including not only
ten “more interesting,” but all the cases, favourable
and unfavourable, if there be any such, no decided
opinion can be come to as to the necessity for opsonic
control of vaccine treatment. R-

Typhoid Agglutinins in a Non-Typhoid Case. —Sym-
mers and Wilson (British Medical Journal, September
21 st, 1907) report a case of cerebrospinal fever, in
which the blood gave a positive Widal reaction to the
typhoid bacillus. The patient was a woman of 27
years of age, who had had no previous illness of any
sort for nineteen years, since as a child she had
suffered from scarlet fever. It was, therefore, un¬
likely that she had ever had typhoid fever. Her
clinical symptoms were those of cerebro-spinal
meningitis, which was epidemic in Belfast at the time
of her illness there. Her blood was twice tested as
to its agglutinative powers on the Bacillus typhosus ,
and on both occasions the serum in dilutions of 1 in
200 gave marked clumping within fifteen minutes. The
illness having ended fatally, an autopsy was per¬
formed, and the clinical diagnosis confirmed. There
was suppurative meningitis of the brain and cord,
and from the pus was recovered in pure culture and
in great abundance the diplococcus intracellularis
meningitides of Wiedaselbaum. An exhaustive
bacterioscopic examination of the spleen, mesenteric
glands, and urine, was made for the typhoid bacillus,
with negative results. There were no lesions of the
intestine to suggest typhoid fever; the Peyer’s patches
being normal. The strain of typhoid bacillus used in
Widal’s test was that customarily employed in Sym-
mers’ laboratory; during the past year it gave in 112
examinations results which, clinically controlled,
were considered correct in 97.3 per cent, of the cases.
The case recorded is of interest from two paints of
view—(1) The presence of a typhoid agglutinins in
the blood of a case which was not typhoid fever.
(2) A possible peculiar property of the serum in
cerebro-spinal meningitis on other bacteria than the
specific coccus.

The presence of typhoid agglutinins in other con¬
ditions than typhoid fever has often been recorded.
The present abstractor frequently examined the
blood of one of his colleagues who had never had
typhoid fever, and who was in robust health; his
blood invariably gave positive results to Widal’s test,
even in high dilutions. R.

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592 The Medical Press. NOTICES TO CORRESPONDENTS

Nov. 20, 19117.

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should be addressed to the Publisher.

St. John's Hospital fob Diseases of the Skin (Lricetter
' Square, W.C.).—6 p.m.: Chesterfield Lecture:—Dr. M. Dookrell:

Coccus Diseases: L, Impetigo Contagiosr ; II., Furuncle; III,

I Carbunole; IV, Coccogenic Sycosis.

Hospital for Sick Children (Great Ormond Street, W.C.).—
4 p.m.: Lecture:—Dr. Thompson: Jaundice in Children.

Fridat, November 22th.

Societt of Arts (John 8treet, Adelphi).—8 p.m.: Shaw
Lecture:—Dr. J. 8. Haldane: The Hygiene of Work in Com¬
pressed Air (Diving, Caisson Work, etc.).

Medical Graduates' College and Policlinic (22 Cheuiw
Street, W.C.).—4 p.m.: Mr. E. Clarke: Clinique. (Eye.)

North-East London Post-Graduate College vPrince of
Wales's General Hospital, Tottenham, N.).—10 a.m.: Clinique —
Surgical Out-patient (Mr. H. Evans). 2.30 p.m.: Surgical
Operations (Mr. Edmunds). Cliniques:—Medical Out-patient (Dr.
Auld); Eye (Mr. Brooks). 3 p.m.: Medioal In-patient (Ur. M.
Leslie).

£ppointmem&.

Falconer, A. D, M.D.Aberd, M.B.C.P.Lond, House Physician
at the Bristol Royal Infirmary.

Hibbert, C, M.B., Ch.B.Vict, House Surgeon at 8t. Mary’s
Hospital, Manchester.

Josceltne, Arthur Edwin, L.R.C.P.Lond., M.R.C.S, L.S.A.,
Public Vaccinator for Taunton

Lacet, Frank Hamilton, M.B, Ch.B.Vict, House Surgeon at St
Mary's Hospital, Manchester.

Meadows, George Stephen, M.B, C.M.Edin, Medical Officer for
Health of Saltash (Cornwall).

Sheppard, Arthur Lewin, M.B, B.S.Durh, Senior Resident
Medical Officer at the Bristol Royal Infirmary.

S. R. P. (Croydon).—The method of injecting air sub¬
cutaneously for the relief of certain painful manifestations, such
as sciatica, was introduced by Dr. Cordier, of Lyons, and the
results in the hands of other practitioners has been, on the
Whole, good—sometimes, indeed, brilliant.

Ubique. —Peroxide of hydrogen, in ten-volume strength. ha“
been found very efficacious in cases of epistaxis. A pledget of
wool soaked in' the fluid is pressed by the finger against f.hp
bleeding spot, and a.ter some moments the haemorrhage generally
ceases.

M. D, L. S. A. (Leeds).—Strophanthus acts more quickly upon
the heart than digitalis, owing to its being more readily
absorbed. Moreover, its action is le.'.a irritant.

A COMMON OCCURRENCE.

When a patient oalls to see you,

Very anxious to be oured,

And he quite forgets to fee you—

Say; now oan this bo endured ?

Take a lesson from the Lawyer;

He's not one to trust to fate.

No advice, or pen to paper,

Till he's sure of six and eight
Doctors still are far too willing;

Free advioe should be abhorred.

Public fight about a shilling;

Go their way: nor thank the Lord! ^ ^

Uoanda. —It cannot be too clearly stated that Dr. Koch no
more discovered atoxyl and its value in sleeping sickness than
that he discovered the moon. The credit, such as it is, is due
to Drs. Thomas and Breinl, of the Liverpool School of Tropical
Medicine. According to the newspapers, Dr. Koch discovers

* lLiLCJLEdin.—It is not usual in England to omit “Edin."
after F.R.C.S. in cases where the diploma has been obtained in

"^Satcbn.—O ur correspondent bad best arrange a consultation
with a specialist in children's diseases.

Dr. Sidnei. W. 8.—We shall be pleased to receive the notes,
and, as far as our engagements permit, will give them early
publication.

Jfttetings of the gkrritL its, &c-

Wkdnesdat, November 27th.

Medical Ghaduateb' College and Policlinic (22 Chenies
Street, W.C.).—4 p.m.: Mr. P. Pafon: Clinique (Surgical.)

6.15 p.m.: Lecture:—Dr. W. Milligan (Manchester): Some
Pr&otioal Points in the Treatment of Suppurative Disease of the
Naaal Accessory Sinuses.

Nobth-East London Post-Graduate Colleoe (Prince of

Wales's General Hospital, Tottenham, N.).—Cliniques:—2.30 p.m.:
Medical Out-patient (Dr. Whipham): Dermatological (Dr. G. N.
Meaohen); Ophthalmologioal (Mr. R. P. Brooks).

Thursday, November 28th.

Child Studt 8ociett (Parkes Museum, Margaret Street, W.).—
8 p.m.: Lecture:—Dr. A. H. Hogarth: The Sohool Clinic.

Medical Graduates' College and Policlinic (22 Chenies
Street W.C.).—4 p.m.: Mr. Hutchinson: Clinique. (Surgical.)

5.15 p.m.: Lecture:—Dr. P. Horrocks: Profuse Menstruation

(with illustrative cases). .

North-East London Post-Graduate College vPrince 0 f

Wales's General Hospital, Tottenham, N.).—2.30 p.m.: Gyneco¬
logical Operations (Dr. Giles). Cliniques:— Medical Out-patient
(Dr. Whiting) ; Surgical Out-patient (^r. Carson); X-Ray (Dr.
Pirie). 3 p.m.: Medical In-patient (Dr. G. P. Chappel). 4.30 p.m.:
Lecture:—Dr. A. E. Giles: Ultimate Results of Inoperable
Gynecological Cases.

l^axanncB.

Castlebar District Lunatic Asylum.—Assistant Medical Officer.
Salary £100 per annum, together with annual allowance (in¬
cluding £50 in cash) valued at £100. Applications to Joseph
F. Kelly. (See advt.)

Cavan Union.—Medical Officer. Salary £100 per annum. Appli¬
cations to Joseph Gur, Esq. (8ee advt.)

Seamen's Hospital Society, Greenwich, S.E.—Medical Superin¬
tendent of the Dreadnought Hospital, Greenwich. Salary
£200 per annum, with board in the Hospital. Applications
to P. Michelli, Secretary.

The Hospital for Sick Children, Great Ormond Street, London.
W.C.—House Surgeon. Salary £20 for six months, washing
allowance £2 10s., with board and residence in the Hospital
Applications to the Secretary. (See advt.)

London County Asylum, Long Grove, Epsom, Surrey.—Fifth
Assistant Medical Officer. 8alary £150 a year, with boprd,
furnished apartments, and washing. Applications to H. F
Keene, Clerk of the Asylums Committee, Asylums Committee
Office, 5, Waterloo Place, S.W.

West Riding Asylum, Wakefield.—Assistant Medical Officer
Salary £150 per annum, with apartments, board, washing sn°
attendance. Applications to the Medical Director at the
Asylum.

Royal London Ophthalmio Hospital (Moorflelds Eye Hospital'.
City Road, E.C.—Bacteriologist. Salary £120 a year, with
lunch in the Hospital. Applications to the Secretary.

Norwich City Asylum, Hellesdon-next-Norwich.—Assistant Medical
Officer. 8alary, £130 per annum, with room*, board tno
stimulants), laundry, and attendance. Applications to the
Medical Superintendent.

Essex County Asylum, Brentwood.—Fourth Assistant Medical
Offloer. Salary, £150 per annum, with board, eto. Applie*-
tions to the Medical Superintendent.

#irths.

Allworth.— On Nov. 23rd, at “Fairholme," West Hill, Sydenbsn.
the wife of A. Leigh Allworth, M.R.O 8., L.R.C.P., L.D.8., of * •"

Barri.—O n Nov. l§th, at Ashfleld Park House, Terenure, the
wife of Dr. P. J. Barry of a son.

Ellis.—O n Nov. 19th, at 157, King Henry’s Road, South Hsmp
stead, London, the wife of Captain W. F. Ellis, R.A.M.C., ■
a son.

4fiarriages.

Colwbll—Wood— On Nov. 23rd, at Holy Trinity Church. Btnwj
Green. London, Hector A.Colwell, M.B^ son of Mr. and Mr*. Alfred
Colwell, of Ridge Road, Hornsey, to Clara Elizabeth, elde*'
daughter of Mr. and Mrs. J. Wilson Wood, of Kldge Road.
Hornsey. , —

Hates—Rotds.— On Nov. 20th, at Bombay, India, Arthur Her
bert Hayes, captain R.A.M.O., son of the Rev. A. H. Have*.
Rector of All Saints', King's Lynn, Norfolk, to Kathicea
Mabel, eldest daughter of the late Ernest E. Molyneux Boyds
of Roohdale, Lancashire.

JBtathe.

Iasard.— On Nov. 20th, at Melbourne, Derbyshire, John Hssani,
M.R.O.S., L.8.A., aged 63.

IcEwbn.—O n Nov. 21. at Ten Rallt, Abergele. Margaret E*»»
relict of William McEwen, BLD., late of 26, Nicholas Street,
Chester.

Digitized by Google

The Medical Press and Circular.

“SALUS POPULI SUPREMA LEX.*

Vol. CXXXV. WEDNESDAY, DEC. 4, 1907. No. 23

Notes and Comments.

The annual meeting of the Royal
Academic College of Surgeons of England
and tound the Council in still the same
Scientific, spirit of obduracy with regard to the
claims of members for representa¬
tion on the governing body. It seems that the
Council, after considerable search for an excuse for
the attitude of “what is our own we’ll hold,” to
which they have clung 90 tenaciously through good
and evil report, have lighted on an admirable one,
namely, that the “ functions of the College are
academic and scientific, and are exercised by the
Council for the public welfare, and not as a trust
received from the members.” After this the mem¬
bers may take heart of grace, for if this is the best
the Council can sav for themselves they must be in
a parlous state, it would be interesting to hear
how the Council have sought to serve the public
welfare, and how much they have sacrificed to that
noble ideal. We search our memories in vain for
any striking example. The claims of the Council
that they are not exercising a trust received from
the members is certainly in accordance with its
deeds. It does not exercise the trust received from
■the members at the reconstitution in 1843; but
there is no need to glorv in the fact. The con¬
ception of the Council of the function of the College
is weird in the extreme. It is “academic,” but it
does not teach , it is “ scientific,” but it does not
pursue research. Tne bulk of its income is re¬
ceived from members’ fees, and these it uses not as
a trust for the members but for the public welfare.
Does the Council really contend that members pay
fees in order that the public may be protected
from them (the members)? Was ever more dis¬
ingenuous stuff put forward to bolster up a shaky
case?

The disturbances among medical
The students with regard to the “ Brown
“Brown Dog” Deg” incident and their treatment
Disturbances, by Mr. Paul Taylor, are much to be

legretted. If we were to say that
they were only the natural outcome of provocation,
the phrase would be widely quoted by those papers
which delight to calumniate the profession, and we
.should be accused of “encouraging” the disturb- i
nnces. We do not say so, but we repeat what we
said last week, that the monument and the inscrip¬
tion remain a standing menace to the reputation for
good conduct that London medical students have
gained. The recent disturbances have allowed to
overflow the pent-up hatred felt by certain classes
towards medical science and medical men, a hatred
which is fomented by certain journals for political
ends, regardless of fact, truth, justice, or honour.

It is instructive to note the unctuous snobberv of
such journals. The medical student, whom thev
have their knife into, is assailed with abuse and

I sarcasm, whi'e the young lord who gets drunk and
smashes windows, or the budding politician who re¬
moves the hands from a public clock, is applauded
as a venturesome and dashing 'fellow. Of the
ragging medical student, however, we hear “ Is this
the sort of man who is .to attend our wives and
daughters? ” or that he is brutalised by vivisection.
The Battersea Borough Council, as a whole, would
seem to adopt much the sarnie attitude, for the
Finance CommitJtee of that body, in presenting its
report last week, mentioned that they had gone out
of their wav to instruct the Town Clerk to convey
to the police, and especially to the two officers who
arrested the students, the Council’s appreciation of
their services.

A correspondent of the Standard,
T . r writing on the subject, expresses

Wav with admirable taste the feelings that
medical men and physiologists feel
with regard to the animals that are
experimented on. In remarking on the inscription
he says, “Can we be expected to regard this
egregious inscription, perpetuated in stone, without
some impatience? ” and a little later proceeds, “ Had
the inscription run somewhat as below, it would
have been more humane and nearer the truth : —

“In memory of the Brown Dog, who died as he
lived, a true friend .to man and to his kind. His
life taught a lesson of fidelity and devotion to duty,
and his death was a sacrifice for the welfare of
others like him, and for man, whom he loved.

“ People of England, remember this.”

Thus speaks the true humanitarian, and the true
lover of dogs. His mouth is not froward, and he
does not seek to use the regrettable sacrifices that
the conditions of life necessitate to impugn the
good feeling of those who support experimentation
- any more than he would seek to impugn that of
a general who ordered his armv to advance when
there was a certainty of loss, but among certain
classes the spirit against medical men that has
been bred by anti-vivisectionists and others of
their kidney, is of a bitterness and .malignancy
which no one would believe who has not had ex¬
perience of it.

.. 4 At an inquest held at Tottenham the

Almost other day, some unusually interesting
Manslaughter, facts came to light, and we recom¬
mend them to the notice of the Com¬
mittee of the General Medical Council which is to
inquire into quackery, and on which we have else¬
where congratulated the new direct representatives
of the profession. The facts are that a fish sales¬
man at Billingsgate was pricked in the thumb by
the thorn ” of a skate, and suffered from an in¬
flamed finger in consequence. Now it seems that
one Gregor)', who had been a fish salesman,
found surgical practice more lucrative than his

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LEADING ARTICLES.

Dec. 4, 1907.

594 The Medical Press.

own business, in consequence of haying acquired
a reputation for dealing with poisoned hands
with a certain salve and plaster. This 6alve
is stated to have consisted of marsh-mallow
leaves, elderberry' leaves, and parsley-tops, while
the plaster was one of resin and turpentine. To
Gregory the wounded salesman resorted and was
charged two guineas for the treatment. However,
he died of septicaemia. The coroner said that
Gregory’s treatment was quackery, and it was either
crass ignorance or arrogance which led him to take
the case up. Indeed, it was “ almost manslaughter.”
The jury censured Gregory, who is, of course, now
free to earn many more guineas in the same
way, just as he admits having already “ cured ”
hundreds in the market. It would be difficult to
find a case better illustrating the conditions of un¬
qualified practice. These salesmen apparently
could produce two guineas for Gregory’s precious
remedies, when a doctor might have got a shilling
or half-a-crown, and a hospital nothing. Had the
patient been under qualified care the finger would
probably not have been allowed to transmit its fatal
effects to the system.

An interesting comment on the state
of the law with regard to medical
^ practice was, furnished by an action

—not Ducal. ; n t h e Westminster County Court last
week, when the “ Derma Featural
Company ” sued a Mr. Spencer for the balance of
fifteen guineas, £7 of which had been paid, for
“ building up a new nose.” The defendant pleaded
infancy, but the plea was disallowed and an order
made for the payment of five shillings a month.
We do not pretend to know what range of treatment
the “ Derma Featural Company ” undertake, but
as one of the advantages of being on the Medical
Register is that it confers the right to sue for fees
for medical treatment, we cannot understand how
this Company can successfully use the County
Court for the recovery of fees for a surgical opera¬
tion. It is to us inconceivable that a new nose
can be “ built up " by other than a cosmetic surgical
process, and therefore the locus standi of the
Company is not apparent. If registrars accept
death certificates from unqualified persons, or give
burial orders without certificates, and if “ Derma
Featural ” companies can recover fees for surgical
operations and medical treatment, the advantages
of registration seem to be that a medical practi¬
tioner is subject to supervision without any corres¬
ponding benefit, whilst outsiders have the advan¬
tages without any restrictions.

LEADING ARTICLES.

A PORTENT FROM THE GENERAL
MEDICAL COUNCIL.

“The mills of God grind slowly, but they grind
exceedingly small,” is a comfortable maxim to the
philosopher, although it savours too much of pro¬
crastination to the man of action. The slow evolu¬
tion of natural laws in social relations presents us
with the series of adjustmepts and readjustments,
sometimes quiet and gradual, sometimes violent
and revolutionary, which, taken together, consti¬
tute history. As regards the particular subject of
medicine, mediaeval ignorance has given way to
twentieth-century exactitude, and legitimate
medical practice has emerged from the craft of the
leech, the apothecary, and the barber to the dignity
of the duly qualified modern medical practitioner.
Side by side with this happy advance there has been
no corresponding diminution in the evil work of
the quack and the charlatan, whosp methods are
much the same, whether we read them in black-

letter or in the columns of a London newspaper of
to-day. The form is somewhat changed, but the
substance is the same. The quack of Queen
Elizabeth’s time was able to deceive his customers
with a far less expenditure of capital and brains
than is needed by the proprietary medicine vendor
of to-day. For many years the “ Medical Press and
Circular " has almost alone of the medical journals
waged an unceasing war against quacks and
quackery. In the interests of the public, no less than
that of the medical profession, we have done what
we conceived to be our duty in the matter, without
fear and without favour. In this case it must be
admitted that the mills of God have indeed ground
exceeding slow, but we trust that within the next
generation the curse of medical quackery will be
crushed with remorseless grip betwixt the upper
and the nether millstones. Of late the subject has
been discussed more or less seriously by some of
the medical societies and journals. For obvious
reasons the lay newspapers, which draw vast
revenues from the advertisements of quacks and
quackery, will give no hand in the campaign. At
length the General Medical Council have taken
action in the important matter of unqualified prac¬
titioners. Not the old familiar Council, be it
noted, as known to us for many years past, but
that part of it which comprises the recently elected
direct representatives, Dr. Langley Browne, Dr.
MacManus, and Dr. Latimer. The original pro¬
position, withdrawn later in favour of another,
ran :—

“That this Council, deeming it to be contrary to the
public interest that any person other than duly quali¬
fied practitioners in medicine and surgery should prac¬
tice medicine in Great Britain and Ireland, appoint a
Committee to draft such amendments of the Medical
Act as may be necessary to secure this prohibition, and
to report to the Council at the session in May."

This proposal was met with a not unfamiliar
jeremiad from the conservative members of the
Council, who talked about the necessary education
of the public, the improbability of obtaining legis¬
lation, and the vested interests that would be roused
into opposition. Finally, however, the following
resolution was unanimously adopted:—

“ That a Committee be appointed to report upon all
the legal provisions existing in the Colonies ana
Dependencies of the Empire, and in foreign countries
for the prevention of medical practice by other than
legally qualified persons, and to consider what steps
should be taken to procure effective legislation for the
same purpose in Great Britain and Ireland.”

It is to be hoped that this event marks a new era
in the history of the General Medical Council.
Unless that body becomes inspired with some of the
wider and more generous impulses of modern
collectivism, it seems not improbable that it will
drift into the position of a hopelessly effete
administrative instrument. It is not a little signifi¬
cant that this most promising resolution has come
from the representatives of the geineral practitioners.
That fact, to our mind, strongly supports the con¬
tention that the constitution of the Council demands
remodelling on the lines of a representative
democratic as against its present individualistic
basis. Meanwhile we congratulate the direct
representatives on having at any rate fired the first
official shot in the campaign. The names of the
committee appointed to report are as follows:—
Dr. MacManus, Dr. Latimer, Dr. Norman Walker,
Dr. Kidd, Dr. Saundby, Sir John Moore, Mr.
Henry Morris, and Dr. Langley Browne.

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Dec. 4, 1907.

CURRENT TOPICS.

The Medical Press. 595

THE CLAIM TO PRIORITY IN TRYPSIN
TREATMENT OF CANCER.

The unwritten laws of the medical world, if at
times of a somewhat misty nature, are on some
points abundantly clear. One of the clearest of
these directions is to avoid, above all things,
the discussion of technical medical matters in lay
•newspapers. That rule has lately been thrown to
the winds by certain members of the profession with
an audacity and a persistence that is unparalleled in
the annals of medical history. In some cases the
offenders are engaged in actual practice; in others
they may not see patients; but in either event
we imagine that it is not altogether improbable
that the attention of the General Medical Council
will at no distant date be called to this undesirable
conduct. On ethical grounds it is not easy to
imagine why a man who has scientific facts to
discuss prefers to submit them to the judgment
of the public while they are still being investigated
and criticised by medical men, whose opinion on
such matters is alone of value. An instance of
the kind may be found in a book recently published
by Dr. C. VV. Saleeby, an M.D. of the University
of Edinburgh, who is generally understood not to
be engaged in actual practice, In the book in
question, to which our attention was drawn by
a correspondent in our last issue, the author lays
down the law upon cancer with an emphasis
and a conviction that has no rival in the
works of scientific surgical authorities. More¬
over, he deals freely with the dangerous weapon
of personal abuse, a fact that obviously does not
strengthen his position. In his desire to attri¬
bute the credit of the introduction of trypsin to a
non-medical investigator—Dr. Beard, of Edinburgh
—he goes to extremes that are calculated to defeat
his object. With regard to priority of claim to the
trypsin treatment of malignant growths, we have,
after careful consideration, ascribed the credit of
originality to Dr. J. A. Shaw-Mackenzie. The
evidence in favour of that view appears to us over¬
whelming, and so far as we can ascertain has not
been seriously discussed either by Dr. Beard or by
Dr. Saleeby. The plain fact of the matter appears to
be that berth Dr. Shaw-Mackenzie and Dr. Beard
arrived at the theoretical value of this special line
of treatment by independent routes, but Dr. Shaw-
Mackenzie was the first actually to treat patients.
It is surprising, therefore, that Dr. Saleeby should
in his book attribute absolute priority to Dr. Beard.
The allowances that have been made for Dr. Saleeby
both by his professional brethren and by the General
Medical Council have been great, but the latitude
of privilege must necessarily reach a limit when
he elects to discuss the action of particular
individuals, and he will be at once challenged to
make good his statements. In settling a point of
priority of claim to a discovery, we must look to
something more than the ex parte statements of a
heated partisan. The clamour and violence of the
market-place must give way to the calm and dis¬
passionate investigations of the court of justice.
So far the stage thunder seems to have come from
Dr. Saleeby, and the argument, clear and supported
by documentary evidence, from Dr. Shaw-Macken¬
zie. It is intolerable that any men claiming the ear
of the public as Drs. Beard and Saleeby have done
should refrain from substantiating the claim they
make to priority, a claim which has already
been strongly challenged. If they are to main¬

tain their position as men of honour and re¬
sponsibility they will either take steps to prove
their assertions up to the hilt, or else will with¬
draw them for all time. The matter is capable
of proof or disproof. There appears to be a grow¬
ing conviction in the orthodox medical world that
the trypsin treatment of malignant growths,
although not in itself a final solution of the
problem, has nevertheless advanced our general
conceptions of the nature and treatment of can¬
cer in a way that is not a little noteworthy. For
even the faintest ray of light cast upon this mystery
all who love humanity and all who are devoted
to the pursuit of medicine will be profoundly grate¬
ful. In any case we think that the time has come
when the claims of Dr. Shaw-Mackenzie in this
matter should be authoritatively considered by the
medical profession. Possibly the Cancer Research
Fund would appoint a committee in conjunction
with delegates from some of the leading professional
bodies for the purpose of investigation and report.

CURRENT TOPICS.

Colonial Appointments.

The Colonial medical service may in some in¬
stances be worth the attention of young medical
men. It is now for the most part essential that
the applicant should have gone through a special
course of study in tropical medicine. Provided that
a man be duly qualified and registered, and can pass
an examination of medical fitness, he may apply
for a Colonial post. The salary commences (as a
rule) at ^300, increasing by annual advances of
£10 to the sum of ^400 per annum. In some cases
there are special transit and other allowances,
while private practice is permitted so long as it does
not prevent the due performance of official duties.
Then there is, of course, the further important
condition of the ultimate eligibility for pension in
accordance with service rules. The suitability of
such appointments must always be more or less
determined by the temperament of the individual
applicant. The great advances in the scientific
knowledge of tropical diseases and the present high
standard of medical education have added vastly
to the attractions of Colonial medical posts in recent
years. Those who are likely to entertain the idea of
following such a career can obtain full details of
all appointments of the kind by applying to the
Medical Department of the Colonial Office.

A “New Remedy” for Consumption.

The Morning Advertiser of the 10th ult. an¬
nounced a new discovery by a “ scientist ” named
A. V. St. Armande, residing at Southend-on-Sea.
The remedial agent is a gas which, when inhaled,
has the power of suspending ordinary sensation,
without interfering with the senses of hearing and
speaking. He would be a bold man indeed who
would declare the impossibility of the existence of
a gas having those curious properties! At the
same time it seems more than likely that the news
of so remarkable a discovery would have wakened
the echoes of the medical world in London and else¬
where. Such a claim is capable of proof or of dis¬
proof, and is of such importance to the community
that it deserves to be put forthwith to an authorita¬
tive test. That remark applies with a thousand¬
fold increase of weight to the further claim of the
talented inventor that his gas cures consumption

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Dec. 4, 1907.

596 The Medical Press._ C URR ENT

(presumably of the lungs), as well as lupus. Were !
that the case it would become the bounden duty
of the State to secure this marvellous weapon
against tuberculosis. If Mr. St. Armande wishes to
have his gas tested upon consumptive patients, and
can furnish sufficient grounds for the faith that in
him lies, we fancy there will be little difficulty in
submitting the matter to accurate scientific exa¬
mination by expert investigators.

Tuberculosis and the Irish Government.

A deputation representative of the chief medical
organisations in Ireland and the leading societies
concerned in the suppression of tuberculosis, waited
on the Lord Lieutenant last week at Dublin Castle
for the purpose of urging on the attention of the
Irish Government certain points on which legisla¬
tion is sought. The deputation was introduced by
the Countess of Aberdeen, and among the members
who spoke were the Presidents of the Royal Col¬
leges, of the Irish Medical Association, and of the
Ulster Medical Society. Action was demanded from
the Government in four directions—the rendering
notification of tuberculosis compulsory, the adoption
of more stringent measures for the control of milk
and food supplies, the granting of power to the
county councils to erect and maintain sanatoria
and dispensaries, and the inauguration of a proper
system for the inspection of schools. No one who
knows anything of the condition of Ireland as re¬
gards sanitary matters can doubt that reform in all
these directions is urgently needed. In all of them
Ireland lags far behind the rest of the kingdom,
and, as a result, the mortality from tuberculosis is
much higher than elsewhere. As was to be ex¬
pected, the deputation received a sympathetic
hearing from the Lord Lieutenant, the Chief Secre¬
tary, and the Vice-President of the Department of
Agriculture. Mr. Birrell promised that the Govern¬
ment would do its best to give effect to the repre¬
sentations of the deputation as early as possible,
and perhaps it was impossible for him to be any more
definite. Mr. Russell, however, was able to make
a definite statement of much importance, though
only touching on one of the points raised. He said
that in the County Wexford, under the Department
of Agriculture, there was being carried out a system
of veterinary inspection, by which it was proposed
to apply the principle of the Medical Charities Act
to the diseases of animals. If the experiment
succeeded in Wexford, there was no reason why it
might not be applied in other counties. We trust
that no opportunity may be lost of forcing the
serious points raised on the attention of the Govern¬
ment.

Dirty Dublin.

In a speech the other day at the inauguration of
the Dublin Branch of the Women’s National Health
Society of Ireland, the Dean of St. Patrick’s very
properly referred to the dirty condition of the streets
of Dublin, and the evil influence of that condition
on the health of the citizens. Without the excuse
of thick smoke or heavy- fogs, Dublin is without
doubt one of the most dirty cities in the kingdom.
No feature of the city so strikes a stranger, or a
resident after a period of absence, on entering
Dublin, as the uncleansed condition of the streets.
In many of the Continental cities, and in London
and the great cities of England, men or boys are
constantly employed in keeping the streets clean.

TOPICS.

! Horse-droppings are immediately removed with
brush and shovel and no refuse is permitted to lie in
the street. In Dublin no attention is paid to
matters of the sort. Horse-droppings, scraps of
paper, garbage of all sorts, and mud of the streets,
are beaten together by wheels and feet till after
nightfall, when the streets may or may not be
swept, and the sweepings may or may not be carted
away. In dry weather the same sweeping-machine
is used, without any previous watering of the
streets, with the result that dust is blown in
eddies to the bedroom windows, carrying indescrib¬
able filth to the lungs of any sleepers who may leave
their windows open. It is as a result of the care¬
lessness shown by the sanitary authorities in such
matters as this, that Dublin retains its position as
one of the most unhealthy cities in Europe.

Florence Nightingale, O.M.

The raising of Florence Nightingale to the Order
of Merit has awakened as much pleasure as sur¬
prise in the country, for though she is old, indeed
nearly ninety, the memory of her heroism and
! goodness still shines brightly in every British home.
We venture to think that there is no other woman
whose appointment to the Order could have passed
without challenge, but every paper in the land has
nothing but praise and congratulation for Miss
Nightingale’s inclusion. To ourselves it is a par¬
ticular pleasure and privilege to add our tribute to
those already bestowed on the venerable lady, who,
already enshrined as a saint in America, in this
country is in actuality, if not by canonisation, the
patron saint of modern nursing. Florence Nightin¬
gale’s career is one of such peculiar beauty and
merit that it awakens good in all who contemplate
it. In all her struggles and official combats she
never forgot her womanliness, and her capacity as
an organiser was never allowed to obscure the fact
that she was a true, tender-hearted nurse. There
was nothing of the arm-chair sentimentalist about
her, but she was always a living and practical
power. When we consider how “honours” are
bestowed, we should have resented at most any of
the ordinary distinctions being conferred on Miss
Nightingale, but to have placed her in the Order
of Merit shows on the part of the Prime Minister
an appreciation of the fitness of things which is
wonderfully to his credit. That Miss Nightingale
may long be spared to wear her insignia, and that
her place among the immortals may help to keep
green the memory of her goodness, we most heartily
wish.

Spurious Sports.

It were well for those who love the lower animals
to divert their attention from experimental re¬
searches, which are conducted in the highest spirit
of altruistic science, to the horrors that are daily
committed u|>on the brute creation merely to satisfy
the lust of s-port. The sentimentalists who cut such
a sorry figure over the “ Little Brown Dog of
Battersea,” and the monumental record of a failure
to prove their statements when tested in a British
court of law, will find abundance of maimed
lower animal life in the shape of rabbits, deer,
pigeons, and so on, to perpetuate in bronze and
marble. Let them lay to heart the following reso¬
lution framed recently by the Royal Society for the
Prevention of Cruelty to Animals:—“That this

Digitized by GoOgle

Dec. 4, 1907

meeting,” it ran, “ representing branches of the
R.S.P.C.A., kindred organisations for preventing |
cruelty to animals, ethical and other societies, and
individuals of various schools of thought, desires |
to record its strong conviction that the time has ,
come when certain spurious sports, to wit, the 1
hunting of carted deer, the coursing of captured !
rabbits, and the shooting of birds from traps, should ,
be forbidden by law, as being not only wantonly ;
cruel to the animals thus hunted, coursed, or shot, I
•under wholly artificial conditions, but also de¬
moralising to those who practise or witness such
things ; and appeals to his Majesty’s Government to
grant facilities in the coming Session for a dis¬
cussion of the Spurious Sports Bill, which would
render these degrading pastimes illegal.” The Hon.
Stephen Coleridge, in supporting the resolution,
was careful to point out that it was absurd to say
they were not to put down one kind of cruelty until -
they had put down all kinds. But why does not
Mr. Coleridge, so to speak, begin at home, that
is to say, with cruelty committed for the sake of
sport, of personal decoration, and in mere wanton¬
ness of slaughter?

The People and the Hospitals.

The continuous readjustment of our social rela¬
tions is a necessary consequence of the laws that
govern the evolution of society. Where from any
cause the gradual changes attendant on such a
process are arrested, things are apt to right them¬
selves in the disastrous upheaval that is termed a
revolution. Fortunately, a crisis of that kind seems
foreign to the British genius and temperament, in
spite of the political agitation that has recently been
raised against Socialism and all its works. As a
matter of fact, there is a good or Christian
socialism, and a bad or nihilistic socialism, which
require to be carefully distinguished. But every
member of the poorer classes of the community,
whatever his political or his social creed, must
reckon with the enormous amount of money directly
and voluntarily given by the wealthier classes to
the medical charities. Incidentally a corresponding
amount of gratitude is due to the medical profes¬
sion, which provides gratuitous service to the
hospitals. The extent of the benefaction may be
estimated from the statement that in London alone
one out of every three or four of its inhabitants
resorts to those institutions in the course of each
year. In some socialistic quarters it is the fashion
to clamour for public supervision of these privately-
subscribed funds. On general grounds there is no
particular reason why a well-devised central control
of some kind should not be instituted. Indeed, to
a partial extent, the principle is being enforced by
the various Hospital Funds of the United Kingdom.

PERSONAL.

Miss Florence Nightingale has been gazetted to
the Order of Merit by the King. Miss Nightingale is
the first woman to receive the distinction.

Princess Christian, president of the Liverpool
School of Tropical Medicine, paid a private visit to
the school on November 27th, and was conducted over
each department by the various heads.

Dr. George Williamson has been elected President
of the Aberdeen Medico-Chirurgical Society.

The Medical Press. 597

Mr. Haffkine, C.I.E., has been offered and has
accepted an appointment under the Indian Govern¬
ment.

Dr. Edwin Bramwell, son of Dr. Byrom Bramwell,
has been elected Assistant Physician to the Edinburgh
Royal Infirmary.

Dr. G. W. Watson has been appointed Physician
to the Leeds Public Dispensary, in succession to Dr.
Wardrop Griffith, appointed Consulting Physician.

It is said that the Nobel Prize of ,£8,000 is to be
awarded to Professor Laverin in recognition of his
studies on Paludism.

Professor Wright, M.Sc., of Leeds, has had the
title of Emeritus Professor of Midwifery conferred on
him on his resignation of the active chair in that
subject.

Professor John Ferguson, M.A., LL.D., will pre¬
side at the Glasgow University annual dinner at the
Trocadero Restaurant, W T ., on Friday, December 6th,
at 7.30 p.m.

The Bradshaw Lecture of the Royal College of
Surgeons of England will be delivered by Rickman J.
Godlee, Esq., M.S., F.R.C.S., on Friday, Decem¬
ber 6th, at s o’clock.

Colonel G. D. Bourkf., C.B., R.A.M.C., has been
selected to succeed Surgeon-General I. D. Edge, C.B.,
R.A.M.C., as principil Medical Officer of the Irish
Command next May.

Dr. Abraham Ellenbogen has been presented by the
B. Division of the Liverpool police with an illuminated
address in recognition of his professional skill in
saving the life of a badly wounded constable.

A statement that was published to the effect that
the King would probably visit West Wales at Easter¬
tide to open the Alltymynydd Consumption Sana¬
torium is unfounded. Princess Christian will pro¬
bably perform the ceremony.

Mr. Jameson Evans, Surgeon -.0 the Birmingham
and Midland Eye Hospital, will deliver the Richaid
Middlemore Post-Graduate Lecture for 1907 at that
hospital on December 12th, at 4.30 p.m. The subject
is “ The Prophylactic Measures in Ophthalmology.”

Mr. John Murray, F.R.C.S., has been appointed
surgeon, and Mr. Gordon Taylor, M.A., B.Sc., M.B.,
M.S., F.R.C.S., has been appointed assistant surgeon
to Middlesex Hospital, vice Mr. Andrew Clark,
F.R.C.S., who has resigned on account of ill health.

Mr. Thomas Donovan, a member of the Cork Muni¬
cipal Corporation, has undertaken that if, during the
coming session of Parliament, a Bill is passed creating
the Queen's College, Cork, a University for the South
of Ireland, he will contribute towards its funds the
sum of £ 1,000.

The Arnott Memorial Medal has been awarded by
the Irish Medical Schools and Graduates Association
to Sir R. Havelock Charles, Physician-in-Ordinary to
the Prince of Wales, in recognition of the great
advances he made in the technique of the surgical
treatment of certain endemic diseases in India.

Mr. Chamberlain has received the following tele¬
gram :—“We, as president and chairman of the Liver¬
pool School of Tropical Medicine, desire, on behalf
of the school, to ask your acceptance of the Mary
Kingsley medal, founded by the school in memory of
the late Mary Kingsley for presentation to those who
have specially distinguished themselves in the nobit
cause of the amelioration of health conditions in the
tropics—a cause which you personally have so much
helped.—Princess Christian of Schleswig-Holstein,
President; Alfred Jones, Chairman.”

PERSONAL

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598 The Medical Press.

CLINICAL LECTURE.

Dec. 4, 1907.

A Clinical Lecture

ON

EXOPHTHALMIC GOITRE AND MYXCEDEMA. («)

By R. W. PHILIP, VLA* MJX, F.R.CP., FXJSX.,

Physician and Lecturer on Clinical Medicine, Royal Infirmary, Edinburgh.

Gentlemen, —I propose to-day to ask your attention
to two cases which have a certain etiological and
clinical relationship, and which present certain re¬
markable contrasts. The first is a case of exophthalmic
goitre, and the second is one of myxoedema. Both
cases are highly illustrative, not merely of the main
features of these diseases, but of certain aberrations
from the more typical clinical type. As you are aware.,
the prevailing view at present is to regard these two
diseases as expressions of two different aspects of
disturbance of the function of the thyroid gland.

Without going into minute details, :t is sufficient for
our present purpose to recall that the thyroid gland
seems to have, as one of its functions at least, the
elaboration and secretion into the blood-stream of a
certain substance necessary for healthy metabolism. I
shall not stay at this point to discuss with you the
nature of that substance, or its exact action in the
normal subject. Apparently the amount of the sub¬
stance elaborated and secreted is most carefully
regulated by some mechanism about which we can
only theorise. Certain it is that from time to time
disturbance in this finely adjusted arrangement takes
place. This may be in one of two directions. Either
an excess of the substance is allowed to pass into the
blood—whether from over-elaboration or extra secre¬
tion we need not discuss for the moment—or, on the
other hand, too little of the substance is supplied.
In the one instance we have the condition 'vhich may
be described in a word as hyperthyrea, and in the
other we have the condition which may be described
as athyrea (or hypothyrea). Returning to the two cases
before us, Urere is considerable reason for regarding
exophthalmic goitre as essentially a condition of hyper-
thyrea, and myxoedema as essentially a condition of
athyrea.

With this general introduction we may pass to a
short account of the history and leading symptoms of
the individual cases.

Case I.—Mrs. H., art. 47, a seamstress, was admitted
to Ward 33 on September 27th. Her chief complaint
was projection of the eyeballs, nervousness and general
weakness.

History .—About 10 years ago the patient suffered
from severe nervous shock. Owing to domestic dis¬
turbance, she was suddenly subjected to intense worry
and to quite unwonted strain in the way of work. For
two or three years, apparently, she worked the greater
part of day and night, four days a week. Two years
after the advent of the severe shock, it was noticed
that her right eye seemed to project unusually. About
a month later the patient noticed her throat to be
“swollen,” as she puts it, and she began to be troubled
with palpitation, at first on exertion, and then latterly
from very slight cause. She became so nervous that
when the bell rang she was unable to open the door.
On a number of occasions she had fainting turns,
either complete or parti'll. From time to time a feeling
of grave efread seized her which quite unnerved her.
Throughout this period the projection of the eyes
became more definite. This continued to be more
marked on, the right side, but the left came to project
almost to the same extent. There was a gradual
advance of symptoms during the eight years referred
to, with alternating periods of remission and subse¬
quent exacerbation of symptoms. About three months
ago—the date corresponding approximately with the
onset of the climacteric—she became rapidly worse.

I (a) Delivered In the Royal Infirmary, Edinburgh, Not. 8 th, 1907 . )

| The nervousness got extreme, and on one occasion she
fell down in the street, believing that she was dead.
Of previous illnesses, we may note that 10 years ago
she was operated on for an ovarian tumour, which
was removed. A year or so later she had an illness
of six weeks standing, which is described as rheumatic
fever. She has had other rheumatic manifestations.
She had pleurisy, with effusion, 10 months ago, and
apparently congestion of the lungs when she was a
child. In the family history there is little of import¬
ance. She has one son, alive and well. One child
was born prematurely at five months. There have
been no miscarriages.

In the above history I shall ask you to note that the
patient, who is now 47 years of age, was at the com¬
mencement of her illness rather beyond the age at
which exophthalmic goitre is most common—that is,
between the twentieth and thirtieth year. As you
remember, the disease is more frequent in women than
in men. You will note also the precedent rheumatic
history. The frequency of this has been emphasised
by Robinson and others, who have based thereon treat¬
ment by salicylates.

The present case affords a striking example of what
seems truly to be the commonest exciting cause of the
disease—namely, mental disturbance, worry and de¬
pressing influences.

Passing now to her present condition, the most re¬
markable feature is the exophthalmos. You have
doubtless seen examples of the condition before. You
probably never have seen it in more extreme degree.
It may be convenient to consider to what extent the
recognised features of the disease are present in the
given case, and to amplify the clinical picture by any¬
thing that may be special to the case.

1.—Exophthalmos.

In the present instance this is, as it is most com¬
monly, bi-lateral. It is extreme, and is more pro¬
nounced on the right side, which we have just seen
was the side first affected. The eyeballs are so pro¬
jected that one feels as if, on excitement or effort,
they might be completely dislocated. There is the
characteristic staring aspect, produced, as you know,
through the presence of the white ring of sclerotic
round the pupil. The upper eyelid is conspicuously
retracted, so that the palpebral aperture is much
greater than usual (Stellwag’s sign). As the patient
casts her eye downwards, there is a hesitancy in the
downward movement of the upper lid, so that the
sclerotic above the pupil is further exposed (Von
Graefe’s sign). In this particular case, the retraction
of the upper eyelid and the projection of the eyeball
is so great that the cornea has become inflamed. There
has been recurrent keratitis and ulceration of the
cornea. Closure of the lids at night is not quite com¬
plete, so that special measures have had to be taken to
protect the eyeball. There is interference with the
natural convergence of the eyeballs (Moebius’ sign).
Accommodation is undisturbed, and there is no inter¬
ference with sight. The pupils and the optic nerve
seem natural.

2.—Thyboid Enlargement.

This is not very conspicuous. There is, however,
some general enlargement of the organ. The right
lobe is rather more affected. The swelling is soft and
elastic to the touch. There is no marked thrill, and
only a slight systolic bruit on auscultation. The
patient reports that the enlargement of the gland was
considerably more at one time.

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CLINICAL LECTURE.

The Medical Press. 599

Dec. 4 , 1907.

3.— Circulatory Disturbance.

This is marked. Palpitation, dyspnoea, and tendency
to faint have been conspicuous, more especially on
exertion or excitement. There has also been some
swelling of the feet. The pulse rate on admission was
128, and has varied from that to 92 yesterday. The
pulse is of medium size. At first the systolic pressure
was conspicuously high, reaching as much as 210 mm.
Hg. (Riva-Rocci’s sphygmomanometer). There is more
or less arterial throbbing. The heart’s action is quick,
forcible and rather diffuse. Auscultation reveals the
presence of a systolic murmur, heaid especially in the
mitral area and propagated towards the axilla.

4.—Neuro-Muscular Phenomena.

The patient is very nervous and excitable. On this
account I have kept her quietly in a side ward. Fine
muscular tremors are observable in the hands and
fore-arms. As compared with many such sufferers, the
patient is not thin. Indeed, her general condition
externally would attract little remark. She is not con¬
spicuously pallid, nor is there much evidence of pig¬
mentation. Flushing of the skin occurs readily, and
generally the skin feels rather moist. The appetite is
good, and digestion is natural. Patient’s intelligence
is quick, and the other cerebral functions appear
normal.

Before we pass to Case II., I should like to read to
you the earliest description of exophthalmic goitre
which occurs in literature—I mean that by Dr. Caleb
Hillier Parry, of Bath. It occurs in his posthumous
works, published in 1825. The observations were made
much earlier. He draws attention to the coincidence
of enlargement of the thyroid gland with enlargement
and palpitation of the heart, and proceeds to give
illustrative cases as follows:—

“The first case of this coincidence which I witnessed
was that of Grace B., a married woman, aet. 37, in
the month of August, 1786. Six years before this
period she caught cold in lying-in, and for a month
suffered under a very acute rheumatic fever, subse¬
quently to which she became subject to more or less
of palpitation of the heart, very much augmented by
bodily exercise, and gradually increasing in force and
frequency till my attendance, when it was so vehement
that each systole of the heart shook the whole thorax.
Her pulse was 156 in a minute, very full and hard,
alike in both wrists, irregular as to strength, and
intermitting at least once in six beats. She had no
cough, tendency to faintness, or blueness of the skin,
but had twice or thrice been seized in the night with
a sense of constriction and difficulty of breathing,
which was attended with a spitting of a small quan¬
tity of blood. She described herself also as having
frequent and violent stitches of pain about the lower
part of the sternum.

“About three months after lying-in, while she was
suckling her child, a lump of about the size of a
walnut was perceived on the right side of her neck.
This continued to enlarge till the period of my attend¬
ance, when it occupied both sides of her neck, so as
to have reached an enormous size, projecting forwards
before the margin of the lower jaw. The part swollen
was the thyroid gland. The carotid arteries on each
side were greatly distended ; the eyes were protruded
from their sockets, and the countenance exhibited an
appearance of agitation and distress, especially on
any muscular exertion, which I have rarely seen
equalled. She suffered no pain in her head, but was
frequently affected with giddiness.”

Could you wish, gentlemen, for any more vivid
description? And, mark you, the record is of a case
seen fifty years before Graves or Basedow wrote of the
disease. It is curious to find that both these names
have become associated closely with it, while if any
name deserves to be kept in memory in relation to
exophthalmic goitre, most certainly it is that of Caleb
Hillier Parry.

Case II.—Mrs. M., ast. 40, keeps her own house,
was admitted to Ward 33 on October 16th. Her chief
complaint was general swelling, which had been in¬
creasing for some years.

History .—Six years ago, shortly after the birth of
her last child, the patient noticed that she was getting
stouter. Her clothes felt tight and small, and her

friends remarked that she was getting bigger-looking.
The swelling gradually increased, affecting the whole
body—face, arms and legs, as well as the trunk. She
was not only fatter, but there was a feeling of stiffness
in the skin. She noticed about the same time that hei
hair was becoming dry and brittle, and fell out. She
experienced advancing weakness and disinclination for
physical and mental effort, shortness of breath and
headache. Her memory, which previously had been
excellent, tended to fail. She found that she forgot
things easily which previously she could not have
failed to remember. From time to time she found
herself stopping in conversation because she seemed
to have forgotten what she wished to say. There is
little in the previous history of importance. For the
last 20 years she has had no serious illness. The
family history is similarly satisfactory. There is no
history of tuberculosis. There has b«n some slight
rheumatic tendency. She has had nine children, all
of whom are alive and well. There have been two
miscarriages, respectively four and two years ago. She
has always been in comfortable circumstances. Per¬
haps the most noteworthy point in the history concerns
her reproductive activity. She is only 40 years of age,
and has had ti pregnancies. Frequency of pregnancy
has been cited as a determining influence by some
observers.

As to her present condition, certain of the features are
less striking than they were ten days ago, for the reason
that the patient has been undergoing special treatment,
to which I shall refer presently. The appearances
are, however, characteristic. The face is conspicuously
broad and expressionless, and the neck and shoulders
much thickened. Similarly the hands are swollen
and broadened. The fingers have lost their expression,
and have become uniformly thick. The whole hand
has what has been described as a “ spade-like ” aspect.
These remarks apply also generally to the feet. The
cutaneous tissues have a firm resistant character.
There is no pitting on pressure. The skin of the face
is pallid and rather yellow, with a bright red spot in
the malar region. The lips, which are rosy, have a
distinctly livid tinge. The skin is markedly dry and
harsh. Perspiration is wanting. The hair is dry and
brittle, and has a coarse aspect, and, as you have
heard, has been falling out. The nails show nothing
unusual. The teeth have almost all gone through
caries. The thyroid gland is small and hardly deter¬
minable. The appetite is poor. The tongue is re¬
markably large.

The expression of the patient is dull and heavy ; a
fortnight ago it was very much more so. The patient
has the strange consciousness of being stiff. Mental
activity similarly is languid. Memory is certainly
defective. The speech is not conspicuously disturbed.
The urine contained .218 gr. albumin per ounce on
admission, but this has disappeared. The mean pulse
rate during three weeks has been 84. The temperature
has ranged from 96.3° to 98°. The patient feels cold
readily.

If we rehearse, then, the leading points in relation
to these cases, the remarkable contrast strikes us at
once. In Case No. I., there is the highly nervous, sen¬
sitive, almost irritable aspect, with the staring gaze
from the widely separated lids and protruding eye¬
balls. In the other case there is the ultra-placid, even
dull and lethargic aspect, with the heavy
look about the eyes, which are seemingly deep-
set behind heavy, thickened eyelids. In No. 1,
the whole neuro-muscular system seems in a
state of flux and vibration, while in the other case
the tissues seem fixed as in a gelatine cast, which
renders impossible all finer vibratory movement. And
what applies to the external aspects of the patients
applies similarly to so-called intellectual motions.
There is no need to elaborate this point further. It
is evident from all we have seen. Then in Case No. I.,
there is enlargement of the thyroid gland, less, it is
true, than often in such cases, but still definite. In
the other case the thyroid gland is hardly, if at all,
determinable. Lastly, in the first case the circulation
is rapid, full and excitable, the skin surfaces are warm
and moist, while in the other case the circulation is
sluggish, superficial surfaces are cold, dry* harsh, and
the cutaneous appendages in a state of low vitality.

D

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6oo The Medical Press.

CLINICAL LECTURE.

Dec. 4, 1907.

So much for points of contrast. The common
meeting-ground for the two cases is the thyroid gland.
In both cases there is evident disturbance in size,
though in opposite directions, and we have abundant
reason to say disturbance in function also. In the
first case the gland is much enlarged, and as histo¬
logical examination shows, is in a state of active proli¬
feration, with corresponding increase of functional
activity. In the other case, the gland is in a state of
partial, or maybe complete, atrophy, with corre¬
sponding reduction in functional value. This common
meeting-ground, with the two opposing aspects of
excessive activity (hyperthyrea) and reduced activity
(athyrea), affords the basis for the now generally
accepted line of treatment in the two cases.

In myxoedema (athyrea), of which Case No. II. is a
good illustration, ihe therapeutic indication is to en¬
deavour to compensate for the insufficient activity of
the thyroid gland by the introduction of thyroid
extract, obtained artificially from another animal. The
procedure first proposed by Horsley and Murray is
now so generally accepted that I need not dwell on
the matter in detail. Liquid and solid extracts are
obtained from the thyroid of the sheep, and are ad¬
ministered subcutaneously or by the mouth. In ordi¬
nary cases we make use of thyroid feeding, and com¬
mence with 1 to 5 gr. of the solid thyroid extract,
three times a day. In the present instance the patient,
after a fortnight’s observation, received 5 gr. of the
extract thrice daily. She has had this for nine days,
with the remarkable result that already her aspect is
much more natural, her expression more lively, her
mental activities keener, and she has dropped 7£ lbs. (a)
—that is, almost 1 lb. per diem. In addition to this,
the albumin has quite disappeared from the urine, and
the hair has assumed a more natural appearance.

On the other hand, in exophthalmic goitre, of which
Case No. I. is so striking an example, many lines of
procedure have been suggested. Restricting our¬
selves, however, to-day to its dependence on thyroidal
disturbance, the question arises how we are best to
meet this? In the foreground we may exclude the use
of thyroid extract which has been actually proposed.

I say we may exclude the use of thyroid extract as
likely rather to intensify than to improve the
symptoms. By a curious paradox, however, benefit
appears to have followed its use in some cases. In
this connection I may remind you that sometimes
myxoedema follows on exophthalmic goitre. It is con¬
ceivable that for such transitional cases thyroid
extract should prove serviceable. Still, exophthalmic
goitre recalls so definitely in various ways the effects
produced by over-dosage with thyroid extract that it
seems undesirable to proceed in most cases to treat
exophthalmic goitre in this fashion.

The assumption has been made, however, that, in
the condition of myxoedema which is so remarkably
benefited by the exhibition of thyroid extract, there
must be present in the circulation some product which
is opposed to and neutralised by thyroid extract. If,
then, myxoedema be artificially induced in an animal,
say the goat—that is to sav, if the thyroid gland be
removed and the condition known as cachexia
strumipriva be established, there is produced within
the circulating blood a certain quantity of this prin¬
ciple, antagonistic in action to the thyroid secretion.
If. then, the serum of such an animal be removed and
administered to the patient suffering from hyper¬
thyrea—excess of thyroidal secretion—the assumption
is that the latter is antagonised, and once more a state
of equilibrium restored. Such a serum has been pre¬
pared under the direction of Moebius, to whom I have
already referred, and is known as “antithyroid
serum ” (Moebius). It is exhibited in doses of from
10 to 60 minims, and is conveniently given in milk, or
it may be in wine.

This treatment was commenced eight days ago in
Case No. I., after the patient had been treated for
five or six weeks on the older lines of rest and cardiac
and other tonics. We began with 10 minims of the
antithyroid serum twice daily, and the dose is being
gradually increased. In the interval a certain im¬
provement has been noticed, both by us and the patient

(a) Three weeks later she had dropped aa much aa 21 ] I be.

herself. It remains to be seen to what extent tbe
effects are traceable to the treatment, and whether they
are progressive. Perhaps on some future occasion I
may have the opportunity of referring to this point.
It seems to me that much may be said for the plan,
both from the theoretical point of view and prac¬
tically from results I have obtained by the method
in more than one case already. The results, both in
my own hands and in those of other observers, have,
however, not been constant. We must admit that the
method is still on trial.

The two cases I have presented to you to-day afford,
then, a particularly interesting study, not merely in
relation to their clinical features and pathological
relationships, but also in respect of their scientific
treatment. I would have you note, however, that in
thus considering the two diseases in relation to the
thyroid gland, we are still far from an exhaustive con¬
ception, either of their pathology or their treatment.

Admitting that a certain number of symptoms occur
together with sufficient regularity to justify their being
grouped as a distinct disease, which we call, on the
one hand, exophthalmic goitre, and on the other
myxcedema, we are still at sea regarding the ultimate
cause of the mechanism of production. The history
of many cases of exophthalmic goitre points to the
nervous system as the primary seat of disturbance.
The disease would thus seem to be traumatic in origin,
using that term in a wide sense. The subsequent steps
in causation still require elucidation. Even the order
of clinical events is different in different cases.
Murray’s statistics indicate that, in the majority of
instances, the first morbid appearance is to be found
in the thyroid gland, which becomes enlarged. LateT,
it may be years after, the circulatory excitement
appears, and then still later the exophthalmos, and
the more general neuro-muscular disturbance. I need
hardly remind you that even if this order of events be
accepted as the more frequent one, the traumatic origin
of the disease—that is, the relation of the disease to
nerve-shock—is in no wise prejudiced.

There are probably other channels through which
the disturbance of the thyroid gland is produced and
maintained, as in the case of other organs. While the
more evident clinical manifestation is more or less
uniform, there may be considerable diversity of causa¬
tion. Such diversity of causation may, after all,
explain the seeming paradoxes to which I have referred
in relation to treatment. And what applies to our
conception of exophthalmic goitre applies, mutatis
mutandis, to that of myxoedema.

The treatment which has been proposed for both
diseases, so far as we have discussed it to-day, is not,
in the true sense, an ultimate one. It is rather a matter
of compensation than of cure. Remove the myxoede-
matous patient from his daily dose of thyroid extract
and he steps back quickly into the old state. The
process of compensation must be maintained,
apparently, in some degree, for the rest of his life.
And so, perhaps, in respect of the treatment which we
have discussed for exophthalmic goitre.

In a certain way the treatment presents analogy
with the treatment of diabetes. We antagonise, we
neutralise, we minimise certain morbid manifestations,
but in the majority of cases we fail to cure. We want
to get still farther behind the scenes, and, if possible,
correct the faulty mechanism (disturbed innervation?i
on which the defect in the secretory function depends.

It remains for me to make reference to an evident
application of treatment which Case No. I. illustrates.
Here the protrusion of the eyeball, as we have seen, is
so extreme that injury is apt to accrue, not only by
day, but also by night, when the eyelids fail to close
completely. In the present instance, inflammation and
ulceration of the cornea has ensued. To obviate this,
it is desirable to arrange a splint of plaster, especially
for night use, which passes from the upper edge of
the upper eyelid down to the upper level of the malar
region. Thereby the eyelids are kept closed.

It has been suggested that in such pronounced cases
the proper course to follow is to practise partial
enucleation of the thyroid gland. Unfortunately, two
difficulties confront us in this connection. In the first
place the operation is a serious one. Statistics are less
favourable than the patient might desire. Thus Mayo's

Dec. 4, 1907.

ORIGINAL PAPERS.

The Medical Press. 601

statistics show that, of 40 patients operated on, 6—
that is, 15 per cent.—died as a direct result of the
surgical operation, 25 per cent, were partially im¬
proved, and 50 per cent, were so much improved that
a cure might be spoken of. In the second place, in
the patient before us, the thyroid gland is now com¬
paratively little enlarged, and has been getting
smaller, while there has been no simultaneous improve¬
ment in relation to the exophthalmos. So definite has
been the diminution in size of the thyroid, that, taken
along with one or two other manifestations in the
patient’s aspect, etc., the query has passed through
my mind whether we may not see realised in this par¬
ticular case the transition from a case of exophthalmic
goitre zo one of myxcedema.

Note .—A Clinical Lecture by a well-known teacher
appears »» each number of thie journal. The lecture for
next week will be by Madeod Yeareley, FB.C.S.,
Senior Surgeon to the Boyal Ear Hospital. Subject:
“ Otosderotie."

ORIGINAL PAPERS.

HIGH FREQUENCY EFFLUVATION
AND SPARKING IN THE TREAT¬
MENT OF MALIGNANT TUMOURS. («)

By Dr. J. A. RIVIERE,

Paris.

[Specially Reported for this Jovrnwl.I

At the present time, when many eminent surgeons
acknowledge the efficacy of physico-therapeutics, I
wish again to bring forward the propositions I was the
first to assert in 1900 and 1903.

Certainly, in spite of the wavering condition of
actual therapeutics, in spite of the fatalism existing in
the theories on the obligatory increase of malignant
tumours, I deem that the cures (pretty numerous), and
the numberless very grave cases in which improvement
has been obtained by the aid of physico-therapeutics,
should make us regard as culpable negligence the fact
that no recourse has been had to these agents which
pre-eminently have a local and general modifying
effect, all the more so because, when in the hands of
experienced medical men, they present no danger and
give rise to no inconvenience.

On those lines I wish to bring before this Congress
a useful contribution by summing up my observations
of more than ten years, and to demonstrate plainly at
this meeting the results of my clinical experience.

Amongst the physico-therapeutic agents whose action
is the most remarkable, I must, above all, point to
high frequency and high tension effluves and sparks.
The regulation of their activity is pretty easy, accord¬
ing to the case. I preferably employ the long currents
and the bipolar spaiks when it is necessary to act on
tumours deeply situated, reserving for epitheliomata
the monopolar applications. At the International Con¬
gress of Medical Electricity and Radiology (Paris,
July, 1900), I gave an account of my first successes by
this method. I mentioned them again in 1903 in a
communication to the Academy of Medicine, the im¬
portance of which was supported by numerous obser¬
vations and by the presentation of several patients.

In these communications, where for the first time
in radiology the diagnosis was sustained by a histo¬
logical examination, I was the first to assert that
which has since been confirmed—namely, that the high
frequency effluves and sparks cure both superficial and
deep malignant tumours; that they destroy the neo¬
plastic masses, whilst they respect the healthy tissues ;
that their action on lymphoid tumours is most
marked; that they should, in conjunction with the
Rdntgen rays, when employed after operations, serve
to prevent recurrence of malignant tumours; that
physico-therapy is the one and only resource in cases
of inoperable tumours; that the strength of the

(e) Read before the French Medical Congrem, Parir, Oct. 14-16,

Rontgen rays can be very great without producing im¬
pairment of the tissues; that occasionally the actino-
dermatitis seems to hasten and to favour the cure; that
it is indispensable to push the treatment as far as
elimination of the necrosed parts, then to come back
to the general circulation; that the neoplastic cell does
not derive any benefit from the synergic forces of the
healthy cells under the influence of the nervous
system ; that it is always necessary to pay great atten¬
tion to the patient’s general condition, as well as to
the treatment of the local lesion ; that in the presence
of a disease as tenacious and grave as cancer, the
medical man should know how to accommodate the
power of the treatment to the resistance of the disease,
and so bring judiciously into play all the ie 30 urces of
the physico-therapeutic armamentarium.

Since that period, without abandoning the use of
the Rflntgen rays, but faithful to my first convictions,
I have, within the knowledge of my colleagues, given
the first place in treatment to lhe high-frequency
effluves and sparks as being more reliable and more
conclusive. However, according to my usual method
(which since 1901 I have many times explained to
learned societies and also in the Annals of i’hysico-
therapy), I regard as legitimate (and, going still
farther, as indispensable) the therapeutical alternation
and superposition of the various physico-therapeutic
agents in order to obtain a cure. The medical man,
dealing with pharmacology, does he not vary, and at
the same time bring together, his authoritative or
galenic formulae? The surgeon, always anxious to
carry out antiseptic methods, does he not know how
to successfully combine the different resources of
materia medica so as to multiply the curative action
with a minimum of possible inconvenience? In the
same way the physico-therapeutic expert should know,
when he realises that the action of one of his remedies
is exhausted, how to have recourse to another in order
to perfect a complete cure. (Here we have a point of
observation the explanation of which can be found
even in the warfare between the cells.) This cure, thus
considered, terminates, even in the most hopeless cases,
in a lessening of the pain, in resolution of the tumour,
in improvement of the dyscrasic condition, in re¬
establishment of the nutritive equilibrium. I have not
thought it necessary to employ chloroform and the
curette, as later on my confrere, Dr. Keating Hart,
has done. The apparatus I have used, all differing
in their mode of production and in their intensity,
are the best and the most powerful made up to the
present date, and I have always maintained that the
patient can bear without pain the longest effluves and
sparking on condition that these last are not too strong.
Those high-frequency sparks and effluves, the different
productive arrangement of which allow of variations
in their application, are the ones which exercise an
elective action on the neoplastic cell.

Between the spark and the effluve there only exists
a question in degree of concentration in the strength
of the high-frequency. The effluve is a spark divided
into more or less fine rain-like spray ; it is emitted from
an electrode bristling with points, whilst on the other
hand the spark is given off from one point only. The
effluves and the sparks, thanks to the perfected
apparatus I have made use of, can be short or long,
scarce or in large numbers, fine or dense; for this it
is merely necessary to alter the working of the appara¬
tus. An even better plan is to have at one's disposal,
as I myself have, several apparatus of different con¬
struction. There are various shades of dissimilarity
between different sparks and effluves, according to
whether they are short, fine, long or dense. The short,
warm sparks of great strength are the ones that exercise
the thermo-electro-chemical action of which I spoke
in 1900. They destroy the neoplastic masses, and their
action proceeds from the periphery to the centre.
These sparks, which are derived especially from the
small solenoid or even from the primary part of the
resonator, cause pain. The long sparks and effluves
act by percussion, and their effect is deep. Their
action from a certain distance is necessary for the dis¬
organisation of the deep neoplastic cells. The short
sparks that are taken up by the small solenoid act
specially by their amperage. The long effluves or the
sparks taken up by the secondary part of the lesonator

aitized by Google

602 The Medical Press.

ORIGINAL PAPERS.

Dec. 4, *907.

act, above all, by their voltage, which can attain
300,000 volts, or 600 watts. The strength of the trans-
formators, the capacity of the condensators, the rela¬
tions of the diderent capacities when brought face to
face, the length and the diameter of the conduction
wires, are so many factors which intervene to modify
the condition of the sparks and of the effluves.

As I have always pointed out, the origin of cancers
is comprised in a direct insufficiency of the nervous
system at a determinate point of the economy. At this
point soon appear unexpected disorganised cells,
wretched waifs that offer a power of resistance abso¬
lutely incapable of withstanding the electrical effluves.
These last without delay eliminate the neoplasm and
at the same time re-establish the nervous influx and
the physiological action of the neurons. I may here
remark that the elimination is very much more rapid
when the cells are denuded, so that the dynamic pene¬
tration can operate directly on the very elements of
the tumour. The cancer cell is a young cell (even
embryonic), containing within itself an inexhausted
reserve of the power of evolution. In my thesis (Paris,
1884) I spoke of the force accumulated and condensed
in the generative cell, and of the evolutionary force
associated with the material (for me the state of con¬
densation of power). Hallion has cleverly put forward
the very likely hypothesis that with regard to cancer
we have to deal with a cell rejuvenated by abnormal
fecundation, and not with a cell that has remained
young and that has taken on again (by reason of any
application of vis a tergo) an evolution which for a
long period had been interrupted. This is the karyo-
gamic theory, a rational hypothesis of renovation by
conjugation or copulation of fertilising nuclei. This
theory explains the injudicious and ill-timed effort
taken on by a species of cell held in “subjection ” to
try to regenerate itself in the same manner as a species
of cell which is autonomous or “ free.” For this reason
the neoplastic cell is much weakened in its resistance.
It conducts itself as a veritable pathological sperm, a
promoter of tumours, inasmuch as this aptitude of
conjugation, this karyokinetic particularity, are patho¬
gnomonic of malignant tumours. Unconfined and
absolutely freed as to its direction, thrown out, as it
were, the cell becomes the founder of a liberated tribe
which renounces, so to speak, all social compact and
ignores its previous obligations with regard to the
organism. Therefore, as the nervous system no longer
directs it, naturally it has a tendency to exhaustion
and atrophy (such is the ephemeral existence of pro¬
tista). All this I have said before, more than twenty
years ago, in my works on nevrarchy and nervism.

The ingenious karyogamic theory (supported by
Maupas, Fabre-Domergue, and Hallion) explains to us
the rarity of cancer at very advanced age, and the
pretty frequent etiological r 61 e flayed by traumatism,
and especially by frequent irritation, in the ordinary
proliferation of malignant tumours. By disturbing
elementary nutrition we always realise these conditions
of imperfect alimentation which, according to Maupas,
favour cellular conjugation in the infusoria. I will
add that uric acid should also be taken into considera¬
tion as a cause of permanent irritation in anatomical
elements. It is for th's reason that arthritic subjects
furnish every day so important a tribute to carcinosis,
tt is also for this reason that this terrible diathesis
presents a development parallel to the curve of the
consumption of meat and of fermented or distilled
drinks (vegetarians and abstemious people in a large
proportion escape the visitation of cancer). High-
frequency currents, by preventing the precipitation of
urates, by favouring elimination and complete com¬
bustion of nitrogenous matter, cut off, as it were, the
supplies to the cancerous process, thus preventing the
organic cells from taking on karyogamic proliferation,
the great abettor of neoplasms and of the most serious
neo-organisms.

Conclusions.

(1) It has always seemed to me that high-frequency
currents, in the form of effluves or of mono- or bi¬
polar sparks, enjoy the property of having the most trust¬
worthy, the most continuous, and the most penetrating,
modifying action on neoplasms. This observation is
the result of experiments and researches lasting over
ten years, and my rights of priority in this respect go

back to my communication to the Congress of Medical
Electrolysis and Radiology (Paris, July 27th, itjoo),
and to my communication to the Academy of Medicine
in 1903.

(а) Nevertheless, one must not be exclusive, and it
is our duty to judiciously utilise against neoplasms all
the practical agents contained in the physico-thera-
peutic armamentarium. Rontgen rays, actinism,
sparks and currents of static electricity, radium (a),
ultra-violet rays, ionisation, electrolysis, etc., etc., all
furnish valuable and often indispensable help in
hastening the cure either by destroying the neoplastic
masses, or by strengthening the neurons, or by
impelling the neoplastic particles destroyed and carried
away by the stream of the circulation to take on the
necessary elimination, or finally by bringing back the
vital processes to the normal.

(3) The power of the big bi-polar effluves or of the
high-frequency sparks is especially more penetrating
and more efficacious in the treatment of deep tumours.
It is this power that foils with the greatest vigour the
whole histogenesis of malignant tumours, and this
without the slightest possible suspicion of inflamma¬
tory reaction, inasmuch as violet irradiation contains
no calorific ray.

(4) It is the karyogamic theory of Hallion (dis¬
ordered liberation of the cells and fecundation of the
embryogenic elements) that best explains the reason
my treatment invariably respects the vitality of healthy
tissues, and at the same time possesses a kind of
elective affinity for the constitutive elements of the
neoplasm.

(5) Malignant tumours from their commencement,
recurrent tumours and those considered inoperable,
are amenable to physico-therapy.

(б) As in 1900 and 1903, I still persist in asserting
that large tumours should be removed liy the bistoury
and treated afterwards by my method to prevent re¬
currence, and to cure a recurrence should it take place.

(7) F.ffluvation and the projection of high-frequency
sparks should follow all surgical operations on
malignant tumours.

(8) With the object of preventing recurrence after
cicatrisation, a few currents applied periodically, then
after intervals whose lengths should be decided by a
medical man, seem to me of paramount necessity.

(9) Physico-therapv, which is the rational method
to employ against malignant tumours, constitutes also
for them a line of preventive therapeutics.

GASTROJEJUNOSTOMY AND
REGURGITANT VOMITING, (b)

By K. W. MONSARRAT, M.B., F.R.C.S.E.,

Surgeon to the Northern Hospital, Liverpool; Lecturer 00 Clinic*
Surgery, University of Liverpool.

It is well known that in a certain number of
cases of anterior gastrojejunostomy, and in a lesser
number of cases of the posterior operation, the result
has proved disappointing owing to the regurgitation
of the contents of the duodenum into the stomach.
If this co-called vicious circle is established, persis¬
tent and exhausting vomiting occurs, and in some
instances this has proved the direct cause of death.

It has been experimentally shown that the mere
entrance of bile and pancreatic fluid into the

(a) With reference to Radium, it is with much pleasure that
I recall a conversation I had wirh my distinguished colleague.
A. Darier, on the oocasion of his visiting me in August, 1903. to
express his astonishment on finding, when he returned from bis
holidays, that a patient, who had suffered from generalised lympho¬
sarcoma, whom he had confided to my care in e i t re m it three
weeks before, and who had been irremediably condemned by him
and by several other medical men, was absolutely cured. I then
told him, word for word, that he had before his eyes the resuh
of a oombined action of Rontgen rays and high frequency effluves
and sparks, that in 1900 I had spoken of the action of the actinic
rays, and that, in my opinion. Radium together with actinic and
Rontgen rays must nave an absolutely certain and positive action
on cancer. We went out together to buy some Radium. A
little while afterwards, in a very important paper he read to
the Academy of Medicine (reported by M. Cornil), be related
the case of this patient I had cured by extensive high frequency
effluves and sparks and the Rontgen rays, and be seised upon
this occasion to speak of the action of Radium on Cancer.

(&) Paper read before the Liverpool Medical Institution.

ized by G00gle

Dec. 4, 1907.

ORIGINAL PAPERS.

The Medical Press 603

stomach Is not capable, in itself, of inducing this
complication. It may conceivably arise from one of
four mechanical defects left by the operation.

In the first place, the duodenum may empty itself
backwards through the pylorus owing to a
mechanical obstruction at the point of anastomosis ;
this is probably the state of affairs in the majority
of the cases. Secondly, the duodenal contents may,
instead of passing on from afferent loop to afferent
loop, empty themselves back into the stomach
through the artificial opening. Such an event can
only happen, as in the first class, if there is some
obstruction preventing the free passage from
afferent to efferent loop. Thirdly, the parts may be
left in such a situation that the stomach empties
itself in the direction of the afferent loop instead
of forwards into the efferent branch. Fourthly,
an obstruction of the efferent branch may arise,
causing it to empty itself backwards into the
stomach.

These four types are illustrated in the accompany¬
ing diagrams.

It is true that fatal cases have been described by
surgeons in which the post-mortem examination
showed none of these defects in the mechanical
arrangements left by the operation. Still, no other
explanations of sucn cases have been offered, and
it is possible that a post-mortem examination might
not clearly reveal a sagging afferent loop and an
acute bend at the anastomosis which had been pre¬
sent during life to a degree sufficient to cause the
complication.

Assuming that in all cases of regurgitant vomit¬
ing the explanation is to be found in one or other
of these mechanical defects, the method of perform¬
ing the anastomisis must be so devised that the
possibility of their occurrence is avoided.

The characteristics of a satisfactory anastomosis
are—

(a) An opening large enough to anticipate a
certain amount of contraction. The in¬
cisions in the stomach and jejunal walls
should be not less than two inches in length,
and an ellipse of .mucous membrane should

be removed according to Moynihan’s re¬
commendation.

( b) A situation at the most dependent point near

to the greater curvature of the stomach. .

(c) A free and unobstructed passage from afferent

to efferent loop, and from stomach to
efferent loop.

For the avoidance of regurgitant vomiting the
third characteristic is all-important, and a whole
series of operations have been devised to provide it.
(a) Kocher’s valvular gastroenterostomy is par¬
ticularly designed to ensure a passage of stomach
contents into the efferent loop, and to prevent their
passage into the afferent loop. ( b ) The Y-anasto-
mosis of Roux has as its object the certain
prevention of the passage of duodenal contents into
the stomach through the anastomotic opening.
(c) The combination of entero-anastomosis with
gastrojejunostomy aims at anticipating any ob¬
struction to the passage of the contents of the
afferent loop onwards into the efferent loop.

Kocher’s method alone without other precautions

does not deal with the most common cause of re¬
gurgitation, viz., obstruction of the afferent loop
at the point of anastomosis. The two other methods
mentioned have the disadvantage that they are
double anastomoses, and therefore add somewha*
to the risk and to the length of the operation.

Petersen was the first to draw attention to a point
in the performance of posterior gastroenterostomy
which promised to prevent obstruction of the
afferent loop at the anastomosis, and therefore to
avoid the commonest cause of regurgitant vomiting.
He pointed out that the posterior surface of the
stomach near the greater curvature and the jejunum
near its commencement are, under circumstances
of moderate gastric distension, in close relationship

with one another, and that these points of normal
apposition should be chosen for the anastomosis.
The importance of this suggestion has been appre¬
ciated by other surgeons. Several advantages
follow the establishment of the anastomosis at the
point indicated.

Digitized by boogie

604 The Medical Press.

ORIGINAL PAPERS.

Dec. 4. » 9 ° 7 -

In the first place, when ithe operation is complete
there can be no sagging afferent loop to cause a
kink at the junction, as, when the parts are re¬
turned to the abdomen, the jejunum simply descends
from duodeno-jejunal flexure to anastomosis in
what is practically a straight line. Secondly, there
will be no tendency for stomach contents to oollect
in the afferent branch; they would have to ascend
against gravity to do so.

The results of operation planned on these lines
have fulfilled anticipations : It wou'd not be true
to speak of regurgitant vomiting as a thing of the
past, but now that the anterior operation has been
almost abandoned and the posterior operation is
carried out in the manner described, it is rarely
heard of. During the past year I have paid par¬
ticular attention to the points in technique which I
have mentioned, and though the number of cases
in which I have thought gastrojejunostomy indi¬
cated is small, I think them worth recording owing
to the entirely uneventful course which they have
all followed.

Case 2 is of special interest from the point of
view of the diagnosis of malignant disease.

1. James R., set. 29, complaining of epigastric
pain and frequent vomiting for about two years,
during the greater part of which he had been under
medical treatment. He was in a medical ward for
a short time before he was transferred, his chief
symptom being vomiting of very large quantities of
sour-smelling grumous fluid containing lactic and
butyric acids and sarcinae. He was treated by
gastric lavage with temporary relief. On exa¬
mination, the stomach was found dilated so that its
lower border reached midway between the umbilicus
and pubis; no epigastric tumour was to be felt.
Gastroenterostomy was performed on October 4th.
There was mechanical obstruction at the pylorus in
the form of a thickened indurated area narrowing
the channel, evidently a stenosis due to ulcer. He
vomited once immediately after the anaesthesia,
but not again, and was discharged well on Octo¬
ber 30th. He was seen on October nth, 1906, a
year after the operation. He had put on 28 lbs. in
weight; the lower border of the stomach was i£ inch
above the umbilicus; he had vomited once or twice
during the year, but had had no other gastric
troubles.

2. Bridget N., aet. 44. Transferred to my care
by my colleague, Dr. Warrington. She had been
subject to flatulence and heartburn for a long period,
had been vomiting frequently for four months, and
had intense epigastric pain. There had been haema-
-temesis and also melaena, and she had lost much
flesh. On examination, a hard mass was to be felt
in the epigastrium about the size of a small orange ;
forcible peristaltic movements could be seen passing
from left to right over the stomach. No free
hydrochloric acid was found after a test meal. In
the vomited matter there were no sarcinae, but
organic acids were present equal to a total acidity
of 50 c.c. decinormal sodium hydrate.

At the operation a large crater-like ulcer was felt
on the posterior wall of the stomach at the pylorus ;
it was adherent posteriorly, where it was surrounded
by a hard indurated mass. Posterior gastrojejunos¬
tomy was performed. She vomited on the night
of the operation, and the following day, and once
on the fifth day, but otherwise her convalescence
was smooth. She left hospital four weeks after the
operation. Seen on October 20th, 1906, seven
months after the operation; no abdominal tumour
.was palpable, she had put on weight considerably,
and had no gastric pain or other symptoms. This
after-history points to the fact that the epigastric
tumour was of an inflammatory nature, although
the clinical signs 'before operation all seemed to
point to malignancy. After the operation the peri¬
gastritis subsided, and apparently the ulcer healed.

3. Elizabeth M., aged 49. Transferred to me by
my colleague, Dr. Bushby. I had previously
operated on her for symptoms referable to a movable
kidney. There was marked dilatation of the
stomach, with splashing and vomiting; the greater
curvature reached within three fingers’ breadth of
the symphysis pubis. There was a distinct hys¬
terical element in the case, which made me hesitate
to operate for some time, as the final results.in
such cases are notoriously uncertain. The point
that decided the question was the absence of hydro¬
chloric acid in test-meal experiments. Posterior
gastrojejunostomy cm July 23rd. The stomach
was thoroughly examined, but no lesion suggestive
of malignant disease was found. She vomited im¬
mediately after the anaesthetic, and once on the
eight day after operation, not otherwise. She left
hospital seventeen days after operation. Seen four
months after operation, she had put on flesh; she
still had various complaints in different parts of her
anatomy, but her gastric symptoms were at any
rate much improved.

4. Thomas C., aet. 43. Sent to me by my col¬
league, Dr. Warrington. Gastric symptoms for
about three years. Pain relieved by food. Had
had haematemesis on two occasions, and he says
also that the motions have often been black. He
had lost 4 stone in weight during the previous four
months. The stomach extended to half an inch
below the umbilicus; frequent forcible and painful
contractions of the stomach wall were a marked
feature of the case. Hydrochloric acid was present.
Operation on July 18th. Duodenal stricture was
found, due to cicatrisation of an ulcer. Posterior
gastrojejunostomy was performed. There was no
vomiting after the anzesthetic or subsequently ; pre¬
viously this had been going on every day. . He left
hospital twenty-two days after operation in good
condition. He has been seen subsequently as an
out-patient several times; he put on flesh rapidly,
and had no further pain or vomiting.

5. William K., aet. 27. Under medical treatment
for eight months for cramp-like pains in the
stomach, coming on from half an hour to an hour
after food. He improved temporarily, but relapsed
whenever treatment was suspended.. On examina¬
tion he presented a marked and localised tenderness
just inside the tip of the right costal cartilage; no
blood was detected In the stools, but patient de¬
scribed meloena on several occasions. The history
and signs pointed to duodenal ulcer. The abdomen
was opened on September 26th, and a firm indurated
area about the size of a florin, evidently an ulcer,
was found In the duodenum close to the pylorus.
Posterior gastrojejunostomy was performed. The
man vomited once on his return to the ward, not
subsequently. His convalescence was retarded by
a smart attack of broncho-pneumonia. He left
hospital in good condition twenty-four days after
the operation. I saw him on November 17th; he
had had no further gastric symptoms.

These cases show w r hat an uneventful and even
course may be expected when posterior gastro¬
jejunostomy is performed in the manner I have
described. Simple suture by means of an inner
continuous layer taking up all coats, and an outer
continuous layer taking up serous and muscular
coats, is the technique to be preferred. Clamps
are used for the stomach and the jejunum.

One point has struck me in regard to these and
other cases of definite gastric and duodenal ulcer,
and that is that in every case the powder of masti¬
cation has been practically absent owing to
wretched iteeth. The first step on the treatment
of gastric ulcer is to remedy the condition of the
mouth. If this is true, physicians and surgeons
need not quarrel over the treatment of gastric ulcer
in its early stages; it belongs to neither of them,
but to the dentist.

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OPERATING THEATRES.

The Medical Press. 605

OUT-PATIENTS’ ROOM.

' CHILDREN’S HOSPITAL, PADDINGTON.

Inguinal Hernia in an Inf ant.—A Simple 1 russ.

By Arthur Edmunds, M.S., F.R.C.S.

Amongst the out-patients was a male child, aet. 9
months, who was suffering from ordinary oblique in¬
guinal hemia. The swelling was about the size of a
walnut, was readily reduced, but reappeared when the
child cried or made any other straining effort. The
penis was well formed, and the foreskin, although a
little long, presented no obstacle to micturition. The
child was in all ether respects normal; the bowels
acted freely and regularly; the appetite was good, and
the boy did not cry to any extent except when the hernia
was down, when he seemed to experience a certain
amount of abdominal pain. The child slept well, the
hernia always reducing itself spontaneously during
sleep. Mr. Edmunds remarked that these cases are
extremely common, several of them being brought for
treatment at every out-patient clinique, and their treat¬
ment was correspondingly important. For a long time
it was taught that operative interference in these cases
should be deferred until the child had acquired con¬
scious control over the bladder and rectum, but more
recently operations have been undertaken in large
numbers and with complete success on these cases.
Postponement of the operation is, he said, often dis¬
appointing, a child which before had complete con¬
trol passing his evacuations without any notice after
the operation. This, however, is not a matter of such
very great moment, inasmuch as it is possible to per¬
form these operations by making the incision rather
high up, so that soiling with faces ran be completely
avoided. The urine, however, is very likely to soil
the dressing, but if the case be carefully watched, and
the dressing changed whenever this occurs, disaster is
very infrequent. Stiles has attempted to overcome this
difficulty by dispensing with a dressing entirely. After
the wound has been sutured, it is carefully dried and
powdered with boracic acid ; a low cradle is then placed
over the child, and covered with an old blanket, so
arranged that it is only a very short distance above the
meatus. The child passes his water directly into this
blanket, which is changed as often as necessary. This
method is very successful, the resistance to sepsis in a
child being sufficient in most cases to overcome the
small amount of infection which is introduced through
the wound after operation. In this hospital an objec¬
tion to this type of treatment i3 the small number of
beds at the disposal of the surgeon, so that attempts
have to be made to treat these cases as out-patients as
far as possible, and this is undertaken with very con¬
siderable success. It must be remembered that hernia
of this description is produced, not so much by a defi¬
nite pathological process, as by a delay in the normal
physiological one—that is to say, the funicular process
remaining unobliterated after birth, so that it is reason¬
able to hope that if distension of the sac of the peri¬
toneum can be prevented, obliteration will follow in
due course. Trusses for children of this age are usually
made of india-rubber, a material which can be readily
washed, but none the les3 becomes sodden with urine.
As a substitute for this, a skein of wool is extensively
used, but it is not very efficient. The best method con¬
sists in taking a strip of soft flannel a yard and a half
long, and an inch and a half wide. This is folded in
two, the folded portion being placed over the neck of
the sac, the two tails carried round the pelvis, and
ultimately threaded through the loop from above down¬
wards, so as to encircle the body with a noose of
flannel. The two ends are then passed under the leg
on the affected side and stitched to the belt of flannel
at above the level of the posterior superior iliac spine.
Attention is now paid to the point where the two tails
pass through the loop ; there is tendency for the knot
produced in this way to wrinkle up, and this must be
prevented by spreading out the loop and by stitching
its upper corner. In this way a ridge is formed across
the inguinal canal, which prevents the hernia from
coming down without exercising undue pressure on the

delicate structures in this region. Sometimes this truss
has a tendency to slip down, and it must then be sup¬
ported by a shoulder-strap passed across the opposite
shoulder. Sometimes there is a little chafing round the
groin, but this is usually easily overcome Dy using a
little vaseline. The child is bathed with the truss on,
a fresh one being prepared for use after the bath. This
treatment must be continued for about 12 months, at
the end of which the hernia will usually be found to
be permanently cured. This mode of treatment fails
in large hernias and in children over 18 months, but
for suitable cases it is a cheap and efficient method.

OPERATING THEATRES.

WESTMINSTER HOSPITAL.

Removal of the Rectum and Part of the
Sigmoid by the Perineal Route.—Mr. Tubby
operated on a woman, aet. 44, who had been admitted
suffering from symptoms of intermittent constipation,
and a muco-sanguineous discharge from the bowel.
She was fairly well nourished, but had a prematurely
aged look. The abdomen was moderately distended,
particularly in the flanks; she was somewhat
tympanitic, but her condition was by no means acute.
On examining the rectum, its lower part was found to
be distended, but with the finger no sign, of growth
could be felt, although it was strongly suspected that
such was present. Ten days after admission an
exploratory operation was carried out, and in the pelvis
there could be distinctly felt an irregular hard tumour
occupying the lower part of the sigmoid flexure and
slightly encroaching on the first piece of the
rectum. It was decided to perform an inguinal
colotomy, which was accordingly done, the bowel
being opened on the second day after the
operation. Faecal matter passed regularly from
the colotomy wound, the patient became more
comfortable, and her appearance was less emaciated.
The question had now to be faced of the best method
of dealing with the growth, and naturally the com¬
bined or abdomino-perineal method suggested itself.
It was, however, finally decided to attack the bowel
from the perineum, and, if undue difficulty was
encountered to perform an abdominal section and
liberate the growth from above. For the past ten days
the lower part of the bowel had been washed out
through the colotomy wound with boracic acid solu¬
tion. Fortunately no faecal matter had passed below
the artificial anus, and the boracic acid solution issued
from the natural anus slightly stained of a dark brown
colour, which originated from breaking down of the
growth. With the aid of Messrs. Carling and
Swainson excision of the growth was undertaken by
Mr. Tubby; it was hoped to preserve the lower part
of the rectum with the sphincters, and to be able to
draw down a portion of the sigmoid and unite it to
the lower part of the rectum. The patient was placed
in the lithotomy position with the buttocks well
elevated, and good artificial light was provided. An
incision was then made from just behind the sphincter
ani, then along the median line to the middle
of the sacrum. The tissues were rapidly retracted,
and the coccyx removed. The levator ani on both
sides was detached from the rectum. The finger was
then passed up along the hollow of the sacrum, and
the bowel detached as high as the sacral promontory.
The bowel was also separated laterally and anteriorly
from the vagina. It was easy to identify the bowel as
it was packed with iodoform gauze. All haemorrhage
having been arrested and the vessels tied, the
peritoneum was opened on the right side, then in
front of the rectum, then on the left. The growth
could now be palpated freely, but at first could only
be brought down with difficulty. It was found to have

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606 The Medical Press. TRANSACTIONS OF SOCIETIES.

Dec. 4, 1907.

increased greatly in size since the preliminary opera¬
tion. The main difficulty consisted in the shortness
of the meso-rectum and the induration of the lower
part of the meso-sigmoid; however, after consider¬
able trouble and very careful detachment of the parts
with the finger and forceps, the growth was brought
well down and partially outside the wound so that a
ligature could be placed rather more than an inch
above the tumour. It was found more convenient to
begin the removal of the rectum from below ; this was
accordingly divided between two ligatures about two
inches above the anus. The remainder of the rectum,
together with the lower part of the sigmoid below the
upper ligatures, was then carefully shelled out; it
was found to be possible to draw healthy sigmoid
down to the remainder of the rectum and join it by
a continuous suture. The patient suffered much from
shock, as the operation was prolonged, but, happily,
Mr. Tubby said, she lost very little blood. The wound
was left open, and was fully stuffed with gauze. Mr.
Tubby remarked that a preliminary colotomy was of
great advantage in these cases, as it not only rendered
the patient comfortable, but also permitted the
lower part of the bowel to be washed and rendered as
aseptic as possible. But it had the disadvantage of
causing some difficulties in a subsequent abdominal
section on account of the possibility of contamination
of the wound. Despite this, in the particular case
under notice, he felt that it would have been better
to have performed an abdominal section, free the
growth from above, and then removed it through the
perineum. The shorter duration of the operation and
the lessened shock to the patient more than compen¬
sated for the risk of sepsis of the abdominal wound.
The removal of so large a mass through the perineal
route, while showing that a very large portion of the
bowel may be removed in this manner, is not, he
thought, so satisfactory an operation as the combined
abdomino-perineal method.

TRANSACTIONS OF SOCIETIES.

ROYAL SOCIETY OF MEDICINE
Medical Section.

Meeting held Tuesday, November 26th, 1907.

The President, Dr. S. J. Gee, in the Chair.

Dr. Alfred E. Russell read a paper on the
NATURE OF EPILEPSY.■

He said that the old theory that epileptic and many
other convulsive attacks were explicable on the hypo¬
thesis of a sudden failure of the cerebral circulation
was worthy of reconsideration. That such a failure
was competent to produce unconsciousness and con¬
vulsions had been proved experimentally by several
investigators, while the phenomena of Stokes-Adams
disease and heart block afforded clinical evidence in
the same direction. Opportunities of making observa¬
tions were scanty because it was impossible to predict
•when a fit would occur and because the period of
cardiac inhibition was of necessity very short. An
attack of ordinary syncope (faint) offered both analo¬
gies and contrasts to the epileptic fit. Intermediate
cases occurred in which it was difficult or impossible
to make a diagnosis. The causation of cardiac inhibi¬
tion in epilepsy must be sought in the marked vaso¬
motor and cardio-motor instability which was a feature
of the disease. Dr. Russell quoted cases in which both
vagal and vaso-motor symptoms were combined. The
phenomena of petit mal were also considered. He
observed that the similarity between infantile convul¬
sions and epilepsy was very marked, and submitted
that the same explanation held good for them. It was
noteworthy that the cardiac ana vaso-motor systems in
the child were very sensitive, as seen, for instance, in

the phenomena of fright. On ibe hypothesis of
cardiac inhibition as the precipitating factor of the
fit, recovery followed on the escape of the heart from
inhibition. If the hypothesis were correct it should
afford a satisfactory explanation of the various phases
of the fit, and Dr. Russell submitted that this was the
case. In regard to uraemic convulsions, experimental
and clinical evidence was brought forward to show
that the cerebral manifestations of uraemia might be
due to a condition of increased intracranial tension
with resulting cerebral anaemia. Concerning Jacksonian
epilepsy, the difficulty of correlating cerebral anaemia
with this condition was discussed, and evidence was
submitted that cerebral anaemia existed both in status
epilepticus and in the epileptiform seizures of general
paralysis.

Dr. D. Ferrier remarked that vaso-motor regulation
of the brain circulation was a small part in the con¬
sideration of the question ; it had been shown that vaso¬
motor spasm caused flushing of the brain. He did
not think there was evidence to show that vaso-con-
striction would cause anything but flushing. Dr.
Russell would transfer the origin of epilepsy from the
brain to the heart, but he (Dr. Ferrier) thought they
ought to have proof of some definite relation between
heart disease and epilepsy, and he did not believe that
such proof existed. He quoted figures showing that put
of 500 epileptics there were about ij per cent, with
some signs of cardiac disease, whereas in 800 cases of
heart disease there was not one case of epilepsy.
Epilepsy was not so much a matter of the circulation
as of the nutrition of the nerve cells. He considered
that the condition of the circulation was secondary to
the epileptic discharge from the <-ortical cells.

Dr. C. E. Beevor said that experimentally by
stimulation of the thumb centre it was possible to get
a tonic localised contraction, but by using a stronger
current it was possible to produce a fit affecting the
whole body, and it was certain that in those cases there
was not inhibition of the heart. In the case of fits
produced by brain tumours, in which it was possible
to have fits without loss of consciousness, it 9eemed
impossible that they could be ascribed to want of
action of the heart. Those brain tumours might grow
and cause fits just like epilepsy, and he did not see
how in such cases the heart’s action could be taken
into account. In regard to petit mal, it seemed impos¬
sible that the heart failure should have such a limited
effect as to produce loss of consciousness, and yet not
cause the patient to fall down. Further, attacks of
petit mal might occur, and be combined with attacks
of idiopathic epilepsy. It was difficult to think that
the petit mal was due to one cause, and the epilepsy
to another; they must be due to one cause, and that
could hardly be the heart. The question was whether
the primary disease was in the heart or in the cortex
of the brain, and in his opinion the primary disease
was in the cortex, and he did not consider that the
heart was responsible in idiopathic epilepsy.

Dr. A. M. Goss age said that if cardiac inhibition
was to be regarded as the commonest cause of epileptic
fits, then there ought to be more evidence of the occur¬
rence of such inhibition than they possessed. He
thought it possible that the cases brought forward by
Dr. Russell might be classed with cases of Stokes-
Adam syndrome.

Dr. J. Lindsay Steven (Glasgow) doubted if enorgb
weight had been placed on the factor of vaso-motor
anaemia of the brain as a cause of cerebral disease and
possibly of epileptic disease. He drew special atten¬
tion to the relationship that existed between cerebral
anaemia and Ravnaud’s disease.

After Dr. E. Farquhar Buzzard and Dr. Biernacki
had spoken, Dr. Russell replied, and the meeting ter¬
minated.

electro-therapeutical section.

The annual conversazione and exhibition of new
apparatus, heretofore held under the fcuspices of the
late British Electro-Therapeutic Society, but now under
the Electro-Therapeutical Section of the Royal Society
of Medicine, will be held in the Queen’s (small) Hall,
on Friday, December 13th, 1907, from 7.30 p.m. to
11 p.m. The exhibition will be ope.i from 3 p.m., and
light refreshments will be provided both afternoon and
evening. All the leading makers of electro-medical and

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Dec. 4, 1907.

TRANSACTIONS OF SOCIETIES. The Medical Press. 607

X-ray apparatus are taking part, and many new designs
will be shown, as far as possible under working con¬
ditions. A noteworthy feature will te a display of
X-ray tubes from the earliest to the latest patterns.
Medical practitioners will be welcome on presentation
of their visiting cards, as also will members of the
dental profession and recognised teachers of the
physical sciences. Others will be admitted on pay¬
ment of a fee of 5s.

Communications regarding cards of admission or
other matters must be addressed to Reginald Morton,
M.D., Hon. Secretary, 22, Queen Anne Street, Caven¬
dish Square, London, W.

ROYAI. ACADEMY OF MEDICINE IN IRELAND.

Section of Obstetrics.

Meeting held Friday, November 15TH, 1907.
The President, E. H. Tweedy, M.D., in the Chair.

EXHIBITS.

Dr. Alfred Smith exhibited two fibro-mvomatous
uteri with ovarian cyst attached. One generally asso¬
ciated with fibroid tumours of the uterus, he said,
certain degenerations of the ovary, but he did not
think he had seen—certainly not in two consecutive
cases like those exhibited—ovarian cystomas associated
with fibroid tumour.

The President said there was no reason why a cyst
should not grow in a woman who was already afflicted
with myoma, yet he did not remember ever having
seen them attached before.

Dr. Purefoy said that a few weeks ago he had re¬
moved a dermoid cyst, with which was associated a
fibroid uterus.

On the suggestion of Dr. Rowlette, one of the
tumours exhibited by Dr. Alfred Smith was opened,
and proved to be a dermoid cyst.

Sir A. V. Macan exhibited a case of uterine car¬
cinoma and double ovarian cystoma. He said the
woman was 45 years of age, had been married since
she was 15, but had had no children. The catamenia
were still regular, and, except for violent haemorrhages,
the patient complained of nothing. On opening the
abdomen an ovarian tumour was found and removed,
and, to his surprise, he then found another. The
uterus was then extirpated. Afterwards the patient
got bronchitis, which gave him some anxiety, and
later, out of one of the stitches, fluid stuff came like
the contents of a dermoid cyst. However, she made a
good recovery.

The President thought it was rather fortunate for a
woman who was suffering from carcinoma to get an
ovarian cyst, as it might cause the diagnosis of car¬
cinoma to be made all the earlier.

Sir A. V. Macan, replying to a question bv the
President, said the patient was first curetted to make
the diagnosis, and it being determined that it was car¬
cinoma of the uterus, it came to be a question of extir¬
pation by the vagina or the abdominal route.

Sir William Smyly exhibited a case of sarccma of
the uterus {?), and regretted the note of interrogation,
but it was difficult to say what organ the tumour really
sprang from. On October 21st he had seen the patient
for the first time. She was feverish, and looked very-
ill. On making a bi-manual examination, he found
a myomatous uterus, and also a detached tumour in
the abdomen. When admitted afterwards to hospital she
had all the symptoms of septic fever. It was quite
evident that one of the tumours was suppurating or
sloughing, and that she could not live any length of
time in her then condition. As a desperate resource
he determined to try to extirpate the source of in¬
fection. It was generally admitted that it was better
to Temove a septic tumour by the vagina, as it was
less likely to cause a general peritonitis or a hernia
than removal by the abdominal route. The woman
was unmarried, and had a narrow vagina, which pre- .
sented the ordinary difficulties. After a good deal of '
labour morcellating the uterus he got it outside the .
vulva. It had been held by the tumour above, which j
had prevented it from coming down. To get the ,
tumour he had, after all, to open the abdomen, and j

he found everything matted together. He separated
the adhesions, scooped out the sloughing debris, and
left a cavity with ragged, infiltrated walls communi¬
cating with the lumen of the gut by an opening as
large as a sixpence. It was evident that the
malignant disease had extended from the tumour
through the walls of the intestines, and it had involved
so many of the coils of intestines that he now reached
the climax of his woes, and found it impossible to
remove the disease. In the desperate circumstances he
stitched the intestines round the cavity as well as he
could, and the woman had not exhibited any bad
symptoms up to that day, which was the fourteenth
from the operation.

Dr. Harvey confirmed Sir William Smyly’s remarks
as to the difficulty of saying what the tumour really
v/as. Histologically it was mixed-celled sarcoma.
president’s address.

Dr. Hastings Tweedy, in thanking the section for
electing him their President, said that the position had
been held in the past by men who had made the
Obstetric School of Dublin famous, and that it was
through the Royal Academy of Medicine in Ireland
that the profession in Dublin have the opportunity of
making known to their countrymen and to the world
at large that their work is worthy of more than pro¬
vincial fame. He complained that the section had not
of late years received the support it deserved, and it
lacked the vitality of the past. This slackening of
interest dated from about the beginning of the Boer
War, and in his opinion might be attributed to it.
The war had a most disturbing influence on men’s
minds, and during a period of almost daily disaster
the members of this section had no heart to attend
the meetings; thus habits were formed of which the
influence is still felt. Of other explanations, the most
plausible is that which suggests that gynaecology has
ceased in its power to interest, and that as an art it has
made no appreciable advance within the last decade.
In combating this view he dealt with the radical
changes which have been effected within the past four
years. Rubber gloves aTe now universally worn not
alone in abdominal but also in vaginal operations.
The rinsing the cleansed hand in methylated spirit,
and the partially filling the gloves with similar fluid,
enables them to be readily slipped on, and secures an
almost aseptic condition of their contained fluid con¬
tents, even after they have been worn during a two-
hours'’ operation ; thus injury to the glove is not
fraught with fear of septic infection through oozing
of its fluid contents. We now dispense with much of
the elaborate ritual formerly considered necessary in
hand-washing. Skin maceration in the neighbourhood
of the field of or>eration is prevented by painting the
surface over with a saturated solution of picric acid
in spirit. This solution is also of great use when
applied to papillary erosions of the less chronic type.
vaginal surgery.

In vaginal surgery the field of operation has been
rendered more sterile by the clipping of a strip of
boiled Billroth tissue across the perinaeum to shut off
the anal region, whilst the bags which enclose the legs
are now connected with an abdominal apron which
prevents the operator’s hands being contaminated in
the event of his having to pause in the midst of an
operation to make a bi-manual examination. The
large semilunar incision of Strasseman provides a
rapid and ready method of separating the bladder from
the cervix, and performing extensive operations
through this route. For vaginal fixation the older
T-shaped incision is to be preferred, but here again
an improved technique is adopted in that the peri¬
toneum is now insinuated between the vaginal wall
and the fixing sutures of the uterus. The technique
for the cure of cystoceles and rectoceles has been
much improved—in the former by tucking up the
bladder and rolling it inwards on itself with fixing
catgut sutures, and in the latter by joining again the
fibres of the levator muscle and pelvic fascia. The
vaginal operation for cancer of the uterus is much
more extensive than formerly. Pus tubes are dealt
with in a way that almost ensures a safe recovery.
If very acute the abscess can be opened by entering the
abdomen through the posterior fornix, and directly
draining through this hole. If a relapse takes place

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Dec. 4, 1907.

608 The Medical Press. TRANSACTIONS OF SOCIETIES.

the pus is rendered less septic, and the case may be |
considered alone amenable to the more radical opera- j
tive procedures. In this eventuality he strongly advised 1
the splitting of the uterus in two halves, the insertion j
of the whole hand into the abdominal cavity, the
breaking down of adhesions, and the forcible dragging
out of the diseased tube with its attached half of the
uterus, the clamping of the tubes outside the vulva,
the pushing the clamps into the abdomen, and the
insertion of iodoform gauze between them (Landau’s
operation). Atmocausis has enabled many haemor¬
rhagic cases to be cured that formerly would have
required removal of the uterus. Through the ab¬
dominal route pus tubes can be removed with greater
safety than formerly by the plan of splitting the uterus
down the centre and removing them together with that
organ. Tubes affected with interstitial salpingitis are
re-sected, and their lumens made patent. Ovaries are
freely resected rather than sacrificed. Raw surfaces
are covered over with peritoneum. It is now a matter
of indifference (so far as the primary operation is con¬
cerned) as to whether the uterus is removed with or
without its cervix. Both operations have become easy
and safe in their performance, whilst unpleasant after-
symptoms have been obviated by the non-removal of
the ovaries. In spite of this advantage the operation
is less often done than formerly, because of the advan¬
tages offered by myomectomy as now performed. The
uterus can be split in halves, the myomas enuc¬
leated from its walls, and the organ again stitched
up after the manner which obtains in Caesarean
section. Operative treatment for cancer of the uterus
has been revolutipnised. Formerly, if the orgin was
fixed, it could not be readily pulled down, or had its
cervix badly eroded, surgical relief was unobtainable.

It is pleasant to contemplate that gynaecologists are
no longer deterred from relieving the suffering woman,
even though prolonged immunity from the disease can¬
not be promised. The three-layer method of suturing
the abdomen has made it possible to operate withoat
any fear of a subsequent hernial formation, and the
sub-cuticular skin suture threaded through a leaden
plate placed on the wound throughout its entire length
has made scar deformity a negligible factor. Anti-
streptococcus serum (Polyvalent variety), if adminis¬
tered in suspected cases before symptoms have de¬
veloped, provides a prophylactic agent against many
forms of sepsis. Fowler’s position, too, is employed
from the first in these cases, and Mr. Moynihan's
enthusiastic advocacy of continuous rectal irrigation
on the appearance of the earliest symptoms of ab¬
dominal sepsis has in all likelihood placed in our
hands another valuable therapeutic agent. The Presi¬
dent concluded by expressing the hope that he had
shown that gynaecology had not stood still, but that its
advance had been as great in recent years as
throughout any period of its existence.

Dr. A. N. Holmes exhibited cases of (a) carcinoma
of ovary, and (d) cystoma of ovary, both from patients,
aet. 48, and in both of whom great difficulty was experi¬
enced in getting into the abdomen. Both patients had
also made a good recovery. In the first case the
woman’s last pregnancy had been a year previously,
and after it the menses had ceased. In the second
case the woman had never been pregnant. The chief
points of interest were that in the second case extensive
adhesions had been set up without causing symptoms,
while in the first case the symptoms had been coming
on for three years, and it was curious that the disease
had not spread further than it did.

Sir A. V. Macan said the cases presented more than
the ordinary difficulties, and expressed his admiration
of the successful results obtained.

Dr. Purefoy said he had been indebted to Dr.
Holmes for giving him the opportunity of assisting at
the cases. The nature and extent of the adhesions in
the first case had impressed him fully that the disease
was malignant, and he was greatly surprised when
Dr. Rowlette told him it was not. It was surprising
also that in the second case there should have been
such continuous improvement in the woman’s con¬
dition. His experience of malignant ovarian tumour
had been that recurrence, ending fatally, took place
within a few months.

Dr. Rowlette said that, as far as could be made

out from the clinical history of the case of carcinoma,
it was a case of primary carcinoma of the ovwy,
which was said to be a rare disease. That, however,
was not the experience of the Dublin Gynaecological
School. The pathology of the tumour was what was
usual. It consisted of large cells without any special
arrangement in glandular formation. Looking at the
first case with the naked eye, one would take it to be
malignant, but there was some twisting of the pedicle,
which led to great congestion and had been the cause
of the inflammation which resulted in the adhesions.
He could not offer any suggestion as to the cause of
the adhesions in the other case.

Dr. Henry Jellett said he had seen several cases
in which there was no evidence clinically of any
primary infection elsewhere, and he had lately seen
three cases in which there was a positive primary focus
elsewhere. It was very curious that if the ovary was
really the seat of the primary disease the cancer should
be double.

The President said he was afraid that the can¬
cerous tissue had worked itself through the adhesions,
and made a permanent cure impossible—though not
necessarily so.

The President exhibited a uterus removed by
Wertheim’s operation in which the amount of adjoin¬
ing tissue taken away was greater than any he had ever
seen. Wertheim said the ureter should not be dis¬
turbed from its bed. In at least one-third of bis
(Dr. Tweedy’s) cases the cancer had got below the
ureter, which had to be lifted in order to dig the cancer
out. It was becoming a common thing with him to
put a bullet forceps under the ureter and then to lift
it up with the forceps while he took away the cellular
tissue beneath. He had frequently had the ureter lying
out of its bed through its whole extent, and yet he had
never had a leakage or a fistula, which showed that
there was a great deal too much respect paid to the
ureter.

The following card specimens were shown :—

(i) The President —(a) Adeno'-carcinoma of body
of uterus, 2 specimens; (£) epithelioma of cervix

uteri, 2 ; ( c ) carcinoma of ovary-, 2 ; (d ) ovarian
cyst, 6 ; (e) fibro-myoma of uterus, 7.

(a) Dr. Purefoy — (a) Dermoid ovarian cyst; (ij
uterine fibroids removed by myomectomy-.

LIVERPOOL MEDICAL INSTITUTION.

Meeting held Thursday, November 21ST, 1907.

The President, Mr. Frank T. Paul, F.R.C.S., in the
Chair.

NATURAL colour photography in diseases OF THE
SKIN.

Dr. Walter C. Oram exhibited a selection of photo¬
graphs in natural colour of various diseases of the
skin taken by the new Lumiere process, and gave a
short account of the theory of the process.

Drs. G. Stopford Taylor and R. W. Mackessa
gave a demonstration of colour photographs of skin
diseases taken by the new Lumi&re process. Dr
Mackenna said that to photograph diseases affecting
the skin was to put any process of colour photography
to a severe test, and in this the Lumiere process had
not been found wanting, for it faithfully- reproduced
the most delicate gradations of colour with an accu¬
racy never attained by the artist’s brush. Their main
difficulty had been to obtain definition. Since an ade¬
quate supply of autochrome plates had been pro¬
curable in this country, the weather conditions had
been much opposed to successful photography. As a
result their exposures had to be prolonged, and they
had not found it possible to work with a smaller
aperture than F.8. Their shortest exposure had been
48 seconds, and their longest 20 minutes, but they had
great hopes that when the light improves again it
would be possible to obtain photos not only perfect
in colour but rich in detail. The photographs shown
illustrated various forms of eczema, psoriasis, scabies,
syphilitic eruptions, and tertiary ulcerations before and
after treatment, lupus and tuberculosis cutis, acne
vulgaris, medicinal eruptions, and sycosis. To photo¬
graph a rose ablaze with colour, or a gaudy orchid, is

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GENERAL MEDICAL COUNCIL. The Medical Press. 609

one thing; to get a correct colour picture of a disease
whose hue varies but little from the colour of the
surrounding skin is quite another matter; but the
autochrome plates survive the ordeal triumphantly.

Dr. K. Crossman gave an account of photography in
natural colours by the three-colour method. The
colour screens used for producing the three negatives
were demonstrated; also the three positives printed
from the three negatives in their respective comple¬
mentary colours. The three negatives were to be super¬
imposed, and, if well done, this gave the correct repre¬
sentation of the original. The process was laborious
and required a great deal of time. A number of slides
of test objects, of leprosy patients, and of micro-
photographs were shown.

NOTIFICATION OF BIRTHS ACT, 1907.

Dr. E. W. Hope read a note on the objects of the
above Act of Parliament. A declining birth-rate and
a high infant mortality had led to various legislative
measures designed to lessen the loss of infant life.
The Act in question would enable help and guidance
to be given to poor women at an earlier period of the
infant’s existence than was possible now, and it was
hoped that such assistance may lessen the mortality
during the earlier weeks and months of life which
occurred to so gTeat an extent in Liverpool and else¬
where. The obligations upon the medical man were
not arduous, but it wa3 hoped that in every case in
which a medical man was in attendance the fact would
be stated upon the form for notification, and in these
cases no visit would be paid by the officer of the
Health Committee unless it was specially asked for.
Out of the 24,000 births which took place annually
in Liverpool, it was estimated that 15,000 were
attended by midwives, nearly all of whom were well
trained and fully qualified.

Dr. Albert £>avis, C.C., was opposed to the
adoption of the Bill on the ground that notification
involved a breach of professional confidence.

Sir James Barr moved the following resolution :—
"In the opinion of this meeting of the members of the
Liverpool Medical Institution, the Notification of
Births Act, 1907 , should be adopted by the County
Borough of Liverpool. ”

Dr. William Carter seconded the resolution, and
said that everyone should support to the utmost Dr.
Hope in his effort to check the waste of infant life in
Liverpool. The startling fact that, of the total number
of deaths ( 4 , 137 ) under one year of age last year, 1 , 057 ,
or more than a quarter, took place in the first month
of life, showed the importance of early information
being given, so that skilled members of the female
sanitary staff might visit the mothers, who were often
very ignorant of the duties of motherhood, and, when
necessary, give them kindly instruction in the way to
rear their infants. “Why,'” he asked, “should it be
a breach of < onfider.ee on the part of the doctor to
state within 36 hours after birth a fact which must of
necessity be known six weeks after it?”

Dr. A. Stookf.s and Dr. J. R. Logan having spoken
in its favour, the resolution was carried with two
dissentients.

A CASE OF PARAPLEGIA TREATED BY OPERATION.

Dr. W. B. Warrington and Mr. K. W. Mon-
sarrat showed a patient who suffered from para¬
plegia due to an intra-medullaTy lesion, and who had
been treated with some success by the removal of a
local accumulation of fluid. The patient, a young
man, was able to walk across the floor of the lecture
theatre with the aid of crutches.

Mr. R. W. Murray, Dr. F. J. S. Heaney, and
Dr. Stansfield discussed the case.

Mr. Rushton Parker showed two patients in whom
he had obtained union of previously un-united frac¬
tures of the humerus by means of implantation of
bone.

CENTRAL MIDWIVES’ BOARD.

A meeting of this Board was held on Thursday last,
at which matter of importance to medical men was dis¬
cussed. We regret that, owing to great pressure on our
space, our report, which is in type, had to be held over
until our next.

GENERAL MEDICAL COUNCIL.

EIGHTY-SIXTH SESSION.

First Day, Tuesday, November 26 th, 1907 .

Dr. MacAlister, President, in the Chair.

The President delivered the following address: —

Gentlemen, —Although in no fewer than eight cases
the tenure of office of members of the Council has
expired during the recess, in every instance the out¬
going member has been re-elected; and I have thus
the satisfaction of reporting that the composition of
the Council is unchanged. [The eight re-elected mem¬
bers are:—Dr. P. H. Pye-S<mith, University of
London (one year) ; Mr. A. H. Young, Victoria Univer¬
sity of Manchester (one year) ; Dr. A. G. Barrs,
University of Sheffield (three years) ; Sir J. W. Moore,
R.C.P., Ireland (one year) ; Dr. F. G. Adye-Curran,
A.H., Dublin (one year); Sir C. L. Nixon, Royal
University of Ireland (five years) ; Dr. D. C. McVail,
Crown Representative, Scotland (five years) ; Dr. J.
Little, Crown Representative, Ireland (five years).] I
may be pardoned for noting that, for the first time in
our history, we are able to count a Lord Mayor among
our colleagues, Dr. Caton, who has, by the suffrages
of his fellow-citizens, been raised to the chief magis¬
tracy of the city of Liverpool.

The petition and draft supplementary charter for the
erection of a medical faculty in the University of
Wales were submitted to you last year, and it was
agreed that no objection should be taken to the grant
proposed. A provisional committee of advice, to be
called the Medical Board, is to be instituted, whose
duty it will be to make to the University Court recom¬
mendations and reports on all matters concerning the
faculty of medicine. The statutes provide that one
member of this Board shall be appointed by the Presi¬
dent of the General Medical Council.

It is clearly intended that the new degrees shall repre¬
sent a high standard of general and professional attain¬
ment. It is, of course, understood that, without
further legislation, these degrees will not admit their
holders to the privileges of registration ; nor will the
University which confers them be entitled to repre¬
sentation on this Council. But it cannot be doubted
that proposals for such legislation will ere long be
made, and that you will in due course be required to
express an opinion upon them.

The prospect of a further increase in our member¬
ship makes it necessary to have regard to the financial
position of the Council. By the exercise of economy
of time and money we have succeeded in reducing our
expenditure ; but our income, derived for the most part
from registration fees, is not increasing, and is not
likely- to increase. While it is to be hoped that the
efforts of the Council to improve the educational attain¬
ments of our future practitioners have not been with¬
out effect on the efficiency of those we admit to the
Register, we must not ignore their inevitable tendency
to reduce the number of persons duly qualified for the
public service, and incidentally to diminish the avail¬
able resources of the Council itself.

We may expect fresh light on these direct and in¬
direct effects of our own action, from the laborious
analysis of statistics respecting the ages and courses
of study of students recently qualified, which has been
undertaken by the Education Committee under the
direction of its Chairman, Dr. Mackay. In pursuance
of your resolution of May 30th, much valuable infor¬
mation on these points has been furnished by the
licensing bodies during the summer. . . . One

necessary advance, howaver, has lately been made by
the Council. I refer to the new requirements in respect
of training in practical midwifery. That such an
advance was opportune, if it was not overdue, appears
to be generally conceded by the profession. That the
advance involves practical difficulties, which in certain
medical centres are not easy to overcome, is also
clear. . . .

Since we last met, the Bills for the protection of the
public by checking the abuses incidental to the practice
of medicine and of dentistry by limited companies,
which were introduced by Lord Hylton in the Upper

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Dec. 4, 1907.

House, have been further considered by Parliament.
As you will remember, the Bills were framed under
skilled advice, and received your approval as embody¬
ing real improvements on the existing law. The Medical
Bill prohibited under penalties the practice of medicine
or surgery by companies. The Dental Bill sought to
provide that every person who under the name of a
company treated or professed to treat patients, should
himself be a legally qualified dentist.

The Bills, having passed the second reading without
objection, were referred to a Select Committee of the
House of Lords. The Medical Bill seemed to find
favour with the Committee, and being reported without
amendment to the House, was duly oassed and sent
down to the Commons. The exigencies of business,
however, prevented its further progress in that House,
and with many other measures it was dropped at the
end of the session. The Dental Bill was strongly
opposed in Committee. Witnesses representing com¬
panies of unregistered persons objected that it was
unjust to restrict practices which the present Law of
Companies had allowed to grow up. Others on behalf
of the British Dental Association urged that the Bill
did not go far enough in the direction of restriction.
It allowed dental companies to exist as commercial
entities, though they could only act by means of dental
operators who were duly qualified. The evidence has
been published, and is worthy of careful study. It
illustrates at once the abuses which the Bill sought to
remedy, the objections entertained by the officers of
the Dental Association to anything short of the total
suppression of companies in connection with dentistry,
and the strength of the opposition to suppression which
such companies are able to offer. In the end their
lordships appeared to be influenced by the arguments
of the companies rather than by those of the Associa¬
tion. Amendments were introduced with the object of
saving for a period of years the interests which existing
companies alleged ; but nothing was done 10 make the
Bill more drastic in its ultimate operation, as the
officers of the Dental Association desired. Fortu¬
nately the amendments, as drafted, proved to be un¬
workable ; and inasmuch as, apart from this defect,
they seriously diminished the protection to the public
which the Bill was intended to afford, it was intimated
to Lord Hylton that the approval of the Council could
not be held to extend to Ihe measure in its amended
form. His lordship thereupon obtained leave to with¬
draw the Bill, and it was not further proceeded with.

Being assured that it would be your wish, I con¬
veyed to Lord Hylton an expression of the Council’s
grateful appreciation of his efforts to procure, in :he
public interest, a useful amendment of the law, and
of his able conduct of the proceedings before the Select
Committee.

The Companies Bills Committee will meet during the
session to consider what steps should next be taken to
give effect to the Council’s instructions on the questions
referred to them. ... In the meantime certain
cases have been decided in the Courts which may have
an important bearing on the subject. . . . The
Irish Branch of the British Dental Association has
been both active and successful in the prosecution of
test cases wherein these important issues have been
raised, and have been settled so far as Ireland is con¬
cerned. . . . It is much to be desired that similar
cases should be brought before the Courts on this side
of St. George’s Channel. . . .

Last May I referred in my address to certain deci¬
sions given in the Chancery Division of the High Court
which touched upon the scope of your judgment of
“infamous or disgraceful conduct in a professional
respect,” delivered in connection with an inquiry into
the methods adopted by certain members of a notorious
dental company. The decisions in question were sub¬
sequently reversed in the Court of Appeal, and when
the cases were brought last week before the House of
Lords, the reversal was sustained. The Lord Chan¬
cellor, in giving judgment, put aside as immaterial the
Question whether, in the circumstances of the par¬
ticular action, the order made by the Council should
have been admitted in evidence cr excluded. But he
pronounced in forcible terms, and the other Law Lords
agreed with him, that the facts proved, which were
those on which the Council based its judgment, aid

constitute “disgraceful conduct” and “professional
misconduct.” Thus, although the decision of the
Council was not in form reviewed by the highest
tribunal, the grounds of its decision were indirectly
declared to be amply sufficient to justify its sentence.

The November session of the Council is in practice
specially appropriated for penal business, and I regret
to say that on this occasion the greater part of our time
will necessarily be occupied by inquiries into case*
of alleged misconduct. . . .

From information which has reached U3 from
Canada, it appears that the provincial authorities in
Quebec have agreed to a modification of the local la*
which assimiliates it to the provisions of Part II. of
the Medical Act, 1886, and removes the difficulties in
the way of medical reciprocity to which I referred in
my last address. The formal notification of the change
has not yet reached the Privy Council, and so we shall
not be required to take any official action at this
session.

In the Province of Nova Scotia, which has already
begun to furnish us with applicants for home regis¬
tration, legislative changes have been made which fulfil
the expectations of the Executive Committee respecting
the assimilation of the provincial curriculum to that
which is in force at home. In other words, the recog¬
nition of Colonial diplomas by the mother country has
had once more the gratifying effect of improving the
conditions of medical education beyond the borders of
the United Kingdom.

Moved by Dr. Little, seconded by Dr. Norvax
Moore, and carried by acclamation:—‘‘That the Pre¬
sident be thanked for his address, and requested to
let it be printed in the minutes.”

Moved by Dr. Norman Moore, seconded by Mr.
Thomson, and agreed to:—“ That the Council do
adjourn at 4 p.m. to-day, to enable certain Committees
to meet for the completion of their reports.”

Moved by Dr. McVail, seconded by Sir John
W illiam Moore, and agreed to:—“ That the yearly
tables for 1907 be received and entered in the
minutes ” :— (a) Table showing results of competition
held on November nth, 1907, for commissions in the
medical staff of the Royal Navy. (£) Table showing
results of competition held on July 25th, 1907, for
commissions in the Army Medical Service, (c) Table
showing results of competition held in July, 1907. for
commissions in the Indian Medical Service.

Moved by Dr. McVail, seconded by Sir John
William Moore, and agreed to ;—“That the thanks of
the Council be conveyed to the Director-General of the
Medical Department of the Royal Navy, the Director-
General of the Army Medical Service, and the Under¬
secretary of State for India respectively, for the
returns which they have again furnished to the Council,
with the request that these returns may in the future
continue to be furnished to the General Medical
Council.”

Moved by Dr. Pye-Smith, seconded by Dr. McVail,
and agreed to :—“ That the following recommendation
of the Executive Committee be adopted, viz., ‘That
the Standing Orders, Cap. XI., 8, be amended so as to
read as follows ’:—‘ Tfie fees for attendance at meet¬
ings of the Executive Committee and the Penal Cases
Committee shall be five guineas a day, and at meetings
of the Branch Council two guineas a day for each
member attending, his travelling and hotel expense
being also paid.’ ”

Moved by Dr. Norman Moore, seconded by Mr.
Morris, and agreed to:—“That the report from the
Executive Committee dealing with an appeal to the
Privy Council against the decision of the General
Medical Council of Mr. James Wilkinson for registra¬
tion under the Medic il Act of Queensland which had
been dismissed by the Privy Council be received and
entered on the minutes.”

Moved by Dr. Langley Browne, seconded by Dr.
Mac Manus :—“That this Council, deeming it to be
contrary to the public interest that any person other
than duly qualified practitioners in medicine and sur¬
gery should practise medicine in Great Britain and
Ireland, appoint a Committee to draft such amend¬
ments of the Medical Act as may be necessary to secure
this prohibition, and to report to the Council at the
session in May.”

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Dec. 4, 1907.

GENERAL MEDICAL COUNCIL. The Medical Press. 611

Dr. Langley Browne, with the consent of his
seconder and of the Council, withdrew his motion,
■and substituted the following :—“ That a Committee be
appointed to ascertain what legal provisions exist in
the Colonies and Dependencies of the Empire and in
foreign countries for the prevention of medical prac¬
tice by other than legally qualified persons, and to
consider what steps should be taken to procure effective
legislation for the same purpose in the United Kingdom
■of Great Britain and Ireland.”

Strangers by direction of the Council then withdrew
in order that the Council might consider in camerd
certain items in the Programme of Business.

Strangers having been readmitted the President an¬
nounced that the Registrar had been directed to restore
the name of John Bate Bawden to the Medical Register.

The President further announced that the following
had been appointed members of the Committee on the
Prevention of Medical Practice by Unqualified
Persons:—Dr. MacManus, Dr. Norman Walker, Dr.
Saundby, Mr. Morris, Dr. Langley Browne, Dr.
Latimer, Dr Kidd, Sir John Moore.

Moved by Dr. Pye-Smith, seconded by Mr. Tomes,
and agreed to unanimously:—“That, on the recom¬
mendation of the Executive Committee, Mr. Norman C.
King be appointed Assistant Secretary to the Council,
at a stipend of £260 a year; and that the stipend of
Mr. Storrs and of Mr. Cockington be increased to
^225 a year.”

Moved by Dr. Norman Moore, seconded by Dr.
Little, and carried with acclamation:—“That the
■Council receives with regret the resignation by Dr.
Pye-Smith of his office as Senior Treasurer, and ex¬
presses to him its thanks for his valuable services
■during the last six years.”

The Council then adjourned.

Second Day, Wednesday, November 27TH, 1907.

The minutes of the last meeting having been read
and confirmed, the Council proceeded to the con-
-sideration of the case of John Sandilands, registered
as M.B., Mast. Surg. 1888, M.D. 1894, Univ. Glasg.,
of the United Free Church of Scotland Mission,
Bhandara, Central Provinces, India, who had been
-summoned to appear before the Council to answer the
following charges, as formulated by the Council’s
solicitor: —

“That you unlawfully caused miscarriage to an
orphan girl under your charge, of which offence you
were on the 25th day of March, 1905, and subsequently
on appeal on the 10th day of July, 1905, convicted at
Bhandara, Central Provinces, India, and that in
relation thereto you have been guilty of infamous con¬
duct in a professional respect.”

Dr. Sandilands was called, but did not answer to
his notice.

The Solicitor read the notice to attend, the receipt
of which had been acknowledged by Dr. Sandilands.

The Solicitor also read the finding and sentence in
the Magistrate’s Court at Bhandara, and the judgment
of the Judicial Commissioner on appeal

Dr. Sandilands being absent this closed the case.

The Council then deliberated on the case in camerd.

Strangers having been re-admitted, the President
announced the decision of the Council as follows: —

That the Council have judged John Sandilands to
have been guilty of infamous conduct in a professional
respect and have directed the Registrar to erase from
the Medical Register the name of John Sandilands.

The Council considered the case of Edward John
Havens, registered as of East Donyland, Colchester,
Mem. R. Coll. Surg. Eng. 1879, Lie. Soc. Apoth.
Lond. 1879, who had been summoned to appear before
the Council on the following charges: —

“That you were on November 5th, 1906, con¬
victed of the following misdemeanour at Thorp
Petty Sessions, Thorp-le-Stoken, Essex, namely, of
obstructing the highway; also that you were on
December 17th, 1906, convicted at the like Session of
disorderly behaviour whilst drunk ; and also that you
were on April 8th, 1907, convicted of the following
misdemeanour at Mistley Petty Session, namely, of
common assault.”

At the conclusion of the proceedings on May 29th,
1907, the President, addressing Mr. Havens, said: —

“Mr. Edward John Havens,—The Council have
deliberated carefully on the convictions which have
been proved against you, but they have adjourned the
further consideration of your case till the November
Session, when you should be present to hear the result
of their final deliberations.”

Mr. Havens attended in answer to his notice.

The Solicitor put in the notice to attend, which had
been acknowledged by Mr. Havens, and read a letter
from Messrs. Birkett, Ridley, and Francis, his
solicitors, dated November 4th, 1907, and a letter
from Mr. Havens himself, dated November 7th, 1907.

The Solicitor also reported as to the result of his
inquiry concerning Mr. Havens’ conduct in the
interval since the last session, and read letters which
he had received from the Cleric to the Magistrates.

Mr. Havens denied the accuracy of the account
given by the police in regard to his conduct, and
addressed the Council in his own behalf. He did not
tender any evidence in support of his statements, or
as to his conduct during the interval.

The Council deliberated on the case in camerd.

Mr. Havens and strangers having been re-admitted,
the President announced the decision of the Council
as follows: —

Mr. Edward John Havens, the Council having
further considered the convictions proved against you,
does not direct the Registrar to erase your name from
the Medical Register.

The Council considered the case of William Shaw,
registered as of Lame, Co. Antrim, Lie. R. Coll.
Phys. Edin., 1886, Lie. R. Coll. Surg. Edin., 1886,
who had been summoned to appear before the Council
to answer the following charges, as formulated by
the Council’s solicitor: —

“That you were on November 27th, 1906, con¬
victed of the following misdemeanour at Larne Town
Court, namely, of being guilty while drunk of riotous
and disorderly behaviour; and on June 25th, 1907, of
the following misdemeanour at Larne Petty Sessions,
namely, of being found on unlicensed premises on
Sunday in contravention of the provisions of the
Licensing Acts; and on August 13th, 1907, at Larne
Town Court aforesaid, of the following misdemeanour,
namely, of being guilty while drunk of riotous and
disorderly behaviour.”

Mr. Shaw attended in answer to his notice, accom¬
panied by his solicitor, Mr. W. M. Woodhouse, of
Messrs. Peacock and Goddard, of Gray’s Inn.

The Solicitor having read the notice, and the three
certificates of conviction, Mr. Woodhouse addressed
the Council on behalf of Mr. Shaw, and read letters
in his favour from Mr. James Adrain, M.B. Bac.
Surg., of Larne, Mr. J. W. McNinch of the Lame
Cottage Hospital, Mr. Thomas Milliken, Justice of
the Peace for County Antrim, and the Rev. Mr.
D. H. Hanson.

He then tendered Mr. Shaw as a witness, and
examined him. Mr. Shaw answered questions put
to him, through the chair, by members of the Council.

The Council deliberated on the case in camerd.

Mr. Shaw and strangers having been re-admitted,
the President announced the decision of the Council
as follows: —

Mr. William Shaw, the Council have deliberated on
your case, and having carefully considered the con¬
victions recorded against you, have not seen fit to
direct the Registrar to erase your name from the
Medical Register.

The Council considered the case of Duncan Shaw
Morrison, registered as of Invergowrie, Perthshire,
M.B., Mast. Surg., 1891, Univ. Edin., who had been
summoned to appear before the Council to answer
the following charges, as formulated by the Council’s
solicitor: —

“That you were on September 24th, 1906, convicted
of the following crime or offence at Lochgilphead
Police Court, namely, of breach of the peace, and on
February nth, 1907, at the same Court, of the same
crime or offence, and on September 18th, 1907. at the
same Court, of the following crime or offence, namely,

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Dec. 4, 1907.

of a contravention of Section 70 of the Licensing
(Scotland) Act, 1903.”

Mr. Morrison was called, but did not answer to his
summons.

The Solicitor read the notice and the three certifi¬
cates of conviction; he also read a letter which he
had received from Mr. Morrison in answer to the
charge.

The Council then deliberated on the case in camera.

Strangers having been re-admitted, the President
announced the decision of the Council as follows: —

I have to announce that the Council have adjourned
the consideration of the three convictions proved
against Mr. Morrison until the May Session, 1908,
when he will be required to be present.

The Council considered the cases of John P. Rafter,
registered as of 338, Stanley Road, Bootle, Liverpool;
Lie. Apoth. Hall, Dubl., 1882; Lie. K.Q. Coll. Phys.
Irel., 1886; Lie. Midwif., 1892, R. Coll. Surg.
Irel. ; and John Spencer-Daniell, registered as of the
Metropolitan Hospital, Kingsland Road, London,
N.E. ; M.B., Bac. Surg., 1906, Univ. Edin., who
have been summoned to appear before the Council on
the following charge: —

“That you have systematically sought to attract
patients in Great Crosby and Waterloo, Lancashire,
by the distribution of cards from house to house and
in the street, and that in relation thereto you have
been guilty of infamous conduct in a professional
respect.”

The complainants were the Medical Defence Union.

Mr. Rafter attended in answer to his notice, accom¬
panied by his solicitor, Mr. Smith, of Messrs. James
.Shakespeare and Smith, of Liverpool. Mr. Spencer-
Daniell also attended in answer to his notice, but was
not represented by counsel or solicitor.

Dr. Bateman appeared on behalf of the Medical
Defence Union, the complainants.

The Solicitor having read the notice, Dr. Bateman
opened the case for the complainants.

He read correspondence which had passed between
himself as Secretary of the Medical Defence Union,
by whom many complaints had been received, and
Mr. Rafter and Mr. Spencer-Daniell.

He then read several statutory declarations.

Mr. Smith addressed the Council on behalf of Mr.
Rafter. He tendered Mr. Rafter as a witness, and
examined him.

Mr. Rafter was then cross-examined by Dr. Bate¬
man. Dr. Bateman read a letter which he had
received from the Royal College of Physicians of Ire¬
land, with reference to a complaint of a similar
character which had been made against Mr. Rafter
eleven years ago, concerning which he had cross-
examined Mr. Rafter.

Mr. Smith re-examined Mr. Rafter, who answered
questions put to him by the legal assessor, by the
chair, and by members of the Council through the
chair.

Mr. Smith then called Mr. Frederick Jackson, Mr.
Rafter’s dispenser, as a witness, and examined him.

Dr. Bateman cross-examined Mr. Jackson. Mr.
Smith did not desire to re-examine Mr. Jackson, who
answered questions put to him, through the chair, by
members of the Council.

Dr. Bateman did not desire to address the Council
again in regard to the case as it affected Mr. Spencer-
Daniell, who then addressed the Council on his own
behalf. He handed in a letter and testimonials which
had been written on his behalf.

Dr. Bateman cross-examined Mr Spencer-Dariell,
who also answered questions put to him, through the
chair, by members of the Council. The letter from
Mr. Peter Daniel, of the Metropolitan Hospital, which
Mr. Spencer-Daniell had handed in, was read.

Mr. Smith put in testimonials which had been given
to Mr. Rafter in 1906.

The Council deliberated on the case in camerd.

Mr. Rafter, Mr. Spencer-Daniell, and strangers
having been re-admitted, the President announced the
judgment of the Council as follows:—

Mr. John Rafter, I have to announce to you that the
Council have found the facts alleged against you in
the notice of inquiry have been proved to their satis¬

faction, and that they have adjourned the further con¬
sideration of your case to the May Session of the
Council, when you will be expected to be present and
to produce evidence as to your conduct in the interval.

Mr. Spencer Daniell, the Council have deliberated
on your case, and have passed the following resolu¬
tion :—

“That the facts alleged against you in the notice of
inquiry have not been proved to’ the satisfaction of
the Council. The case against you is therefore at an
end.”

The Council considered the case of Joseph Fitz¬
gerald, formerly registered as of 59, Red Rock Street,
Liverpool, but now as of Beach Buildings, Queens¬
town, Co. Cork, Lie. R. Coll. Surg. Irel., 1871, Lie.
R. Coll. Phys. Irel., 1873, who has been summoned
to appear before the Council on the following
charge:—

(1) “That you have acted as cov r to an unqualified
person, namely, Mr. Hamilton Williams Jolly, and
knowingly enabled him to attend and treat patients
and otherwise to engage in medical practice as if the
said Hamilton Williams Jolly were a duly qualified
and registered medical practitioner.

(2) “That you knowingly allowed the said Hamilton
Williams Jolly to fill up and sign in your name certi¬
ficates of death and vaccination in Novemoer or
December, 1905, and in June, 1907, whereas in fact
you had not attended or seen the patients in any of
the cases, but the said Hamilton Williams Jolly had
alone attended and seen them ;

J And that in relation thereto you have been guilty
of infamous conduct in a professional respect.”

Mr. Fitzgerald was called, but did not answer to his
notice.

The Solicitor having proved the sending of the
notice, which he read, proceeded to lay the facts of the
case before the Council.

The Solicitor read the evidence which had been given
by Mr. Hamilton Williams Jolly and Mr. Fitzgerald
at the inquest on Jessie Gogarty. He gavj a history
of the case, and also read letters written by Mr.
Fitzgerald to the Registrar and to himself in answer
to inquiries and to the notice.

The Council deliberated on the case in camerd.

Strangers having been Te-admitted, the President
announced the judgment of the Council as follows :—

The Council have judged Joseph Fitzgerald to have
been guilty of infamous conduct in a professional
respect, and have directed the Registrar to erase from
the Medical Register the name of Joseph Fitzgerald.

The Council then adjourned.

Third Day.—Thursday, November 28th, 1907.

The minutes of the last meeting were read, and,
as amended, confirmed

The Council proceeded to the consideration of the
case of John Papa Nicolas, registered as of 87.
Dowanhill Road, Catford, S.E., M.R.C.S. Eng.,
L.R.C.P. Lond., 1904, who had been summoned to
appear before the Council on the following charge:—

“ That you have systematically canvassed in Catford
for patients, by personal visits to patients of Mr.
Thomas William Atkinson and to others, both while
vou were in the employment of the said Thorns'
William Atkinson and subsequently, and that in the
course of such canvass you disparaged the qualifica¬
tions and skill of the said Thomas William Atkinson
and extolled your own, and that in relation thereto
you have been guilty of infamous conduct in a pro¬
fessional respect. ”

The complainants in this case were the London and
Counties Medical Protection Society.

Mr. Papa Nicolas attended in answer to his notice,
with Mr. H. J. Randolph Hemming, his solicitor, and
witnesses. The latter gentleman was accompanied bv
a lady, who acted as his adviser, and by' a female
shorthand writer.

Dr. Hugh Woods attended on behalf of the London
and Counties Medical Protection Society, the com-
i plainants, also with witnesses.

On question from the chair, Dr. Hugh Woods stated
that he had no objection to the presence of witnesses
I during the hearing; but on Mr. Hemming being asked

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Dec. 4> 1907. _GENERA L MEDICAL COU NCIL^ Th e Med ical P »sss 613

the same question, he took exception to their presence.
Witnesses, therefore, by direction from the chair, with¬
drew.

The Solicitor having Tead the notice, Dr. Hugh
Woods proceeded to open the case for the com¬
plainants.

Dr. Woods called Mr. Thomas William Atkinson,
M.B., B.S., R. Univ. Irel., of Berrymead, 78, Bromley i
Road, Catford, as a witness. He read Mr. Atkinson’s !
statutory declaration, and questioned him as to its i
accuracy, which he confirmed. 1

Mr. Atkinson was then severely cross-examined by I
Mr. Hemmrng, who, however, was unable to materially [
shake the statement brought forward by Mr. Atkinson. |
In the course of the cross-examination, the Legal 1
Assessor of the Council intervened, and on behalf of j
the President, requested Mr. Hemming to confine his 1
questions to the occasions when Mr. Papa Nicolas had, |
as alleged, used his opportunities to disparage Mr.
Atkinson

The Legal Assessor at a later stage again objected
to Mr. Hemming’s cross-examination of Mr. Atkinson,
in regard to a conversation which had not taken place
in his presence.

Mr. Hemming cross-examined Mr. Atkinson in
regard to the statutory declarations which had been
prepared in support of the charge, and read statutory
declarations made by several of the witnesses con¬
tradicting those previously made by them in support
of the charge, and put in a declaration by Mrs.
Lavallin.

Mr. Hemming asked to see the original letter of
complaint. The Council’s Solicitor explained that the
documents to which parties were entitled were those
which were sent to the Council in support of the
charge or in answer thereto.

Mr. Hemming pressed his application for the pro¬
duction of the document, and asked for an adjourn¬
ment to enable him to apply to the Court for a
mandamus.

Dr. Woods having expressed his willingness that his
letter of complaint should be produced, the Council
allowed the letter to be read by their Solicitor, and
Dr. Woods undertook to supply Mr. Hemming with a
copy.

The Legal Assessor explained the procedure of the
Council in regard to the matter.

Mr. Atkinson was then re-examined by Dr. Woods,
with several interruptions by Mr. Hemming.

Mr. Atkinson answered a question put to him.
through the chair, by a member of the Council.

The Council then adjourned.

Fourth Day.—Friday, November 29TH.

The minutes of the previous meeting having been i
read and as amended confirmed, the Council pro- l
ceeded to the consideration adjourned from Thursday, 1
November 28th, of the case of John Papa Nicolas, j
registered as of 87, Dowanhill Road, Catford, S.E.,
M.R.C.S.Eng., L.R.C.P.Lond., 1904.

The complainants in this case were the London and 1
Counties Medical Protection Society. 1

Mr. Hemming, defendant’s solicitor, on the case I
being called, stated that he had applied for writs of !
prohibition and of mandamus against the General
Medical Council and against John W. Atkinson.

The Council having deliberated in camerd , it was
announced, on strangers, etc., being re-admitted, that
the case was adjourned until the next session of the
Council.

The Council next considered the case of William
Henry Roberts, registered as of 63, Lower Mount
Street, Dublin, Lie. R. Coll. Phys. Edin., 1885, Lie.
R. Coll. Surg. Edin., 1885, who had been summoned
to appear before the Council at 4.30 p.m., on
November 28th, on the following charge: —

“That you have knowingly assisted certain persons
who are not registered as dentists, namely, Mr.
Keogh, of No. 4, Lower Mount Street, Dublin, and
Mr. John Blake Dillon, Messrs. W’illiam-Steyn and
Mr. M. William-Steyn, all of 23, Rathmines Road,
Dublin, in performing operations in dental surgery
by administering and offering to administer

anaesthetics, and have so enabled these persons to
treat patients and to engage in dental practice as if
they were duly qualified in dentistry and dental
surgery, and that in relation thereto you have been
guilty of infamous conduct in a professional respect. ”
The complainants were the Irish branch of the
British Dental Association.

Evidence having been gone into, the President,
after the Council had deliberated in camerd,
announced that it had been decided that the defendant
was to come before the Council next May for judg¬
ment.

The Council then proceeded to the consideration of
the case of John Bernard Gabe, registered as of
Pentrepoth House, Morriston, Swansea, Lie. Soc.
Apoth. Lond., 1881, I.ic. Fac. Phys. Surg. Glasg.,
1881, who had been summoned to appear before the
Council on the following charge: —

“That you have employed as your assistant in con¬
nection with your professional practice a person not
duly qualified or registered under the Medical Acts,
namely, Mr. Frank Hannah, and have knowingly
allowed him to attend and treat patients in respect
of matters requiring professional discretion or skill,
j and that in relation thereto you have been guilty of
| infamous conduct in a professional respect.”

1 The complainant was Mr. John Jenkins, of Temper¬
ance House, Tirdeunaw, near Swansea.

And of the case of Morgan Watkin Williams,
registered as of Trewernen, Llantwitfardre, Ponty¬
pridd, South Wales, M.B., Bac. Surg., 1900, Univ.
Glasg., who had been summoned to appear before
the Council on the following charge: —

(1) “That you, being a duly qualified and registered
medical practitioner, while acting as assistant to Mr.
John Bernard Gabe, also a duly qualified and
registered medical practitioner, by your countenance,
assistance, and co-operation knowingly enabled an
unqualified and unregistered person, namely, Mr.
Frank Hannah, who was also acting as assistant to
the said J. B. Gabe, to attend and treat patients and
engage in medical practice as if the said F. Hannah
were duly qualified and registered ;

(2) “That you signed a certificate of death, namely,
of Alice Mary Jenkins, which stated that you had
attended the said Alice Mary Jenkins in her’last ill¬
ness, and that you last saw her alive on May 4th,.
1907, whereas in fact you had not so attended her
or seen her, but the said Frank Hannah had alone
attended and seen her:

“And that in relation thereto you have been guilty
of infamous conduct in a professional respect. ”

Mr. G. F. Evans, K.C., M.P., appeared for both
the defendants.

Evidence on both sides having been heard, the
President, after the Council had deliberated in camerd,
announced (1) that the facts against Mr. J. B. Gabe
had not been proved to the satisfaction of the Council,
and (2) that the facts alleged against Mr. M. W.
Williams had been proved to the satisfaction of the
Council, but that he was called upon to come before
the Council next May for judgment.

The Council then considered the cases of Arthur
James Arch, of Leicester House, Coventry, registered
as Mem. R. Coll. Surg. Eng., 1904, Lie. R. Coll,
l’hys. Lond., 1904; William Walter Fenton, of Avon-
more, Warwick Road, Coventry, registered as M.B.,
Bac. Surg., 1893, M.D., 1894, Univ. Dubl., Lie.
Midwif. K.Q. Coll. Phys. Irel., 1884; Thomas Alfred
Hird, Norton House, Coventry, registered as M.B.
Mast. Surg., 1882, M.D., 1900, Univ. Edin. ; and
William James Pickup, Swanswell, Coventry, registered
as Mem. R. Coll. Surg. Eng., 1876, Lie. Soc. Apoth.
Lond., 1877, M.B., 1880, M.D., 1893, Univ. Lond.,
who had been summoned to appear before the Council
on the following charge :—

“That you have joined with other registered medical
| practitioners in forming and are one of the medical
1 staff of a dispensary, namely, the Coventry New
I Dispensary Service, which systematically canvasses
| for patients, and that in relation thereto you have been
guilty of infamous conduct in a professional respect.”

The complainants are Andrew St. Lawrance Burke,
Gosford House, Coventry, registered as Lie., Lie.

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6l4 The Medical Press

CORRESPONDENCE.

Dec. 4, 1907.

Midwif., 1895; R. Coll. Phys. Irel. ; Lie., Lie.
Midwif., 1895 ; R. Coll. Surg. Irel. ; Alfred Pytehes
Blanchard Ellis, of Earlesdon House, Earlesdon,
Coventry, registered as Lie. Soc. Apoth. Lond., 1896;
and John Inman Langley, formerly registered as of
Parkside Arcadian Gardens, Bowes Park, N., but now
of 14, Warwick Road, Coventry; Mem. R. Coll. Surg.
Eng., 1898, Lie. R. Coll. Phys. Lond., 1898, who were
represented by Mr. McCardie, barrister.

Mr. J. A. Hird unfortunately died on November 28th.

Evidence having been heard, the Council, after
deliberating in camerd, found that the case had not
been proved.

The motion by the President, as Chairman of the
Companies Bills Committee, “That the following be
appointed additional members of the Companies Bills
Committee, Sir Charles Ball, Dr. Langley Browne,
Mr. Morris, and Dr. Kidd,” was carried.

The report from the Education Committee, proposed
by Dr. Mackay, seconded by Sir John Moore, was
agreed to, adopted, and to be entered on the minutes.

The report from the Pharmacopoeia Committee,
proposed by Dr. Norman Moore, seconded by Dr.
Lindsay Steven, was agreed to, adopted, and entered
on the minutes.

The following reports from the Examination Com¬
mittee, proposed by Dr. McVail, seconded by Mr.
Young:—

(a) On the returns as to examinations for entrance
to the Navy, Army, and Indian Medical Services since
the last Session of the Council.

( b) On the final examinations (July, 1907) of the
Apothecaries’ Hall, Dublin.

After some remarks from Dr. Adye Curran with
reference to inspectors, were received, adopted, and
entered on the minutes.

A report from the Students’ Registration Com¬
mittee, proposed by Sir Hugh Beevor, seconded by
Dr. Norman Moore, was received, adopted, and
entered on the minutes.

Mr. Henry Morris was unanimously appointed
Treasurer to the Council, owing to the resignation of
Dr. Pye-Smith.

A vote of thanks to the President was proposed by
Dr. Norman Moore, seconded by Sir J. Moore, and
carried by acclamation.

The Council then rose.

CORRESPONDENCE

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Pari*. Dec. ist, 1907,

Artificial Abscess.

A few additional remarks are necessary to complete
what we have already written on artificial abscess.

Prompt reaction to the chemical agent injected, con¬
stitutes one of the most favourable signs and the rapid
and abundant formation of pus should excite no
anxiety, as it is a proof of the resisting power of the
organism.

Towards the third day the pus begins to form and
the abscess opens spontaneously between the sixth and
fifteenth day. According to Fochier, ihe abscess should
never be opensd, but generally, as soon as fluctuation is
well evident and above all if the patient has entered
on convalescence, the collection is incised and dressed
antiseptically. The wound cicatrizes slowly, a month
or more being sometimes neccessary.

The effects of the abscess are as follows: —
Immediately after the injection the temperature may
rise a little, but as soon as reaction sets in it falls,
the pulse becomes less frequent, and the quantity of
urine increases, and if albumin exists it is reduced
in quantity. This improvement may take place within
twelve hours after the injection, but the temperature
becomes normal only when suppuration is formed.

The therapeutic method of this artificial pvogenesis

may be resumed as follows:—(a) Artificial abscess
seems to possess indisputable therapeutic, effects in a
j patient suffering from infection of no matter whit
i source; (b) artificial abscess is indicated in all cases
of ordinary septicoemia, after other methods of
; treatment have failed ; (c) an injection of 20 drop of
sterilized turpentine into the cellular tissue is sufficient
to produce it. The intensity of the local reaction
that the injection provokes is in direct ratio with the
degree of resistance of the patient; (dl the incision of
the abscess must coincide with local abundant
suppuration and improvement in the alarming general
symptoms ; (e) from the moment of the injection to
complete cicatrization, the artificial abscess must be
treated antiseptically.

Artificial abscess, it must be confessed, is at most an
empiric treatment, as its mechanism has never been
established, either clinically nor by experiment.

Fochier considers it to be an organ of attraction for
the microbes and the toxines.

Dieulafoy is a partisan of the bippocratic ideas of
metastasis. For Trifon, the abscess neutralizes the
toxines, while Pinna and Mercaudino consider it to
be a laboratory for the formation of bactericide,
antitoxic substances which penetrate by absorption
into the lymphatic circulation.

Thiosinamin in Heart Disease.

For the last few years Prof. R£non has been
utilizing the curious properties of thiosinamin to
soften cicatricial tissue, for the treatment of certain
valvular diseases of the heart, cardiac symphysis and
arterio-sclerosis.

For mitral affection no improvement was observed,
but he had considerable success in aortic disease.
Patients who could not mount stairs nor carry heavy
loads were able to make those exercises without any
or but very slight oppression. The arterial tension
was lowered, and albumin diminished or dis¬
appeared. However, the stethoscopic signs were in
no way modified, no difference in the intensity of the
souffle was ever remarked. Its effects were limited
to reducing the dyspnoea and lowering the arterial
tension, advantages that can be appreciated. The
solution he uses is : —

Thiosinamin, 15 gr.

Distilled water, 7 dr.

Each subcutaneous syringe contains four-fifths of
a grain. Five syringes are injected at the one time,
beneath the skin of the abdomen, and repeated every
day for a month. The injections are not painful, nor
do they produce indurations.

GERMANY.

Berlin. Dec. 1st, 1907.

At the Medical Society, Hr. L. Michaelis reported
that he had been successful in producing a direct re¬
action in a case of hereditary syphilis bv making use
of a serum of very high power. The reaction of 0.01
corresponded to 0.2 of the other that had been dis¬
covered ; it was therefore 20 times stronger. For
proving the reaction syphilitic liver extract was em¬
ployed. The reaction was checked by excess of liver
extract. From this it followed that this contained the
antigen, the material within the patient on the other
hand, the “antistoff.”

Hr. Falkenstein gave a retrospect of
The Treatment ok Gout by Hydrochloric Ann.
after observations extending over five years He re¬
minded his hearers of an address on the same subject
delivered before the Society four years ago. He then
discussed the nature of gout and its treatment bv
hydrochloric acid. Since that time he had daily given
50 to 60 drops of hydrochloric acid, and had also
carried out the same course of treatment in a large
number of other cases. The large doses of hydro¬
chloric acid were perfectly harmless, so ’ong as they
were sufficiently diluted and taken along with a suffi¬
cient quantity of food. The alkalescence of the blood
was not diminished by the acid, nor were the teeth or
organs in any way injured.

The speaker proceeded on the assumption that uric
acid was harmful only when it was associated with
alkalies whereby its tendency to deposit became

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CORRESPONDENCE.

The Medical Press. 615

Dec. 4, 1907.

heightened. In gouty patients the primary fault lay
in a deficiency of hydrochloric acid in the stomach.
It was only then that imperfect digestion of nuclein-
albumen arose, with excessive alkalescence. Where,
however, there was disease of the mucous membranes
of the stomach, the hydrochloric acid was otherwise
abnormal and the deficiency of it was of subordinate
importance. During the attack of gout itself hydro¬
chloric acid had no effect; it should rather be used
permanently during the intervals.

The objection that not infrequently there were cases
of deficiency of hydrochloric acid without gout he
rejected; there must be a primary antacidity; imper¬
fect digestion of nuclein-albumen could only oiiginate
then, along with excessive alkalescence.

He had treated 390 cases by this method, and divided
them into three groups according to their severity and
the age of the patient, on which the results of treatment
depended. It was only in the most severe and most
chronic cases that the progress of the gouty changes
could not be influenced.

Hr. Kraus considered the most important thing in
the treatment of gout to be the food—the long-con¬
tinued giving of foods containing no uric acid. Along
■with this, the long-continued use of mild alkalies
appeared to have an effect on the frequency and
severity of the attacks.

Hr. Brugsch, in opposition to the reader of the
paper, considered gout to be not a hereditary disease
of the stomach, but a diseased nuclein tissue change.
If the hydrochloric acid constituent of the stomach
was greater then the quantity of pancreatic secretion
increased and the balance remained always the same.
Hydrochloric acid did not cure gout; the chief thing
■was the diet.

Hr. Falkenstein meant to say that vegetarians even
did not get free of their gout, whilst under the use of
hydrochloric acid, patients improved, notwithstanding
they were taking fresh meat in large quantities.

At the meeting of the 13th ult., Hr. Albu showed a
female patient, ret. 72, who for seven years had
suffered from a copious fluid discharge from the
rectum, which had been collected and examined. It
was found to consist of watery thin mucous. Just
above the anus a rather large warty growth was felt,
■which the patient could easily force down by strain¬
ing. The tumour was certainly not malignant, as a
portion examined under the microscope showed. Con¬
sidering the age of the patient, it was deemed ad¬
visable not to operate.

He then showed a tumour taken from a woman,
set. 62, that had been removed two years previously.
Here also the growth could be made to protrude from
the anus. It was clearly malignant. The removal was
carried out by the late Prof. v. Bergmann. Recovery
was normal, and the patient had had two years’ good
health.

Prof. Ewald is about to retire from the editorship of
the Berliner Klinisfhen Wochenschrift, and will be
succeeded by Dr. Hans Kohn, of that city.

AUSTRIA.

Vienna, Dec. ist, 1907.

Fistula Gastrocolica.

Falta presented a case of gastrocolica to the Gesell-
shaft which he operated on in 1902, who came to him
then with typical stenosis from ulceration of the
stomach, which demanded gastro-entero-anastomosis.
In spite of this operation, the ulceration of the stomach
still persisted, 1904-5 and 1907. A tube was passed
into the stomach, and faeces extracted or vomited. Air
was next blown into the rectum, passing up the
descending colon with a metallic noise and rush into
the stomach, whence it was ejected by the mouth.
Water coloured with methylene blue was injected
through the rectum, which took the same course as
the air, and was thrown out by the mouth. The
ROntgen rays confirmed the passage of the air out of
the colon into the stomach by a direct communication
through which the contents of the colon passed readily
into the stomach. Before this time no symptom indi¬
cated that a direct communication existed between the
stomach and colon. He thought there was nothing left
but to perform another operation to correct the morbid
change.

Holznecht said he had one of these rare cases where
the history of anastomosis appeared to be established,
but it was found later that the pylorus was perfectly
patent, and no other communication existed.

Eiselberg thought that gastro-enterostomy should
only be performed on careful deliberation after open¬
ing the parts, and before severing any of the internal
organs. There are many of the pyloruses that are un¬
suitable for removal at one time, but after the ulcers
have healed can be removed with advantage.

Traumatic H-ematoma.

Eiselberg exhibited a boy, ret. 16, with a large soft
fluctuating swelling on the left side of the "head.
Around the base of the tumour it was as hard as bone
and painless on pressure, the latter being true of the
whole swelling.

The history of the case was that twelve days before
this exhibition he had been playing with other boys,
and was caught up by the hair of the head on the left
side in their fun. On the following day he found it
swollen a little, but gave it no further heed; on the
second day it was larger, and has gradually increased
every day till it has reached the present dimensions.

Syphilis and Valvular Disease.

Fein presented a young soldier, ret. 20, with insuffi¬
ciency of the mitral valve and complete paralysis of
the left vocal cord. The Rflntgen rays showed an in¬
crease of the heart in all directions, as seen from the
pulsating shadow, but no aneurysm could be detected.
From the history the young man had syphilis six
months previously. Energetic anti-syphilitic treatment
was immediately commenced, and the patient improved
in voice and general health within three weeks, although
the vocal cord had been greatly atrophied The great
difficulty in breathing had quite disappeared, and the
cardiac sensation had returned to its normal condition.
After commencing the inunctions, the vascular walls
began to repair rapidly, which is unusual in fresh
cases. The widening of the aorta soon began to con¬
tract, and thus relieve the vocal nerve.

Perl-Cyst.

Tertsch presented a young female, ret. 20, with a
cyst in the anterior chamber of the right eye. the result
of a stab. It appears that some of the epithelial cells
were carried through the cornea into tbe anterior
chamber, where they commenced to proliferate and
form a sac like a hair bulb or gland, and finally attach
itself to the iris. Having once got a root, a cyst was
formed, till a good-sized tumour was formed, but hap¬
pily began to break down in the centre. These neo¬
plasms resemble the atheroma or cholesteatoma in the
destruction of the eye, and should be removed at the
earliest opportunity, as the prognosis is alwav3 favour¬
able.

Foreign Body in Trachea.

Marschitz showed a boy, ret. 5, who had allowed a
fish-bone to get down the trachea and it was caught at
the bifurcation of the bronchi. There was no choking,
but sudden aphonia appeared, with difficulty in
swallowing. With the laryngoscope the bone could be
seen lying in the sub-glottic space directly in the
median line. The boy was narcotised, and the body
caught with Schrotter’s forceps and brought up to the
glottis, where difficulty arose to get it through. The
child, feeling the pain, made a sudden move, causing
the operator to press the body tighter, which broke,
allowing part of it to fall back into the bronchi, where
it could afterwards be seen with the bronchoscope; it
was removed with another pair of long forceps. In
spite of this successful removal with the bronchoscope,
he thinks tracheotomy the safer operation, as there is
not such fear of oedema of the glottis.

CONTINENTAL HEALTH RESORTS

1.—A SUDDEN FLIGHT TO THE SUNNY
SOUTH.

[From Our Continental Correspondent.]
Nice is undoubtedly the most important town on
the French Riviera. It has become a general favourite
with all nations, and with the advent and persistency
of the November fogs, the annual migration to the
sunny south has been hastened. Thanks to the excel-

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6 l6 The Medical Press.

CORRESPONDENCE.

*

Dec. 4, 1907.

lent service of the South-Eastern and Chatham Rail¬
way, with their new and fast boats vi& Dover and
Calais, Folkestone and Boulogne, and special train
service of the popular P.L.M., the Riviera can be
reached in comparatively few hours under exceptional
circumstances of enjoyable comfort.

The climate of Nice and of Cimiez is dry and
bracing, such as to strongly stimulate metabolism.
Glorious excursions far and near, and delightful walks
in the immediate environs, afford the necessary
attractions to those in search of health ; and for those
who are suffering from nerves, throat troubles, or
rheumatic tendencies, Nature and Art appear to have
joined hands to Tender the beautiful region of Cimiez
(the favourite resort of her Majesty the late Queen
Victoria) one of the most desirable places for winter
residence along the Riviera. Excellent hotels also
abound, each endeavouring to excel the other in all
matters of hygiene, cuisine and comfort, thus leaving
power to the visitor to decide according to his tastes
or his purse. I would specially draw attention to the
recently constructed “Winter Palace” and Hermitage,
luxuriously furnished with all home-like comforts, and
commanding, as they do, a magnificent panorama, sur¬
rounded on all sides by well-kept and picturesque
gardens, rejoicing in an atmosphere free from dust and
noise. Both ends of this charming resort are to be
strongly commended, so that it is purely a matter of
personal choice where hotels are all good and do their
utmost to satisfy the tastes and meet the wishes of
their guests. Excellent concerts twice daily delight
the musical ears of those who spend the mornings and
afternoois inhaling the ozone-laden atmosphere,
together with the tonic woodland and perfume of
flowers. Cimiez is not a place for chronic invalids,
and it is well that physicians should bear this fact in
mind when deciding on a winter health resort for
patients; but for people who are convalescent and
jrequire bracing up it stands unique. Well-known
physicians, English and foreign, are to be found in
this ideal spot.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

Treatment of Incipient Mental Disease.— The
question of the treatment of early and “border-line ”
cases of mental disorder in the Edinburgh Infirmary,
which caused a good deal of discussion some years
ago, and was then dropped for the time being, has
again been brought before the public bv a letter from
Dr. Clouston, and an editorial which appeared in the
Scotsman of November 29th. Dr. Clouston recapitu¬
lates the facts which were brought out three years ago
—the general favour with which the proposal to treat
such cases in the infirmary was received by the medical
profession ; the approbation of the Commissioners in ,
Lunacy ; and the welcome of the philanthropic public. '
The managers of the infirmary, impelled largely by
financial considerations, however, decided that the time
had not yet come to institute such wards. Since that
time, says Dr. Clouston, wards for suitable mental
cases have been successfully established in America, ,
Canada, and Australia. “To have a patient suffering !
from a short attack of child-bed delirium formally
committed to a mental hospital on two doctors' certi* |
ficates and a sheriff's order, when a few weeks' treat- '■
ment in suitable wards in the Royal Infirmary would 1
cure her disease and restore her again to her family, J
is almost a scandal.” While arguing that this is a I
question for the public, and not merely doctors to ;
settle, Dr. Clouston goes on to say that the overwhelm- i
ing opinion of medical men who are specially in- ]
terested in mental diseases was in favour of the scheme 1
four years ago. Sir Arthur Mitchell, Sir John Tuke, i
Sir John Sibbald, Dr. Fraser, Dr. Macpherson, Dr. j
Urquhart, Dr. Robertson, Dr. Brace, and Dr. Easter-
brook are quoted as having supported it. Every ,
general practitioner he has spoken to has backed up 1
his opinion that such wards would be of enormous !
use, and are urgently needed. Glasgow is ahead of !
us in this respect, having provided for the treatment !

of incipient and uncertified mental disease in a way
that is doing a great service to the most helpless class
of mankind. It appears to Dr. Clouston that the time
1 has now come for the managers of the infirmary to
take the matter up. In addition to providing early
treatment for cases which are now allowed to drift into
1 incurable mental conditions, such wards would have
I the great advantage of helping to strengthen in the
! public mind a realisation of the fact that insanity is
| a bodily disease, and so remove the reproach or stigma
| which ignorance or prejudice attach to it. It will be a
1 great gain to Dr. Clouston that he has secured the aid
of the Scotsman in his crusade, and the strongly-
written editorial in which reference is made to his
| letter will strengthen the hands of those who urge that
I mental wards are required. The editorial speaks of it
I as “a highly deserving cause,” and emphasises “how
seriously defective is our equipment for treating in¬
sanity in its curable stages” compared with the pro-
| visions made on the Continent. The ground taken is
that the infirmary was compelled to defer the scheme
because it had other work on hand ; now the con-
! tributors should recognise that they have an enlarged
responsibility, and provide funds for Dr. Houston's
ideal. “It would complete on a side hitherto neglected
a great charitable institution for the help of suffering.
It would extend ths sphere of experience and in¬
struction available for a great medical school. It might
even effect some saving in the public cost of main¬
tenance of pauper lunatics in the asylums.”

Trinity Hospital Fund Appointments. —The Town
Council have appointed the following gentlemen
Medical Officers to the Trinity Hospital Fund:—Dr.
James Murray, Dr. John McLaren, Dr. J. A. H.
Duncan, and Dr. Balfour. The Medical Officership
was formerly held by the late Dr. Dunsmure, but when
it became necessary to elect a successor, the Council
resolved to divide the appointment and elect four
medical officers resident in different parts of the city.

Scottish Orphan Homes. —The thirty-sixth annual
meeting of these homes, founded by the late Mr
Qluarrier, was held in Glasgow on November 27th.
In the homes on October 31st, 1907, there were 1,268
children—687 boys and 599 girls. In the consumption
sanatoria were treated 336 patients during the year,
and there were 2,030 attendances at the dispensary
The first home for epileptics has been in operation for
15 months, and is now filled with 30 young men
! Among those who spoke at the meeting were Dr. W. 1 .

| Reed and Professor Stockman. “Quarrier’s Homes.”
as they were formerly called, arose through the labours
of one man, and are among the best known charities in
Scotland. Everyone has always recognised the ad¬
mirable way in which they were conducted, and as
the Scottish Orphan Homes they will remain as an
enduring monument to the memory of their founder.
Mr. James Quarrier.

BELFAST.

Ulster Medical Society.—Annual Dinner. —Tbe
annual dinner of this society was held in the Medical
Institute, Belfast, on Thursday, 28th ult., and was a
most successful function. The chair was occupied by
Dr. John McCaw, the President of the Society. Tbe
toast list was brief, and the intervals were filled by
songs and recitations by members. After the toast of
“The King,” proposed by the President, had been
drunk, Mr. A. B. Mitchell proposed “The Lord
Lieutenant and Prosperity to Ireland,” and in doing
so appealed to those present to help in promoting thi-
prosperity by spending their holidays in their" own
country, of the remoter parts of which most know so
little. The High Sheriff of Belfast, Dr. Pett:
O’Connell, J.P., replied, and in an eloquent speech
prophesied brighter days for Ireland, in which tbe
members of our profession would occupy important
places as the apostles of preventive medicine. “Ou:
Guests ” was proposed by Dr. Walton Browne, and
responded to by President Hamilton, of Queen'-
College, and Dr. Warnock, of Donegal, President 0;
the Ulster Branch of the British Medical Association
The health of the President of the Society was pro¬
posed by Dr. J. B. Moore, and, in replying, Dr
McCaw gave some particulars of a golf prize which

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Dec. 4, 1907.

CORRESPONDENCE.

The Medical Press. 617

he is offering for competition among the members this
winter. Decidedly the most entertaining item of the
evening’s programme was the reading by Dr. R. J.
Johnstone of a poem, which he said he had been
privileged to take down in shorthand on the opening
■of the Tuberculosis Exhibition in Belfast last week,
“The Last Dying Speech and Confession of Bacillus
Tuberculosis, Esq., late of Belfast, with a Full History
of his many Crimes and Murders, and his most Edify¬
ing End.” The allusions to the work of Sir John
Byers, Dr. Thomas Houston, and others named in the
poem were received with great applause, and after the
reading Dr. Johnstone quickly disposed of many copies
at sixpence each for the benefit of the Royal Medical
Benevolent Fund of Ireland.

LAST DTING SPEECH AND CONFESSION OF BACILLUS
TUBERCULOSIS, ESQ.

'Twas a weariful bacillus, old and faded, worn and gray,

Who, drying on the ooveralip spake thin and far away:

“ Proud mortal, ere my form you steep in carbol fuohsin stain,
Ere I bathe in acid alcohol again and yet again,

I would fain recount my story to your sympathetic ear;

But wet my lips with saline, for the Bunsen flame’s too near.

I was once a gay young microbe, and I floated round the town,
Wrapped up in well-dried mucus, light a« the thistle down.

My rno-e was old and mighty; Koch made us known to fame.
For the Tuberole Bacillus is my far-renowned name.

In the heyday of my vigour, when the world and I were young.
My aims were high—I sought and found the apex of the lung.
With a ohemotactic longing leucocytes came flocking round,

We dallied fondly till we changed, th’ expiratory sound,

80 Professor Lindsay spotted me, and ordered mo to quit—

I find fresh air unhealthy, I thought it best to flit.

More cautious now, I songht fo rest embraced by giant cells,
Within a deep cervical gland that near the phrenic dwells.
Unhappy choice! for Surgeon Kirk removed me all complete,
With half a foot of jugular and half a pound of meat.

My bonds with man, so rudely torn, gave all my faiths a shock,

I doubted—'Am I human ? p'ropa I ought to try the flook;

I may be bovine after all; since man evicts me still
I’ll look for compensation under Mr. Birrell’s Bill.

80 I found a oountry dairy, just back of Grosvenor Street;

A friendly stripper took me in and lodged me in her teat
Here, amid rustic sights and smells, I ruralised a space,

Then borne upon a stream of milk rejoined the human race.
-Snug in mesenterio nook I soon addressed my mind.

By fission's simple easy arts, to propagate my kind.

■Over the serous surface quick spread my hardy brood;

Ascitic fluid came in floods—we found it very good.

But Thomas, prince of opsonists, by fell mischance came nigh:
Hte took the index of our host, and found it very high.

Treatment on scientific lines we heard him then discuss—
Tuberculin, one milligramme, soon decimated us!

Fleeing the slaughter of my tribe, my powers now rather weak,
With hearty zest I made a nest upon’a damask cheek.

There, in an apple-jelly speck, I’d hoped to end my life,

But X-Rays pieroed me to the quick—I left th' unequal strife.
Since then I've wandered round Belfast, but find the world
grown hard,

Man's bowels yearn no more for me, and bovine beasts are
barred.

A band, with demonstrating ways and eloauenco profound,
*C>ainst me the people's passions raise, and loud the tocsin sound.
Chief instigator of the fray. Sir John—' No quarter ’—cries,
When knights were bold they fought with things—well, nearer
their own size!

A surgeon, too, a vet. as well, physicians odd their breath,

And gents from sanatoria, where we are fed to death.

And several more who show ray orimes, while all the people
stare;

Though many a fee they’ve got for me—they'll get no more, I
swear!

For now those oft-respired airs, in which a microbe blooms,

Are blown to Hades by the breeze denouncing ' Stuffy Rooms.’
They’ve cleared away the dust, in which I used to lurk and
hope;

They hear ' What other nations do ’—the Dutch are fond of soap.
I lived with darling children once, in tissues soft as silk;

I simply can’t get near them now—they sterilisj the milk!
Aye, worse than that—excuse the tear of pity in my eye—

The poor milch cows that harbour us, for that offence must die.
The very things I most detest I strive in vain fo flee,

All round it’s sunlight, food, fresh' air, to kill ‘ the Soourge ’—
that's me.

Why, many good, hard-drinking souls are sorely put about—
They’re going to dock the beer, because I like men fond of stout.
At peril oft before I scoffed, I’ve managed to outpace
The dreaded phagocyte’s pursuit, his fatal slow embraoe;

I’ve laughed to scorn iodoform, and once—’twas rather warm—
Passed through a disinfector, hid in blankets, without harm I
But at the fate we’ve met of late imagination swoons—
Frizzling to death by millions in combustible spittoons!

Well, when assailed by these alarms I had begun to quake.
Professor Symmers welcomed me for old acquaintance sake.
Said he—' Can I believe my eyes, and have we met at last,

Sole Tubercle Bacillus left alive in all Belfast f

Nay, come; I’ll gladly take thee In, and gladly give thee place

Upon this spacious agar slope, last scion of thy rnoe.

With glucose will I nourish thee, and human serum, too,

And thou shalt grow apace, and I will put thee oft on view—
The parasite that lived and throve—believe it now who can—

In pre-Exhibition ages on pre-Exhibitlon man.’ ”

The murmur ceased, the microbe passed; the relics are on view—
A crimson speck, in balsam, on a ground of methyl blue.

Cerebro-Spinal Fever. —At the last meeting of the
Public Health Committee, Dr. Gardner Robb reported
that for some time past he has been using a new serum,
not yet upon the market, for the treatment of cerebro¬
spinal meningitis cases, and that the results have been
very much better than those obtained from any of the
other serums he has tried. Details of thi3 seium will
be awaited with interest, as Dr. Robb’s very extensive
experience gives great weight to his words, apd those
who know his caution will be the first to expect a
good deal of a remedy of which he speaks as he does
of this.

LETTERS TO THE EDITOR.

SAN DOW AS PHYSICIAN.

To the Editor of The Medical Press and Circular.

Sir, —Ours is a great and noble profession. It ; n-
volves complete self-sacrifice. Our mission is to
succour suffering humanity without any kind of sordid
consideration. How much we get paid for arduous
services calling for expenditure of our best vital forces,
or whether we get paid at all, matters not one jot;
we must give ourselves up body and estate to our
altruistic mission. With feelings like these which
inspire all of us, I am certain every one of your leaders
has, with me, welcomed the establishment in London
within the past few weeks of two noble institutions
which promise to bring speedy relief to crowds of
sufferers to whom the slow, uncertain methods of
scientific medicine are of no use. These two great
institutions, “The Nauheim,” in George Street, and
“The Sandow,” in St. James’s Street, have been suffi¬
ciently referred to in your columns, and have been
fully described in articles in the Times and all the lay
Press. “The Nauheim” establishment cures all the
maladies which are uncertainly dealt with at Nauheim
itself, besides a good string of diseases not dealt with
at Nauheim. It does this by the Nauheim bath treat¬
ment and other wonderful methods which a purblind
medical profession is not cognisant of. “The
Sandow ” institution cures the sams string of maladies
—a few more or a few less—by marvellous muscular
exercises of which a quite blind medical profession
has never perceived the value. “The Nauheim” in¬
stitution assures us—although no reasonable man can
need such assurance—that the profession was repre¬
sented by eminent doctors at its opening, and that
they are flocking with their patients to enter upon a
“new era in medicine.” It modestly Tefrains from
giving the name of a single doctor—modesty which
every member of the profession, although sym-
pathisingly, must regret. “ The Sandow ” institution
claims, no doubt with equal Tight, the support of
leading doctors, and quite properly puts the name of
a distinguished supporter in its advertisements. This
gentleman, it seems, is Sir Conan Doyle, who, we are
told, has given his imprimatur to the work of Mr.
Sandow. I am sure we would all like to back up Sir
Conan in his philanthropic endeavours in ihis con¬
nection, and we should all be glad to know from him
how best to set about it. Can you. Sir, ask Sir Conan
Doyle for an explanation through your widely-read
pages?

I am, Sir, yours truly,

An Obscure Practitioner.

November 29th, 1907.

[We regret our correspondent, a well-known member
of the profession, prefers to withhold his name, and
we trust that this fact may not prevent Sir Conan
Doyle from acceding to his request. Sir Conan Doyle
now holds a position of complete detachment from
professional life, and it would be most interesting to
learn his views with regard to Mr. Sandow’s new
pathological ideas and therapeutical practices.—E d.
M. P. and C.]

DO MEDICAL MEN ASSIST IN THE SALE OF
PROPRIETARY MEDICINES?

To the Editor of The Medical Press and Circular.

Dear Sir, —The workers of the medical profession,
i.e., those who have to gain their living solely from

zed by GoOgle

618 The Medical Press.

MEDICAL NEWS IN BRIEF.

Dec. 4, 1907.

what the practice of their profession produces, will
be grateful for your leading article on, “Do Medical
Men Assist in the Sale of Proprietary Medicines?”
Every sensible man of business knows that they do
assist, and that for many practitioners the Pharma¬
copoeia might almost as well be non-existent, as
So-and-so’s special preparation is almost invariably
ordered. I grant that the manufacturing chemist puts
up many of the usual preparations in a pleasant and
agreeable form—more pleasant that an ordinary pre¬
scription following the lines of the Pharmacopoeia
would probably be—but does that make it right that
leaders of the profession should advise these pro¬
prietary or registered formulae, which are frequently
ordered to be dispensed in the original packages? If
the Pharmacopoeia is defective, it ought to be improved.
If special tablets or mixtures are required, it ought
smely to be possible to write a prescription for them.
Why should medical men recommend some special
firm’s cod-liver oil, or emulsion, or other such pre¬
paration except through laziness; or why should they
advise some tablet or varalette which is advertised in
all the lay papers as obviating the necessity of in¬
curring a medical bill? Recently I (and I presume
most other medical men) have received a reprint of
a paper by one of the leaders of the profession
advocating the use of a proprietary article in septic
throat cases. Need I point the moral that the intelligent
but parsimonious public will, at any rate in the first
instance, go to their chemist and get a bottle of these
tablets, and thus in some cases avoid calling in a
medical man, but in other cases the doctor, when
called in, will find that a diphtheria has been too
long neglected for serum treatment to be of avail.

Yours etc.,

James Hamilton, M.D., Q.U.I.

60, Sydney Street, Chelsea, Nov. 30th, 1907.

CLOSE OF THE MAGUIRE FUND.

To the Editor of The Medical Press and Circular.

Sir, —In sending you the final list of subscribers to
the Maguire Fund, which is now closed, I wish to
repeat my expressions of thanks to you and to the
generous subscribers.

The fund realised in all ^63 12s. 6d., a sum sufficient

for all present requirements.

Amount already acknowledged .^57 15 o

Miss Knox, Cranmore, Ballinrobe . 100

T. Houghton Mitchell, M.D., Ambleside ... 1 1 o

Major G. H. Frost, I.M.S., Bakloh, Punjab 100

Dr. Humble, Corfe Castle, Dorset. 050

Dr. J. Mills, County Lunatic Asylum,

Ballinaslce . 100

Dr. Elliott, Verulam, Natal*. 1 1; 6

^63 12 6

Disbursed .13 3 6

Balance unexpended to date..£50 9 6

* Dr. Elliott, with kind forethought, wishes 10s. 6d.
to go to the little boy as a Christmas present.

I am, Sir, yours truly,

R. B. Mahon.

Ballinrobe, November 25th, 1907.

Medical News in Brief

Irish Medical Schools Graduates' Association ~

A most successful evening was the result of the
autumn dinner of the Association, held on Wednesday
November 27th, at the Hotel Cecil, the President, Sir
John William Moore, in the chair. The autumn general
meeting of this Association was held before the dinner,
Sir J. W. Moore in the chair, when, after the ordinary
business, a proposal concerning the formation of a
northern branch, to include Manchester, Liverpool,
Leeds, Sheffield, and other places near to them, was
considered, which was approved by the meeting, the
dets V ls being left to be worked out by the Council.

About 200 members and guests, including ladies, sat
down to the dinner. Amongst those present were Sir

John and Lady Moore, Sir James and Lady Digges la
Touche, Sir Shirley Forster and Lady Murphy, Sir
Dyce and Lady Duckworth, Colonel Sir R. Havelock
Charles, General W. Carnell, Surgeon-General Si r
Thomas Gallwey, Sir Charles Cameron Lamb, Dr.
Macnaughton Jones, Dr. Fegan, Dr. James Little, Dr.
F. J. and Mrs. Roberts, Dr. McVail, Dr. James Macan,
Dr. and Mrs. Giles, Mr. and Mrs. Chas. Ryall, etc.
After the usual loyal toasts. Dr. J. Macan presented
the Arnott Medal to Sir R. Havelock Charles. This
medal was founded in 1900 by Mr. Arnott in memory
of J. Arnott for heroism or distinguished service on
duty in civil life or in the naval or military services. It
was awarded to Sir R. H. Charles for his very im¬
portant services in epidemic diseases in India. Sir
R. H. Charles said a few graceful words in acknow¬
ledgment. The toast of “Our Defenders ” was pro¬
posed in a very humorous speech by Dr. J. Little, and
responded to by Dr. Samuel Browne, R.N., and
General William Carnell, the latter making a few terse
and soldier-like remarks anent the service be repre¬
sented. After “ Our Guests ” had been proposed by
Dr. Fegan, and responded to by Sir J. Digges La
Touche and Sir Shirley Murphy, Dr. Fred. Roberts
gave the toast of “ Our Guests ” in a few quaint and
amusing words, prefacing his remarks by expressing
his surprise at having to propose this toast, as be
himself was a Welshman. The President, in respond¬
ing, after a few words about the propinquity of Ireland
and Wales, called on Dr. Roberts for a song. Dr.
Roberts sang “Tom Bowling,” and, as an encore, “My
Pretty Jane,” in his well-known admirable style. The
musical arrangements were in the capable hands (in
Irish it would be mouths) of Miss Gertrude Woodall
and Mr. Anderson Nicol, Miss Edith Pratt presiding at
the piano. •

Statute of Limitation.

At Runcorn County Court, on the 14th Inst., before
Judge Shlress Will, Dr. Carruthers, of Halton, sued
George Kuight, of 58, Park Road, Southport, “gentle¬
man, for ^53 ns. 6d., balance of an account for
professional services.

Mr. A. Browne said Mr. Knight was formerly a well-
known accountant in Runcorn, but retired some yean
ago. In 1890 Mr. Knight had a serious illness,' and
Dr. Carruthers attended him night and day, and had
to call in a specialist. Mr. Knight had made two pay¬
ments of >£10, the last in 1897.

Mr. Knight now pleaded die Statute of Limitations,
and his Honour said he had no alternative but to give
judgment for the defendant. Mr. Browne asked that
defendant should not receive costs, but his Honour
said the plaintiff could have withdrawn the case when
the Statute was pleaded, and he granted defendant
costs.

Death under Chloroform. T

Mr. Brighouse held an inquiry at St. Helens, cn
November 23rd, into the death of Richard Mayor, 51,
a collier. Mayor died at the St. Helens Hospital on
the previous Thursday, while being operated on by
Drs. Cotton and Latham. Deceased had been treated
for several years, off and on, by Dr. Valentine, of
Earlestown, for hernia, and he on Thursday last de¬
cided that an operation was immediately necessary.
Dr. Cotton said that the operation was started in the
usual way, after the condition of the man’s heart, etc.,
had been considered, but very soon after chloroform
was administered Mayor collapsed. The operation had
not actually been entered upon, and the man died.
The Coroner said the percentage of deaths of people
under chloroform was very small. Dr. Cotton said
that was so. A verdict of “Death from Misadven¬
ture ” was returned.

The Women's National Health Association.

A meeting was held during the past week at tbe
Royal College of Physicians of Ireland, under the
Presidency of the Countess of Aberdeen, for the pur¬
pose of inaugurating a Dublin branch of this Associa¬
tion. The meeting was very largely attended, and
amongst the audience were a number of prominent
members of the medical profession. Her Excellency,
in an opening speech, said that the objects of the

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Dec. 4, 1907.

MEDICAL NEWS IN BRIEF.

The Medical Press. 619

Association were threefold. The first was a crusade
against tuberculosis. The second the lowering of
infant mortality, which was very high in Dublin and
Belfast. The third was the improvement of school
hygiene. Resolutions were passed inaugurating the
branch, and appointing an Executive Committee.

In connection with this meeting it is interesting to
note that at a conference of representatives of the
Clinical Hospitals of Dublin, held last week, under
the presidency of her Excellency the Countess of
Aberdeen, it was unanimously agreed to recommend
the various Hospital Boards to co-operate with the
Women’s National Health Association of Ireland in
their efforts to provide adequate home treatment for
tuberculosis patients.

Royal Metical Benevolent Food Society of Ireland.

A quarterly meeting of the Central Committee was
held at the Royal College of Surgeons on Wednesday,
November 27th. Present, Sir Francis Cruise (in the
chair). A letter was read from Dr. Minchin, tender¬
ing his resignation of the post of hon. secretary and
treasurer of the Co. Meath branch. Hi9 resignation
was accepted, and the secretary was instructed to give
the thanks of the Central Committee to Dr. Minchin
for his services on behalf of the Society. Urgent
applications for grants were then considred, and
awards amounting to ^54 10s. were made. The meeting
then adjourned.

The Moray) T ream tent of Inrbrlate*.

We understand that the Normyl Treatment Associa¬
tion is about to open a home, near Sevenoaks, for
patients suffering from alcoholism who require special
care and supervision. The cost, it is understood, will
be kept as low as possible, the members of the Associa¬
tion being pledged to make no personal profits. All
inquiries should be addressed to the Hon. Secretary,
Normyl Treatment Association, 91, Victoria Street,
London, S.W.

Plague In India.

A distinct decrease in the plague mortality is re¬
ported from Simla. There were in India during the
week ending October 26th only 8,785 deaths, of which
7,034 were in the Bombay Presidency, 203 in the
Punjab, 236 in the Central Provinces (including Berar),
589 in Mysore State and 229 in Hyderabad State. The
remaining provinces returned even smaller totals. Mr.
S. H. Butler. C.I.E., Deputy Commissioner, and chair¬
man of the Lucknow Municipal Board, lately presided
over a special meeting of the Municipality to consider
measures for rat destruction. A number of the general
public were present. It was resolved that an active
campaign against rats be declared immediately; that
a special staff be employed temporarily for this pur-

E ose; that poison be laid down systematically in
ouses where owners consent, and that house to house
action be taken with poison, as well as with traps.
“Axoa” poison i9 to be tried experimentally, and a
stock of traps will be kept and distributed, as also
leaflets explaining the facilities for rat destruction.
Representative ward committees were formed and the
co-operation of the public gives every hope that the
risk of a serious outbreak of plague this season will be
greatly minimised.

•Sleeping Slckneas— Formation of a Committee.

An independent Sleeping Sickness Committee has
been formed in Liverpool to collect information deal¬
ing with Sleeping Sickness, and to stimulate research
into the cause, method of transference, and cure of
Sleeping Sickness, and to publish from time to time
communications with reference to this disease. The
following gentlemen are members of the Committee :—
Sir Alfred Jones, K.C.M.G. (Chairman); The Rt. Hon.
the Lord Mayor of Liverpool (Dr. Richard Caton);
Professor B. Moore, Director of the Bio-Chemical
Department, Liverpool University; Professor Salvin-
Moore, Director of the Cytological Department,
Liverpool University; Professor Annett, Director of
Comparative Pathology Department, Liverpool Univer¬

sity; Professor Sherrington, Director of the Physio¬
logical Department, Liverpool University; Dr.
Stephens, Walter Myers Lecturer in Tropical Medicine,
Liverpool University; Dr. Anton Breinl, Director
Runcorn Research Laboratories; Dr. Prout, C.M.G.;
Dr. Arthur Evans; Dr. M. Nierenstein; J. W. Garrett,
International Fellow, Liverpool University; Dr. J. L.
Todd, of Montreal.

Corresponding Secretaries:—Professor Sir Rubert
Boyce, F.R.S. (Dean of the Liverpool School of
Tropical Medicine), and A. H. Milne, B.A., Cantab.

St. Thomas'* Hospital, London.

Mr. C. A. R. Nitch, M.S.Lond., F.R.C.S.Eng., has
been appointed Surgeon to Out-patients at this
Hospital.

The following gentlemen have been selected as
House Officers from Tuesday, December 3rd, 1907: —
Casualty Officers:—(Senior) C. M. Page, M.B.,
B.S.Lond., M.R.C.S.; (Junior) C. E. Whitehead,
B.A.Cantab., M.R.C.S. Resident House Physicians : —
G. G. Butler, B.A.Cantab., M.R.C.S. ; S. L. Walker,
B.A., B.C.Cantab., M.R.C.S.; W. H. R. Sutton,
B.A., M.B., B.C.Cantab., M.R.C.S.; S. Churchill,
M.A., M.B., B.C.Cantab., M.R.C.S. ; A. L. Lough¬
borough, M.R.C.S., L.R.C.P. House Physicians to
Out-Patients:—B. T. Parsons-Smith, M.B., B.S.Lond.,
M.R.C.S.; A. J. S. Pinchin, M.B., B.S.Lond.,
M.R.C.S.; H. B. Weir, B.A.Cantab., M.R.C.S.; R. G.
Bingham, M.R.C.S., L.R.C.P. Resident House
Surgeons:—H. J. Nightingale, M.B., B.S.Lond.,
M.R.C.S.; H. R. Unwin, M.A., M.B., B.C.Cantab,
M.R.C.S.; G. M. Huggins, M.R.C.S., L.R.C.P.;
F. M. Neild, M.B., B.S.Lond., M.R.C.S. House
Surgeons to Out-Patients:—H. H. Carleton, B.A.,
M.B., B.Ch.Oxon. ; R. E. Todd, M.B., B.S.Lond.,
M.R.C.S. ; W. R. Bristow, M.B., B.S.Lond.,
M.R.C.S.; H. E. T. Dawes, B.A.Cantab., M.R.C.S.
Obstetric House Physicians:—(Senior) H. B. White-
house, M.B., B.S.Lond., M.R.C.S.; (Junior) T. G.
Starkey-Smith, M.R.C.S., L.R.C.P. Ophthalmic
House Surgeons:—(Senior) A. S. Burgess, M.A.
Cantab., M.R.C.S., L.R.C.P. ; (Junior) A. I. Cooke,
B.A., B.C.Cantab. Throat Department:—A. W. C.
Drake, B.A.Cantab., M.R.C.S.; H. N. Little, B.A.
Cantab., M.R.C.S. Skin Department:—J. F.

Windsor, B.A.Cantab, M.R.C.S.; A. L. Sachs, M.A.
Cantab, M.R.C.S. Ear Department:—W. Patey,
M.B., B.S.Lond., M.R.C.S. ; W. G. H. M. Verdon,
B.A.Cantab., M.R.C.S. Children’s Surgical:—E. C.
Sparrow, M.R.C.S., L.R.C.P. Electrical Department,
X-Ray Department:—A. L. Sachs, M.A.Cantab.,
M.R.C.S.

Royal Collaya of Surgeon* la Ireland.

Fellowship Examination.—The following candi¬
dates having passed the necessary examination, have
been admitted Fellows of the College:—R. Counihan,
B.Ch., etc., Univ. Dub.; R. W. Haslett, B.Ch., etc.,
Roy. Univ. Irel.; D. L. Harding, L.R.C.S.I., etc.,
Captain R.A.M.C. ; M. G. McElligot, L.R.C.S.I., etc.,
and G. A. Walpole, L.R.C.S.I., etc. The following
candidates have passed the primary part of the Fel¬
lowship Examination :—H. W. A. Kay, student R.C.P.
and S.I.; and T. S. Reddy, L.R.C.S., Edin., etc.

Trinity Collar*. Dublin.

The following candidates passed the Final Medical
Examination, Part II., during Michaelmas term,
1907:—Midwifery: Gordon A. Jackson, Johannes C.
Pretorius, George B M'Hutchison, Henry H. Ormsby,
George Halpin, Wilfred J. Dunn, William E.
Hopkins, Samuel F. A. Charles, Gerald G. Mecredy,
Herbert V. Stanley, Dixie P. Clement, Thomas Ryan,
Ernest C. Lambkin, William H. Sutcliffe, James R.
Yourell, James E. M'Causland.

While a drinking fountain erected at Kettering to
the memory of the late Dr. Dryland, for many years
medical officer of the town, was being unveiled last
Saturday by Admiral Lord Charles Scott, that gentle¬
man gave the rope a too vigorous pull, and the upper
part of the fountain came down with a crash.

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620 The Medical Press.

WEEKLY SUMMARY.

Dec. 4 , 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT MEDICAL LITERATURE.

Herpes facialis in diphtheria. —Rolleston [Brit. Journ.
of Dermatology , November, 1907) reports the result of
his investigation into the frequency of this condition,
based on 1,370 cases of true diphtheria under his care
during the last five years He found herpes labialis
present in fifty-five cases, or 4.01 per cent. Orsi, who
analysed 2,400 cases in Mya’s clinic, found herpes
facialis present in 2.45 per cent, of the cases. Rolles¬
ton has found that herpes increased in frequency till
the twentieth year of age, and that both sexes were
almost equally' affected. He also found the condition
much more frequently present during the colder
months of the year. The occurrence of herpes
labialis in over 4 per cent, of cases of diphtheria com¬
pletely disproves the idea, which was at one time
held, that the presence of herpes on the lips was
proof that the concomitant angina was not diphtheritic,
even though the condition is much more common,
13.1 per cent., in non-diphtheritic angina. Herpes
zoster was found in only two of Rolleston’s cases. In
this respect diphtheria resembles pneumonia. In
pneumonia herpes labialis occurs in about 40 per
cent, of the cases, but herpes zoster is very rare.
Sannd and Baginski both think that the presence of
herpes facialis is of no prognostic value in cases of
diphtheria, as it occurs equally in the mild and.
severe cases. Orsi, on the other hand, regards it as
a favourable sign, as all but two in his fifty-nine
cases recovered. In Rollestcn’s series of cases the
herpes was considerably more common in the severe
than in the mild cases. K.

In the first group the heart lesion alone does not
cause the symptom complex, which only originates
when a new weakening influence interferes with the
action of the heart. In a damaged heart with weak
cardiac muscle the slightest provocation may cause an
attack, but in fully compensated heart disease an at¬
tack does not occur. As regards the second group.
Schmoll has seen one case of paroxysmal tachycardia
in a patient with adiposis dolorosa, and refers to
several observations of cases in which paroxysmal
attacks complicated an exophthalmic goitre. Many
observations have been recorded in recent years,
showing the connection between various lesions of
the central nervous system and paroxysmal tachy¬
cardia. . Thus the condition has been observed in
tabes, in multiple sclerosis, in tumour of the brain,
and lesion of the medulla oblongata. Schlesinger has
observed epilepsy in 25 per cent, of his cases, but all
these cases belonged to the symptomatic group of
epilepsy caused by anatomical lesions. Schlesinger
also records a very interesting case, in which inflam¬
mation of the right vagus was discovered post
mortem. In this case the attacks could be at once
stopped by compression of the right vagus, while
compression of the left vagus did not appear to in-
fluence the attack. In the fourth group are cases in
which no anatomical lesion can be discovered, and
which resemble the so-called functional epilepsy to
which condition paroxysmal tachycardia has manv
analogies. The mechanism of the attacks is illus¬
trated by tracings taken during the paroxysms. K.

Hemorrhages In Bright’s Disease. —Riesman (Amer.
Journ. Med. Sciences, November, 1907) discusses the
various forms of hemorrhage which may occur in
Bright’s disease, and reports two cases in which a
true haemorrhagic diathesis existed. The first was a
male, aged thirty years, who had had two previous
attacks of nephritis. On admission to hospital it was
found that his rrine contained 0.15 per cent, of albu¬
men, with numerous granular and hyaline casts and
blood corpuscles. Three days later haemorrhage
from the mucous membrane of the mouth set in, and
was followed by extensive subcutaneous haemorrhages.
The patient died eleven days after admission to the
hospital. The second case was a man, aged 55 years,
who had suffered from haemorrhages for some weeks
before admission to hospital. These haemorrhages
continued, and the patient died eight day’s later from
uraemia. Riesman suggests that while ordinary
haemorrhages in nephritis are due to the hypertension
and arterial disease, these conditions are not in them¬
selves sufficient to cause the haemorrhagic diathesis.
This condition he attributes to a toxin which re¬
sembles the haemorrhagins of snake venom. Recently
Eriedeman has found in the pancreatic juice a
hacmolysin capable of causing haemorrhages. This, in
normal health, is apparently neutralised by some
protective substance, but under certain conditions,
among which may be Bright’s disease, this protective
substance fails to act, and the haemorrhagic diathesis
results. Riesman looks on this complication of
nephritis as of particularly’ bad prognostic sig¬
nificance. K.

Paroxysmal Tachycardia.— Schmoll (Amer. Journ.
Med. Sciences, November, 1907) based his study of this
condition on nine cases which he details, and from
which he concludes that the condition is not a single
pathological entity. He divides the cases into the
following four groups: (1) Cases occurring in patients
with a previously damaged heart, (2) cases in patients
affected by dysthyreosis, (3) cases in patients exhibit-
ing central nervous lesions, and (4) cases of apparently
functional character, the so-called idiopathic group.

Diagnosis of Syphilitic Heart Diseanes.-Herzor

writes on the above subject, and calls attention to
the great importance of early diagnosis, though he
admits the difficulty presented by these cases (Berlin
Aim. Woch., 1907. No. 31). Increased blood pres-
sure accentuated aortic second sound, heaving and
diffuse impulse, with irregularity of rhythm, and the
pressure of Mussel’s phenomenon (nodding of the head
synchronous with the pulse) all point to disease of the
aortic and coronary arteries, and when there is a
syphilitic history, are of special significance. Pota>-
sium iodide and mercurials are often of great value in
these cases. Another striking characteristic is a rapid
development of symptoms, and the appearance of
nervous palpitations in patients who are in no wav
neurasthenic. Aortic insufficiency occurring in middle
life, in persons who have no rheumatic history, is
also often a syphilitic phenomenon. y

erythema Nodosum.—Langford Svmes calls atten-
POSfble infectious nature of this disease
7 0urnal °f Children's Diseases , July, 19071.
He has lately observed many cases which suggest thai

wei c * se ‘ Most of 111056 who suffered

were together m the same hospital, and he noted
multiple cases in houses. The disease set in in even
case with pronounced febrile symptoms, and in one
case a systolic murmur developed, which however
disappeared during convalescence. The writer more-

tune ? obs ? rved erythema nodosum as a
preliminaiy symptom in cases of meningitis, and
therefore believes that it should in all cales be re-
garded more seriously than is usually the case.

M.

Opthalmoscopic Appearances in Vaquez Diseasc.-

Jackson has carefully studied the conditions of the

CaSC u hr0nk c >' anotio polycythemia
(Opthalmology, October, 1907). The parieit. who
suffered from extreme cyanosis, and whose Wood
count showed the presence of over nine million red
cells per c.m came complaining of blurring of sight,
and of epiphora. Examination with the opthahno-

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The Medical Press. 621

WEEKLY SUMMARY.

Dec. 4, 1907

scope showed that the dioptic media were clear, but
that the retinal veins were large, dark, and tortuous,
and about double the size of the arteries, which last-
named vessels appeared normal. Later it was found
that the pupils were unequal, and did not react well
to light, and that some retinal haemorrhages had ap¬
peared. These haemorrhages were not flame shaped,
but were rounded with faintly shaded borders. No
white spots were seen, and no other fudal changes.
The above observations agree with what has previously
been noted in any of these cases that were subjected
to proper examination. M.

The Relation of Intestinal Infection to Visceral Tuber¬
culosis. —Whipple, as the result of previously re¬
corded work, has come to the conclusion that the in¬
testinal tract does not play an important role as a
portal for the entry of tubercle bacilli into the various
organs of the body. He now amplifies this work by
an analysis of several new cases, and by experiments
carried out on animals. He formulates his conclu¬
sions as follows : The tubercle bacillus can not pass
from the intestine through the lacteals, mesenteric
glands, and thoracic duct, into the lungs, without
leaving some record of such passage. A few bacilli
may, under favourable circumstances, be swept along
this course to the lungs, but the majority surely will
lodge in the glands, and in time cause a tuberculous
process, which can be recognised. When the
mesenteric glands are not involved we may exclude
the intestinal tract as the portal of entry, but the con¬
verse does not hold for the tuberculous mesenteric
glands, which may be secondary to some pulmonary
forms that are discharging tubercle bacilli into the
alimentary tract. The thoracic duct is often the dis¬
tributing agent in cases that show scattered tubercles
in the viscera and tuberculous mesenteric glands.

M.

Treatment of Tuberculous Peritonitis. —Bussi \C,azz.
deg. Ospedali Milan, September, 1907) relates a number
of instances in which he was able to cure the patient
by medical measures alone, tapping the effusion and
painting the abdomen with iodine and guaiacol, supple¬
mented by hypodermic injection of a solution of 1 gm.
of iodine to 10 gm. potassium iodide, with 20 gm.
guaiacol and 80 gm. glycerine; in some cases an
iodised gelatine preparation was given by the mouth
later. The results were good in all the cases related.
He ascribes almost a specific action to iodine in tuber¬
culous affections. In one severe case recovery followed
tapping and insufflation of heated air into the ab¬
dominal cavity, supplemented by a compressing ban¬
dage and administration of iodised gelatine. In
another very severe case, in a girl of 16, no benefit
was derived from medical measures, and the peri¬
toneum was drained and wiped dry. Typical tuber¬
culous granulations were found disseminated over the
peritoneum and intestines. After the abdomen was
sutured the iodine and guaiacol applications were re¬
sumed, with prompt recovery to date, a year later.

Treatment of Acute Articular Rheumatism with
Constriction Hyperaemla. —Steinitz (Zeib. f. Klin. Med.
Berlin, 1907) reports his experiences with 175 patients
treated by constriction hyperaemia with and without the
salicylates. The application of the constricting band
almost invariably relieved the pain. A large number
of patients recovered in f rom 4 to 20 days, as early as
those treated with the salicylates. Even if the Bier
treatment fails to cure, it can scarcely ever do harm.
Complications seemed less frequent and milder than
under exclusive salicylic medication. High temperature
does not contra-indicate it. In case moderate tem¬
perature persists unmodified after the fifth day under
the Bier treatment, he advises giving salicylates, as also
when the affection changes rapidly from joint to joint.
In cases of recent endocarditis, he advises restricting
the salicylates as much as possible and relying mainly
on the constricting band. D.

Hysterical Sweating. —Curschman (Mvn. Med. Woch.,
September, 1907) reports two cases of long-continued
periodic sweating in a mother and daughter. They

] appeared two or three times daily, were of a drenching
i character, unaccompanied by chill or by fever, and
without any preceding hysterical manifestations (con¬
vulsions, etc.). During the attack the mind was clear,
the patient quiet and peaceful, no preceding embar¬
rassment or excitement was demonstrable. The sweats
' presented the picture of those resulting from the use
of diaphoretics. Blood pressure and frequency of
pulse were never increased. No organic changes in
1 the central nervous system could be made out. Treat¬
ment by suggestion proved promptly effective in both
! cases. The author considers the etiology to have been
j hysterical. He has found no similar cases reported
in the literature. D.

Apomorphln in Diagnosis of Bnlbar Affections.—

Ferreira (Presse Med. Paris, September, 1907) an-
I nounces that a weak or negative response to a small
, test injection of apomorphin will reveal bulbar paresis
i before it is clinically manifested. Glossolabial-
laryngeal paralysis can thus be detected in its inci-
, piency by the degree of nausea and the amount of
j vomiting. If there is no vomiting at all, the medulla
! oblongata is already seriously affected. D.

I

Nasal Origin of Lupus of Face. —Caboche ( Presse
! Med. Paris, October, 1907) presents an array of evi¬
dence to sustain his assertion that lupus of the face, in
nearly every case, is the result of the propagation to
1 the skin, by wav of the lymphatics, of a lupous lesion
on the nasal mucosa. Treatment of the latter alone
is sometimes followed by the retrogression of the super¬
ficial lupus, and inversely if the latter is treated alone,
there is liable to be re-inoculation from the nasal
lesion. D.

Diagnosis and Treatment of Tuberculous Skin
Affections. —Nagelschmidt ( Deut. Med. Woch., Berlin,
October, 1907) relates that a drop of tuberculin inocu-
I lated into a tuberculous lesion of the skin causes
j ulceration. Inoculation of sound skin causes the de-
I velopment of a papule, but no ulceration. He has
j found this an excellent means of determining whether
a lupous patch has entirely healed under Finsen treat¬
ment, or whether there are still some points left,
especially those embedded in cicatricial tissue which
; it is difficult for the Finsen rays to reach. The inocu¬
lation has not only diagnostic value, but also a direct
1 curative action, as the nodules heal definitely under
I the influence of the transient ulceration. Minimal
I quantities of tuberculin suffice for the reaction. He
deposits two or three drops of tuberculin around the
lesion, and scrapes the skin between them. After 15
1 or 20 seconds he wipes off the tuberculin without
touching the excoriated part. This avoids absorption of
| superfluous tuberculin, and prevents any general re-
| action. Sometimes he injects a drop of tuberculin
directly into the nodule. He commends this local
j tuberculin treatment for lupus when Finsen treatment
is not accessible, especially for isolated foci, also for
1 differentiation of tuberculous cutaneous affections, and
as supplementary to other methods of treatment. Its
: drawbacks are the loss of substance left by the ulcera-
' tion and the liability to a general reaction if too much
tuberculin is absorbed. D.

a lit for Cripples.

At a meeting in connection with the Birmingham
Crippled Children’s Union on November 23, a com¬
munication from Mr. George Cadburv, offering the
Woodlands, a large residence standing in four acres of
ground at Northfield. as a convalescent home for child
cripples, was considered. A resolution was passed
accepting the gift, and thanking Mr. Cadbury for his
munificence. It was stated that the house, which con¬
tains fifty rooms, had been inspected by the medical
officers of the Union, who were entirely satisfied as to
its suitability for the purpose to which it is now to be
devoted. It will accommodate forty children. The
site adjoins the Bournville Village Trust property, so
that the maintenance of healthy surroundings is as¬
sured. It is in contemplation to hand the Woodlands
over to the Birmingham Corporation, but this is left to
the discretion of the committee of the Crippled
I Children’s Union.

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622 The Medical Press. NOTICES TO CORRESPONDENTS.

Dec.. 4 , 1907 .

NOTICES TO
CORRESPONDENTS, ffe

tm- Oor*xsfond«nt* requiring a reply in tkie column are par¬
ticularly requested to make dm of » DitUnetiv Signature or
Initial, and to avoid the praotioe of signing themselves
” Header,'' ** Subscriber," “ Old 8ubaoriber," eto. Much oon-
fuaion will be apared by attention to this role.

nUBftCiUPTlONd.

StJBscBimoNs may oommenoe at any date, bat the two volumes
each year begin on January 1st and July 1st respectively. Terms
par annum, 21a.; post free at home or abroad. Foreign sub¬
scriptions must be paid in advanoe For India, Messrs. Thaoker,
Spink and Co., of Calcutta, are our officially-appointed agents.
Indian subscriptions are Ha. 15.12.

ADVhRTICKMENTS.

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Quarter Page, £1 6 s.; One-eighth, 12s. fld.

The following reductions are made for a series: —Whole Page, 13
insertions, at £3 10s.; 26 at £3 3s.; 62 Insertions at £3, and
pro rata for smaller spaces.

Small announcement* of Praotioes, Assistances, Vacancies, Books,
Ac.—Seven lines or under (70 words), is. 6 d. per insertion;
6 d. per line beyond.

Original Articles oh Letters intended for publication
should be written on one side of the paper only and must be
authenticated with the name and address of the writer, not
necessarily for publication but as evidenoe of identity.

Post-Graduate (London).—In all oases of malignant disease
the blood should be examined as a matter of routine. But upon
this point our correspondent had better oommunioate with Dr.
John A. Shaw-Maekenzie, who, no doubt, would supply all the
information required. Dr. Shaw-Mackensie was the first to show
the value of this method of examination in cases of the kind.

X. Y. Z.—The case is Obviously one in whioh the medical man
concerned should be summoned to give evidenoe. But coroners
in rural districts are often disposed to ignore this necessary
detail, presumably for the purpose of saving the fees.

Tu quoquE.—We have carefully considered our correspondent's
communication, and our advioe to him is to leave the n.otter
alone.

ANATOMICAL QUESTIONS AND ANSWER8.

The Professor: Some of you gentlemen are not giving me
your closest attention. Mr. Biggs, what do we find under the
kidneys ?

Future M.D.: Toast, sir.

Dm. Gaskell.— The expression “ oourir comme un derate " is
derived from the belief (founded, we are assured, on actual prac¬
tice) that persons whose Bpleen has been removed are nbic to
run better than their brethren who are still burdened with this
visous. The operation is not a recognised surgical procedure,
at any rate, for purely athletio purposes.

M. R. F.—Bier’s method of treatment by provoking a deter¬
mination of blood to, or its stasis in, a given part is applicable
to boils and carbuncles, and gives very good results, lu a
sense, of course, the historical practice of sucking a ;>olsoned
wound may be said to aot somewhat in the same way, though
the action must be in a measure mechanical, the blood washing
away the poison.

Dm. Lionxl Tatlkb.—Y our letter has been forwarded to
“ Paterfamilias Medicus ” for reply.

JRtctirge of the ^orielifg, Eectareg, &c.

Wednesday, December 4th.

Royal 8 ocrtrr of Medicine (Neurological Section) (20
Hanover 8quare, W.).—8.30 p.m.: Papers:—Dr. J. S. Collins:
On Certain Peculiarities of Intra-oranial Gummata. —Dr. F. E.
Batten and Dr. G. Holmes: Nervous System of a Dog with
Ataxia. Dr. T. G. 8tewart: Four Cases of Tumonr of the
Fourth Ventricle.—Dr. E. F. Buzzard: Case of Tubercle of the
Sixth Nuoleus.

Medical Graduates’ College and Poltclinic (22 Ohenles
Street, W.C.).—4 p.m.: Mr. C. Ryall: Clinique. (Surgical.)

6.15 p.m.: Lecture.

Nobth-East London Post-Graduate College (Prince of
Wales’s General Hospital, Tottenham, N.).—Cliniques 2.30 p.m.:
Medical Out-patient (Dr. Whipham); Dermatological (Dr. G. N.
Meuchen); Ophthalmologlcal (Mr. B. P. Brooks).

Thursday, December 5th.

North-East London Clinical Society (Prince of Wales’s
Hospital, Tottenham, N.).—4.15 p.m.: Clinical Cases.

Medical Graduates’ Colleoe and Polyclinic (22 Chenies
Street, W.C.).—4 p.m.: Mr. Hutchinson: Clinique. (8urgical.)

5.15 p.m.: Lecture:—Mr. J. Berry: The Treatment of Hip
Disease in its Later Stages.

Nobth-East London Post-Graduate Colleoe (Prinoe of
Wales’s General Hospital, Tottenham, N.).—2.30 p.m.: Gynaeco¬
logical Operations (Dr. Giles). Cliniques:—Medical Out-patient
(Dr. Whiting); Surgical Out-patient (Mr. Carson); X-Ray (Dr.
Pirie). 3 p.m.: Medical In-patient (Dr. G. P. Chappel).

St. John's Hospital tor Diseases of the Sein (Leicester
Square, W.C.).—6 p.m.: Chesterfield Lecture:—Dr. M. Dockrell:
Fungous Diseases of the Hair: I., Hvphogenic Syoosis; II.,

Hospital for Sic* Children (Great Ormond Street, W.C.).—
* p.m.: Lecture:—Dr. Batten: The Treatment of Infantile
Paralysis.

Friday, December 6th.

Royal Society of Medicine (Larynoolooical Section) (20
Hanover Square, W.).—5 p.m.: Cases and Specimens will be
exhibited by Dr. C. Potter, Dr. J. Horne, Mr. A. Evans, Mr.
H. TiUey. and Mr. H. Barwell.

West Kent Medico-Chiruroical Society (Miller Hospital,
Greenwich, S.E.).—8.45 p.m.: Purvis Oration: Dr. R. Hassell:

The Diagnosis of Organic from Functional Affections of the
Nervous System. Conversazione.

Wist London Mbdico-Chiruroical Society (Wert London
Hospital, Hammersmith Road, W.).—8.30 p.m.: Papers:—Dr.
M. Mouilin: Treatment of Uterine Fibroids.—Mr. S. Jleadley:
Chronic Appendicitis in Women.

Child Study Society (Parkes Museum, Margaret Street, W.).—
8 p.m.: Lecture:—Prof. J. Edgar: Imitation and Individuality
in Children.

Society or Anesthetist* (20 Hanover Square, W.).—&30 pm.:
Paper:—Dr. W. J. MoCardie: Status Lymphationa. Adjourned
Disoussion on Mr. H. Hilliard's paper.

Medical Graduates’ Colleoe and Polyclinic (22 Chenies
Street, W.C.).—4 p.m.: Mr. R. Lake: Clinique. (Ear.)

North-East London Post-Graduate Colleoe v Prinoe of
Wales’s General Hospital, Tottenham, N.).—10 a.m.: Clinique: —
8 nrgical Out-patient (Mr. H. Evans). 2.30 p.m.: Surgical
Operations (Mr. Edmunds). Cliniques:—Medical Out-patient (Dr.
Auld); Eye (Mr. Brooks). 3 p.m.: Medioal In-patient (Dr. M.
Leslie).

Saturday, December 7th.

Royal Society or Medicine (Otolooical Section) (20 Han¬
over Square, W.).—10 a.m.: Cases, eto., will be shown by Mr. 8.
Scott, Mr. A. HI. Cbeatle, Mr. H. Tod, Mr. R. Lake, Mr. M.
Years ley, Dr. W. Milligan, Mr. L. A. Lawrence, and Dr. W. H.
Kelson.

JLppointnume.

McRae, G. Douolas, M.D., F.R.C.P.E., has been appointed
Medioal Superintendent to the Ayr District Asylum.

Bunch, J. L., M.D., B.S.Lond., Physician in Charge of rt-e 8kia
Department at the North-Eastern Hospital for ChUdren.

Clarke, H. M., M.B., B.C.Camb., Clinical Assistant to St.
John’s Hospital for Diseases of the Skin.

Friend, G. E., M.R.O.S., L.R.C.P.Lond., Clinioal Assistant to
the Chelsea Hospital for Women.

Griffith, T. Wardrof, M.D.Aberd., Honorary Consulting
Physician to the Leeds Public Dispensary.

Michie, W. A., M.D.Aberd., M.R.C.S.Eng., Clinical Assistant to
St. John's Hospital for Diseases of the Skin.

Morton, John, M.B., M.S.Glasg., Clinical Assistant to the
Chelsea Hospital for Women.

Tylecote, F. E., M.D.Vict.. M.R.C.P.Lond., Clinical Assistant
to St. John's Hospital for Diseases of the Skin.

Bacanrus.

Seamen's Hospital Society. Greenwich, 8.E.—Medical Superin¬
tendent of the Dreadnought Hospital, Greenwich. Salary
£200 per annum, with board in the Hospital. Applications
to P. Michelll, Secretary.

University of Manchester.—Senior Demonstrator in Physioljgy.
Salary, £150 per annum. Applications to the Registrar.

Bristol General Hospital.—Senior House 8urgeon. Salary, £120
per annum, with board, residence, etc. Applications to the
Secretary.

Manchester Hospital for Consumption and Diseases of the
Throat and Chest.—Resident Medical Officer. Salary, £100
per annum, with board, apartments, washing, and reilway
contract. Applications to C. W. Hunt, Secretary, Haidmam
Street, Deansgate, Manchester.

Wandsworth Union Infirmary, 8t. John's Hill, near Claphaa
Jnnotion.—Junior Assistant Medical Officer. Salary, £100 a
year, board, lodging, and washing. Applications to the
Medioal Superintendent.

The Homes for Little Boys, Farningham and 8wanley, Krrt.—
Medical Offloer. Salary, £100 per annum, with board, resid¬
ence, and laundry provided. Applications to Percy Robtrtt,
Secretary, Homes for Little Boys, 100, Temple Chamber*,
Temple Avenue, E.C.

girths.

Gavin.—O n Nov. 26th, at 61, Blddnlph Mansions, Bigin Avenue,
London, Evelyn the wife of A. C. Gavin, M.B., of a son.
Tebb. —On Nov. 25th, at 226, Finchley Road, Hampstead, Bertha
Mary, the wife of Albert Edward Tebb, M.D., of a son.

JBarriagcjs.

Burleigh—Wallace.— On Nov. 20th, at Glasgow, James Seatk
Burleigh to Edith Christine Wallace, M.D., daughter of the
Rev. James Wallace, Church of Scotland, Glasgow.
Robertson—Tooley. —On Nov. 28th, at Mombasa Cathedral.
East Africa, Alexander Robertson, M.B., C.H.B., D.8.H., of
Elgin, N.B., to Gertrude Emilie, third daughter of Mark
Tooley, Esq., Denmark Hill, London.

Beaths.

Iooter. —On Nov. 24th, at 9, Trinity Square, Borough. Daniel
Hooper, B.A., M.B., London, for many years physician to
the 8nrrey and Clare Market Dispensaries, in the 8Sth year
of his age.

^aisd.—O n Nov. 27th, at 58. 8alcott Road, Wandsworth Com
mon, Elizabeth Ann Laird, widow of the late James Laird.
M.D., R.N., aged 82 years.

’orteb.— On Nov. 27th, at Salisbury Road, Sonthsea, Mary J.

R. Porter, widow of Surgeon-Major J. H. Porter, A.M.D.
Voodford.— On Nov. 27th, at 67. Eardley Cresoent, Londoa.
Jeeeie Jane, widow of the late C. T. O. Woodford (M.D..
F.R.C.S.London), of Calcutta, aged 75.

Digitized by G00gle

The Medical Press and Circular.

** &ALUS POPUU SUPRKMA LEX."

Vol. CXXXV. WEDNESDAY, DEC. u, 1907. No. 24.

Notes and Comments.

The recent proceedings of the
G.M.C. mm! General Medical Council meeting
Penal bring out into relief the fact, which
Pewers. has long been patent to those in¬
terested in the doings of the Council,
that that body is badly equipped in the matter of
penal powers. It has, in fact, but one power,
namely, that of striking a medical man off the
Register. So inelastic and clumsy is this instru¬
ment of discipline, that in course of time the
Council have evolved various devices for using it
with less than full force. For instance, a culprit in
whose case there are extenuating circumstances may
be told that judgment will be delivered next session,
a course which gives him the opportunity of reform
in the meanwhile; or an accused may be summoned
to appear in person before the Council, a course
which may mean the loss of some days’ work and a
good many incidental expenses. But, still the point
remains that the inability to mete out different
specific degrees of punishment is a serious handicap
to the administration of justice and the maintenance
of discipline. It is a gross anomaly that the man who
has been convicted of procuring criminal abortion
and a man who has been fined five shillings for a
trivial offence should both be subjected, or oe liable
to be subjected, to the same penalty, namely, strik¬
ing off the Register. It will be argued that serious
crimes are dealt with by the law, and therefore the
General Medical Council merely has to strike
offenders automatically off the list after their con¬
viction, but the point remains that in any future Bill
dealing with the Council the power should be sought
for ability to grade penalties. A power to fine a
medical man ^50 or jQ\oo would be most useful in
the case of civil offences of a minor character, and
would not be so severe a punishment as completely
striking him off the Register.

In the present state of the law at
Value any rate, everything should be done
of Repre- which can properly be done to keep
gestation. a man on the Register, because
while he is still there he is under
some kind of discipline and control, whereas if he
be struck off, as likely as not he has no alternative
to his profession whereby to earn his living, and
his uncontrolled practice goes on. On the other
hand, if the Council had power to impose a heavy
fine, and to repeat it if necessary, the proper conduct
of the offender’s practice would be more effectively
ensured. Diversified powers of this kind are badly
needed, and now that the Council are beginning to
awaken to the fact that there is a body of men called
general practitioners which has many grievances
and trials, we hope they will seriously set them¬
selves to work to think how they may best reform
their own constitution and powers. The fresh blood
infused into their veins by the new direct representa¬

tives has had an oxygenating effect already, and the
rank and file of the profession will not be slow to
recognise the result and the credit its authors de¬
serve. Perhaps In the future, when the General
Medical Council is like that of other professional
bodies, namely, representative of the profession it
is supposed to represent, it might be possible to
affect the members directly by the feelings and
opinions durrent at the titne.

The Bill for the prevention of
Anti-Qaackery quackery in New Zealand is before
Legislation in the House of Representatives, and
New Zealand, has reached a very exciting stage,
namely, that which follows the re¬
port of a Parliamentary Committee. It will be
remembered that the Bill was violently opposed
not only by the traders in quack drugs, but by the
newspaper interest generally. Indeed, the storm
raised by the latter threatened toengulph the infant
at its Dirth. However, so far it has survived,
although the Committee have toned it down a good
deal, in form at any rate. The gist of the matter
is the disclosure of the formula, which, of course,
is diametrically opposed to the interests of the
trade, because not only are the formulae of these
preparations utterly devoid of originality, but they
command their sale by working on the awe and
superstition of people. The committee have given
in on this point to the extent of providing that
a formula need not be disclosed if it is original,
and the proprietors can satisfy the High Court
that it is not fraudulent or harmful, that it is by
way of doing what it claims to do, and that it may
with safety be entrusted to inexperienced and un¬
informed persons for the purpose of self-treatment.

If the authority to which refer-
F art her ence as to the character of the

Recem- preparation is to be made had been
mendatlons. the medical council of the Colony,
which should surely be better able
to form an opinion on the effect of drugs than the
High Court, this proviso would not be very much
of a hindrance to good administration, but it is
obviously a great experiment to make the High
Court the arbiter, for the questions raised would
not be legal in any 'sense, and no one can
predict ‘how they would present themselves to
a Lawyer’s mind. Still, on the whole, the pro¬
vision ought not to spoil the Bill, for even if it
did not work quite equitably In practice, there are
other valuable provisions, such as that measures
should be taken to stop the sale and advertisement
of all preparations and medicines which do not com¬
ply with the regulations just mentioned. The
committee urge the Government to put the matter
through this session, and we hope indeed they will
If the measure can be carried now while the m.v

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LEADING ARTICLE.

Dec, ii, 1907.

624 The Medical Press.

is alive it will have far more effect than if it is
allowed to drivel through session after session,
continually being watered down by the trade and
the papers. Now, if New Zealand carries this
legislation through, we take it that three-quarters
of the patent medicine trade will be done away
with, and that the quarter that remains will be
emasculated, so far as its powers for harming
people are concerned. New Zealand, too, is the
most democratic country in the world, and it is a
bitter lesson of the power of interest over the
good of the community that all the advantages of
experience and intellect which the mother country
enjoys do not enable her to tackle a simple question
of this type.

The unfortunate incidents connected
“ The School with the u Brown Dog ” have had the
o! effect which we feared, namely, the
Brutality.” opening of the vials of antivivisec¬
tion vituperation on medical students.
Under the title of “The School of Brutality,” Miss
Lind-af-Hageby, the lady whose incorrect state¬
ments—to use the language of courtesy—let Mr.
Coleridge in for his slander action and an adverse
verdict of ^2,000, has-published a collection of cut¬
tings about the disturbances, preceded by a
waspish introduction by herself. This is being
circulated with the announcement of a lecture by
herself on “Vivisection and Medical Students,” and
therefore it may be guessed what the character of
the lecture will be. Miss Hageby, having laid the
train, lighted the fuse, and seen the building ex¬
plode, now, has the exquisite pleasure of talking to
her friends and rubbing her hands over the effects of
the explosion. We hope that in common honesty
Miss Hageby will explain the part she took in
igniting the flames and the mechanism of the
Coleridge action.

A significant light was thrown on
the composition of the Royal Corn-
Drink ” Cures.”mission on Quackery—when it does
come, as come it must sooner or
later—by the reply made by the
Home Secretary to a temperance deputation that
.waited on him the other day. Mr. Gladstone said
that he recognised that the 1898 Act for con¬
trolling inebriety had been to a great extent a
failure, and that he would appoint a departmental
committee to inquire into the question of inebriety
and narcomania. In the meantime he would
await the report of the Royal Commission on
Feeble-mindedness, which is shortly to be issued,
because it will contain a large amount of evi¬
dence as to drunkenness, and certain recommenda¬
tions for legislation might be made. He then
proceeded to discuss the composition of the Depart¬
mental Committee, and expressed the opinion that
the medical element should be adequate, but sub¬
ordinate to the lay. Mr. Gladstone indicated that
drink “cures” would begone of the matters speci¬
fically referred to the committee, because of the
number that have appeared on the market of
late, and the interest shown by the public in
them. Now, we should have thought that in
a matter so technical as this medical men
would have been the only people whose opinion
was worth having, and that if laymen were
appointed they should be but few proportionately.
However, the view of the Home Office is different,
and they have the deciding voice. At any rate, we
offer a warm welcome to such an inquiry.

LEADING ARTICLES.

LONDON UNIVERSITY CRISIS.

It is now almost a hundred years since the Uni¬
versity of London entered on the most chequered
career that ever University pursued. Almost from
its birth the academical institution of the hub of the
Empire has been in the throes of construction or re¬
construction, with the result that after a century of
tinkering it remains a monument of the inefficiency
of Londoners to manage educational affairs. If
the cause of the fiasco be sought, it will be found
to consist of several complex factors, such for in¬
stance as a lack of civic patriotism in Londoners,
in a contempt dor education which distinguishes
many commercial minds, and above all perhaps, in
a want of idealism. Still, there is no gainsaying
the fact that the University of London is as little
interwoven with London life as is the University of
Brussels. This aloofness is found not only in medi¬
cine, indeed perhaps is seen less in medicine than
in any other faculty, but is to be found in arts,
science, law, and music. Indeed, the London Uni¬
versity, instead of being an expression of the civic
ardour for culture, is like the “ foreign garrison ” in
Ireland, a kind of extraneous authority placed over
the heads of the natives to see that too much free¬
dom and independence does not exhibit itself. We
have only to compare these university methods with
those in Scotland to see exactly where failure occurs.
In Scotland the elementary school lad, if he is able
to go on with his studies, passes naturally to the
intermediate school, and from the intermediate
school to the university, where after an average
career he finds himself M.A. in two or three years.
That is to sav, the university caters for the average
man, provides him with his progressive scale and
the means to mount it, and ends by conferring on
him the cachet of M.A., because that degree is a
commercial asset wherever he goes for a job. The
London University takes no notice of its students
till they come to it, and then insists on their pass¬
ing an examination which 'would pretty nearly win
them a university degree in Scotland. Although
Ixrndon has lately assumed teaching functions,
these are yet pretty far divorced from the examin¬
ing ones, which remain the prime object of the
system. The students are sent up for exceedingly
difficult examinations, and a comparatively small
proportion are passed ; whilst it has been recognised
for years that the examinations are “tricky.” In¬
deed, when the object of an examination is rather
to keep candidates from a degree than to provide a
gateway to it, the "tricky” element is bound to
appear. The consequence of this throttling policy is
that the London University is an ogre to London
students instead being ithe friend that helps to
success, and it is distinctly understood that the
desire of the authorities is that only a small pro¬
portion of the students are to be eventually success¬
ful in graduating. Now, this same principle holds
good in the London University attitude towards
medical students. Instead of all students going in
for the London M.D., and about 75 per cent, being
successful, about 30 per cent, or so go in, and
about 15 per cent, or so eventually attain it. The
London University may, and does, demand a high
standard , for its degrees, but as a University’ for
London it has completely failed. It is a mere
geographical accident that it happens to be situated

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Dec. ii, 1907.

CURRENT TOPICS.

The Medical Press. 625

in the Metropolis. The last scene of all in this
strange, eventful history is the recen-t ruination of
the work of that band of devoted reformers who,
largely under the inspiration of Dr. Kingston
Fowler, nearly succeeded seven years ago in adapt¬
ing the university to the needs of the teeming
millions in London. The work we are specially
concerned with is that of medical education. When
the university was reconstructed in 1900, and “in¬
ternal ” students created, it was obvious, not only
for the sake of economy for the medical schools
but for the creation of the “ University” idea, that
a centre of teaching should be established. The
elementary medical subjects needed such united
teaching, schemes was made out and approved,
funds were appealed for and in part promised, a
splendid site was granted, and everything was
ready for the university to go ahead, when the old
prejudices, prepossessions and vested interests,
surged into force again, and the scheme was de¬
feated. The Senate of the University has conse¬
quently given up the site, and purposes to send the
money back to the donors, and the hands of the
clock are put back for another twenty or thirty
years. The history of the London University is a
string of ineptitudes, of which the lasit item is per¬
haps the greatest. Londoners and lovers of culture
can only hope that God does not slay all those
whom he drives mad.

CURRENT TOPICS.

Mountain Sickness,

Dr. W. H. Workman, in the course of a lecture
recently delivered before the Royal Geographical
Society, gave an interesting account of his climbing
experiences in the Nun Kun group in Kashmir.
He dealt particularly with the glaciers, and notably
with the ttivcos penetrantes, which he met with for
the first time in five seasons of Himalayan explora¬
tion. An interesting part of his paper to all moun¬
taineers is that connected with mountain sickness.
Dr. and Mrs. Workman stayed one night alone at
a camp 21,300ft. above sea level, the highest point,
up to the present, at which mountaineers had passed
the night. There were nine Europeans—a guide
and six porters, with the two heads of the expedition
—and only one porter really suffered from moun¬
tain sickness. “ Although complaining of headache |
and weakness,” said Dr. Workman, “at the third
camp (20,632ft.), he started to go to the fourth with
a light load of instruments, but was unable to keep
up with the rest of us, and soon fell behind, showing
unmistakable signs of mountain sickness. Before
reaching an altitude of 21,000ft., though naturally a
strong and healthy man, he collapsed entirely and
became helpless. He complained of loss of sensation
in his hands. His woollen mittens being drawn off,
his fingers w-ere found white and stiff, and if not
already frostbitten on the point of becoming so.
Vigorous rubbing and pounding of his hands finally
restored circulation, when he was sent down to the
third camp. The fact that his hands, even when
protected by thick woollen mittens, were brought
by the cold to the verge of frostbite, while my own,
without any covering, were comfortably warm,
shows how profoundly the circulation and vitality
are prostrated by mountain sickness, and how dan¬

gerous it is for one suffering from this malady to
be exposed to the cold of high altitudes.” None of
the other members of the party were incapacitated,
but, said Dr. Workman further, “Every one, as
was to be expected, felt the effect of altitude on
the respiration, though some to a greater extent
than the others. This, as is usual, manifested itself
by shortness of breath and panting on slight exer¬
tion. In the erect position, when resting, the
respiratory disturbance was not so noticeable, being
marked only on movement, but at night on lying
down it became more urgent, being accompanied
by a feeling of oppression, for the relief of which
a number of deep inspirations were necessary. The
frequent repetition of these wearied the respiratory
muscles and even became painful. During the five
nights at our three highest camps no one obtained
more than a few snatches of sleep, and four, of
whom I was one, practically none at all. It is
scarcely necessary to say that even the strongest
could not hold out for long against the depressing
influence of loss of sleep, combined with the lower¬
ing of vital energy due to the scarcity of oxygen
at these high altitudes.”

Candour between Physician and Patient.

In an address to the Medical Society of the State
of New York, a week or two ago, ex-President
Cleveland put in a plea- for greater candour on the
part of the medical attendant toward his patient.
According to Mr. Cleveland, a critic friendly to the
profession, the medical man still likes to maintain
a certain air of mystery as to the means by which
he works, and is loath to give the patient any
information as to the methods employed in curing
his disease. In the past there certainly was this
tendency on the part of the physician, who cloaked
his ignorance in learned words, and others beside
Mr. Cleveland charge us with it at present. There
is no doubt that in all cases there should be perfect
frankness so far as the intelligence of the patient
will permit, and it is astonishing how much
further this is than many medical men imagine.
Moreover, in many cases the curative effect of the
physician’s labours may be materially increased by
obtaining the intelligent co-operation of the patient.
The physician should proceed, not by Eddyist
hocus-pocus, but by measures whose rationale he
should be able and eager to explain.

Victory at Cheltenham.

We have had occasion before to refer to the case
of Dr. J. H. Garrett, Medical Officer of Health for
Cheltenham, whose services a section of the Council
of that town proposed to reduce from £600 to ^500
a year. Last week the matter came before the
Town Council, the Health Committee bringing for¬
ward a report against the decrease in reply to one
in its favour presented by the Expenditure Inquiry
Committee. Alderman Norman, who moved the
adoption of the Public Health Committee’s report,
said that probably the Council were unaware that
the Local Government Board had controlling power
in that matter, and that it was exceedingly im¬
probable that they would consent to the decrease,
as ^500 was the minimum recognised by the Board
for a town of the size of Cheltenham, and, more¬
over, that Dr. Garrett had put in six years’ good
service since the increase was granted. Alderman
Skillicorne, who moved an amendment, said that

626 The Medical Press.

CURRENT TOPICS.

Dec.

Dr. Garrett had “insulted” members of the
Council, and that if they did not decrease his salary
they would be laying themselves open to be simi¬
larly insulted by all their officers. Now, Dr.
Garrett had previously shown that the “insult”
consisted in putting a wrong interpretation on his
words, and it seems that the councillors who felt
themselves insulted must have had very tender con¬
sciences. The Health Committee, who were cer¬
tainly in the best position to judge of Dr. Garrett’s
work, were in his favour; and a medical member of
the Council said that no sort of case had been made
out for reducing the salary, but that the Inquiry
Committee, failing to find anything wrong any¬
where else in the various departments, pitched on
the medical officer’s salary. When it came to
voting, the amendment was only defeated by the
narrow margin of eleven votes to ten, and the
Health Committee’s report was adopted by a
majority of twelve to nine. We sincerely con¬
gratulate Dr. Garrett on his well-earned success.
Fortunately, matters at Cheltenham did not come
to the pitch they arrived at at Southend, but they
were near enough to be uncomfortable. At any
rate, the same solidarity might have been looked
for in the profession if the crisis had been brought
about.

Town Water Supplies.

The rapid growth of the great centres of popula¬
tion renders the problem of the national water
supply one of increasing difficulty. Many of the
rjvers have been drawn upon to the extent of their
capacity consistent with the maintenance of their
own streams. Moreover, as the rural and provincial
density increases, the inevitable resulting pollution
of rivers makes them more and more undesirable
for potable purposes, so that the cities are driven to
the great watersheds and mountainous districts for
their supplies. The whole question, so far as
London is concerned, must became a matter of
urgency before many years have passed away. The
Metropolitan Water Board is at present discussing
the momentous question as to the desirability of
securing an additiohal water supply for Londoners,

“ after increased supplies from the Thames are no
longer economically available.” Sooner or later it
seems probable that they will have to resort to the
Welsh mountains for their catchment area. The
Standard has advocated the widening of their
scheme of operations so as to secure a national
basis. There is a good deal to be said in
favour of thpt proposal, for water is just
as much a necessity of life as air or earth. So
long ago as 1869 th e Royal Commission, presided
over by the Duke of Richmond and Gordon, recog¬
nised the necessity of parliamentary interference in
order to prevent the selfish appropriation of water¬
sheds by local authorities. It is tolerably clear that
Londoners have been caught napping, and have
been to a great measure forestalled in the matter
of the Welsh hills. Under any circumstances,
however, it is unlikely that a more enlightened
generation will consent to drink river water that
has been extensively polluted with sewage.

Civilian Doctors and Army Medical
Training.

W’e are informed by the War Office that, in order 1
to utilise the valuable clinical field provided by the j

U» 1 9°7-

Queen Alexandra’s Military Hospital, the Army
Council have decided to associate that hospital with
the Royal Army Medical College, as an integral
part of its medical school, for the purpose of further¬
ing the earlier and advanced education of officers
of the Royal Army Medical Corps. They have
further decided to obtain the assistance of certain
prominent members of the medical profession as
consultants in medicine and surgery, whose profes¬
sional skill will conduce to the efficiency of the
hospitals as regards both the treatment of the sick
and the investigation of the various diseases inci¬
dental to military life. These appointments will
have the further effect of fostering among the civi#
members of the profession a greater interest in the
work of the Army Medical Service, and in those
special problems with which its officers have to deal.

The following appointments have been approved:

To be Consulting Surgeons :—

A. E. Barker, Esq., F.R.C.S., Professor of Surgery,
University College of London.

A. A. Boiwlby, Esq., C.M.G., F.R.C.S., Surgeon u>
St. Bartholomew’s Hospital; and

G-H. Makins, Esq., C.B., F.R.C.S., Surgeon to
St. Thoipas’s Hospital.

To be Consulting Physicians :—

Dr ; J. Mitchell Bruce, F.R.C.P., Consulting
Physician Charing Cross Hospital.

,.P r - J- Kingston Fowler, F.R.C.P., Physician to
Middlesex Hospital.

, y?\ Osier, F.R.S., F.R.C.P., Regius Professor

of Medicine, University of Oxford.

Medical Examination of Children for
Factory Work.

A school attendance officer has written a perti¬
nent letter to the Manchester Guardian on the
medical examination to which children and young
persons are subjected before being permitted to
enter the factory or workshop. The journal in
question makes some sensible comments on the
communication, and endorses generally the scep¬
tical attitude of its correspondent. Out of 700
children who have in the latter’s experience been
allowed by the education authorities certificates of
practical and complete exemption from school
attendance, only one, to his knowledge, has been
declared fit by the certifying surgeon to work in the
mill. Obviously, if these children were unfit lo
attend school, they were not proper candidates for
factory life. The last report of the Chief Factory'
Inspector shows that, out_ of a total of 390,829
examinations, there were only 3,257 rejected on
medical grounds, or three-quarters per cent., a
result that certainly does not justify the pessimists
who talk in so dejected a w’ay about our physical
degeneration as a nation. In 1906 only 800 condi¬
tional certificates were given—that is to say, re¬
stricting the child to' certain occupations. It is hard
to think that out of 390,829 children all except 800
were fitted for all and every kind of work. Among
the 800, moreover, were cases of infantile paralysis,
hip and spinal disease, epilepsy, heart disease,
phthisis, bronchitis, and scrofula. It is no excuse
for the certifying surgeons that the fee for examina¬
tion is absurdly inadequate, and that in the case of
rejection their reasons must be stated in writing.
If the duty be accepted by the certifying surgeons,
it should clearly be performed with a full sense of
responsibly^. On the other hand, it is clear that

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Dec. xx, 1907.

PERSONAL.

The Medical Press. 627

a rigid examination and a high standard would
make demands upon the surgeon’s time out of all
proportion *0 the emoluments. If the Government
of this country are in earnest in their desire to
exclude diseased and feeble children from our fac¬
tories and workshops, they will do well to attend to
this serious defect in industrial legislation.

The Irish University Question.

The most important announcement on this sub¬
ject was made on Thursday last at Manchester,
when the Provost of Trinity College announced that
he had received positive assurances from Mr
Birrell that, in the proposals which he hopes to lay
before Parliament, Trinity College, its constitution,
and its endowments are absolutely excluded. The
Provost further announced that the governing body
of Trinity College would be prepared to give Mr.
Birrell every’ assistance in their power in working
out any scheme for the real good of the country.
We cordially congratulate both Mr. Birrell and the
Provost, the former because he has decided to work
in the path of the least resistance, rather than in
that of the greatest resistance, the latter because
a great danger to the institution over which he pre¬
sides has been averted. It was a foolish policy
which led Mr. Birrell’s successor to try to begin his
work by felling mighty oaks across the path which
he must travel to reach his end, and now that such
a policy has been abandoned it is to be sincerely
hoped that head-way will be made. To judge from
a further statement made by the Provost, it would
appear that the general lines along which Mr. Bir¬
rell intends to work are similar to those at W'hich we
have already hinted Ln these columns. Thus,
there may be a revival in Belfast of the old Queen’s
University, which will have an “atmosphere” of
its own decided by the majority of its students,
while the remaining three Colleges will be united
with another University, which will also have an
“atmosphere” of its own. Like Sir Edward Car-
son, we prefer to see Mr. Birrell’s new Bill before
we express an opinion thereon, but it should follow
the lines at which the Provost hints. It will, at any
rate, start with a far greater prospect of success
than did Mr. Bryce’s happily defunct scheme.

The Nature of the Soul.

When Descartes thought fit, nearly three
hundred years ago, to publish his “Discourse,” in
which, among other topics, he treated of the loca¬
tion of.the soul, he was subjected to a certain
amount of opprobrium in' that he chose to appeal
to the ignorant rather than to the learned, by
couching his reasonings in the vulgar tongue. It
is, therefore, in good company that Dr. Albert
Wilson, “who is shortly publishing the result of
his researches into the brain, which he has been
carrying on for the last twenty years,” addresses
himself first to the unlearned, and makes the
earliest disclosure of his results, not through the
medium of one of the scientific journals, but in
the columns of Black and White. He has, doubt¬
less, been wise in his choice. Moreover, like a
discreet man of business, Dr. Wilson discloses so
little of the secrets he has discovered that all his
readers are left agog for more information. We
are told that his researches “ have helped to
demonstrate both the existence of the soul and the
possibility and probability of its existence after
death.” The soul, we arc told, “is a superstruc¬

ture of the mind ”; and the mind, being a super¬
structure of the brain, if not, as is suggested, the
cortical layer itself, we are led to the conclusion
that the soul is a superstructure on a superstruc¬
ture, which, nevertheless, can exist after the dis¬
appearance of its foundation, the brain. Dr.
Wilson’s researches are rich in practical as well
as theoretical points of interest. For instance, the
“pre-frontal arc of the brain” is the seat of con¬
trol, which can be put out of action by alcohol. Our
whole prison system, too, is wrong, as, to quote
Dr. Wilson’s own words, “The antiquated law
methods of so much punishment for so much crime
is too fossilised to deserve any toleration.” No
more, alas! must the punishment fit the crime.
Mr. Bernard Shaw tells us that what the poor
suffer from is poverty. Not so Dr. Wilson; he
finds that they suffer from deficient brain-cortex,
“due to the destructive influence of enforced
education.”

PERSONAL.

H.R.H. Princess Christian of Schleswig-Holstein
opened the new operating theatres and anaesthetising
rooms at the Royal Free Hospital on December 3rd.

Mr. Francis Reckitt has given a donation of
^10,000 to the Great Northern Central Hospital.

Professor Landouzy has been selected for the post
of Dean to the Faculty of Medicine at Paris, in place
of M. Debove (resigned).

In memory of Professor Pirogoff, the Moscow Town
Council propose to name a street after him, and
triennially to award a prize of £60 value for a work
on Surgery.

It is announced that Professor Ronald Ross is to
be invited to accept the post of Physician to the Ward
for Tropical Diseases lately established at the Royal
Southern Hospital, Liverpool.

The annual Bradshaw lecture was delivered before
the Royal College of Surgeons on Friday last by Mr.
Rickman J. Godlee, vice-president of the college and
surgeon in ordinary to the King.

Brigade-Surg.-Lieut.-Col. David D. Cunningham,
C.I.E., I.M.S. (retired), has been appointed Honorary
Physician to the King, vice Surgeon-General Sir J.
Fayrer, Bart., K.C.S.I., deceased.

Dr. E. M. Grace, the cricketer and coroner, has
resigned his position as District Medical Officer and
Medical Officer to the Workhouse of Thornbury,
Gloucestershire, after forty years’ service.

We understand that Dr. William Carter, Senior
Physician, and Mr. \\ illiam Alexander, Senior
Surgeon, propose shortly to retire from the active staff
of the Royal Southern Hospital, Liverpool.

A MARBLE bust of Dr. Huglings Jackson has been
presented to the National Hospital for the Paralysed
and Epileptic, Queen’s Square, W.C., in recognition
of his distinguished services to neurology.

Surg.-C»en. Sir Alfred Keogh, Director-General,
gave a dinner at the Royal Army Medical College,
Millbank, on the 27th ult., to which gtests repre¬
sentative of the War Office and the General Medical
Council were invited.

628 The Medical Press.

CLINICAL LECTURE.

Dec. ii. 1907.

A Clinical Lecture

ON

“OTOSCLEROSIS.” (a)

By MACLEOD YEARS LEY, F.R.C.S.,
Senior Surgeon to the Royal Ear Hospital.

Gentlemen, —The condition to which the name,
“otosclerosis,” has been applied is one of which the
morbid anatomy has been worked out only compaia-
tively recently, and there is still much to be learned
as to its real significance, and, still more, as to the
best means of combating its insidious onset.

The term “otosclerosis ” is a misleading one, both
from the point of view of the morbid anatomy and
from the fact that it has led to some confusion between
it and the post-catarrhal changes which form the latest
stages of catarrhal inflammation of the middle ear.
Strictly speaking, it is not a middle ear process at all,
but is essentially an affection of the labyrinthine
capsule. It is characterised by a bony ankylosis of
the stapes in the fenestra ovalis, together with osleo-
phytic outgrowths in the lower parts of the scalse
tympani and vestibule, and in the fossula ovalis, and
often with isolated spots of osteoporosis in the bony
labyrinthine wall. The meanbrana tympani is normal,
or approximately so, and the Eustachian tubes retain
their patency.

The most important changes demonstrable are in the
stapes, annular ligament, and those parts of the laby¬
rinthine capsule which are in the vicinity of the
fossula ovalis. It appears that the superior and anterior
circumference of the oval window is to be regarded as
the seat of election of these changes.

The change which takes place in the capsule is a
process of resorption of old, and apposition of new,
metamorphosed tissue. Macroscopical examination
reveals the stapes fixed to the oval window by bone,
either along the margin of the footplate, or by means
of bony trabeculae from the stapedial crura to the walls
of the fossula ovalis. In some cases the whole margin
of the footplate is so fixed by bone that no trace of a
joint remains. In many cases the fossula ovalis be¬
comes more or less filled with spongy osteophytic out¬
growths. Occasionally osteophytes encroach upon the
interior of the labyrinth, and sometimes affect the
fenestra rotunda also.

Coincident with these changes in the region of the
stapes there may appear foci of osteoporosis in other
parts of the capsule, notably in the region of the
cochlea, in the modiolus and semi-circular canals.
These foci spread towards the endosteum of the
capsule, so that the intra-labyrinthine fluid may be
separated from the large lymph spaces of the newly-
formed spongioid areas only by a delicate membranous
partition.

The exact process of this formation of the normal
compact labyrinthine capsule into abnormal osteoid
new growth has been carefully investigated by Sieben-
mann and Habermann. The necessary limit of time
will not alloyr me to take you through all its stages in
a lecture like this. Suffice it to say that the process
begins in the Haversian canals, which become widened
towards the side of the labyrinth by lacunar resorption
of their walls. At some points this resorpti-'e process
proceeds further, whilst at others it results in the
apposition of new bone.

Another and important point is that the capsule is
peculiarly rich in remnants of primary cartilage, and
these become disintegrated and replaced by new bony
growth, as do also the cartilaginous coverings of the
fenestra ovalis and stapedial footplate.

In the early stages of the condition there is a very
sharp distinction between the newly-formed spongioid
bone and the surrounding dense normal bone; this is

(a) A Pott-Graduate Lecture delivered at the Royal Ear Hospital.

in marked contrast to the absence of any line of de¬
marcation between the spongioid tissue and the
sclerosed bore formed in the later stages.

Nearly every investigator has endeavoured to find a
cause for the condition I have briefly described. I will
not detain you with all the pathengenetic theories that
have been enunciated, but will give you the most im¬
portant only. Numerous earlier theorists have ascribed
to otosclerosis an inflammatory origin, but the rarity
of any evidence of past or present tympanic inflamma¬
tion, and the complete absence of signs of inflammation
of bone, are strongly against this view.

One of the most probable explanations yet suggested
is that of Siebenmann, who considers it to be the final
stage of a developmental process which does not nor¬
mally take place in the petrous bone, but which is the
rule in other bones. As I have pointed out, the bony
capsule of the labyrinth is rich in remnants of primary
cartilage ; these are found most frequently about the
region of the fossula ovalis, which is the seat of
election of the changes just described. In the long
and flat bones growth, without change of shape, is
brought about by a process of resorption and apposi¬
tion after birth. The labyrinthine capsule, however,
attains its ultimate size at birth, and the cartilage
remnants it contains are not, therefore, used up ; so
that, unless the abnormal development which Sieben¬
mann considers as constituting otosclerosis takes place,
they are retained in the capsule until old age.

Gray rejects this theory as in no way explaining the
involvement of the stapedio-vestibular articular car¬
tilage. He points out that otosclerosis is rare before
puberty, almost uniformly bilateral, more common in
women, hereditary, and that certain bodily conditions
are recognised as favouring its development (such as
anaemia, pregnancy, gout, etc.). Reviewing these facts,
together with the peculiar features of its morbid-
anatomy and the absence of any signs of inflammation.
Gray suggests that the sharp line of demarcation,
between the areas of absorption and the healthy bone
means death of the tissue in that area, and that the
dead tissue is absorbed without the occurrence of in¬
fection. This view is the most satisfactory one at
present advanced, and it is pleasing to know that it
has been enunciated by a British otologist.

Having thus briefly reviewed the nature of oto¬
sclerosis, I must now pass on to certain points in its
etiology before dealing with symptoms and treatment.

Otosclerosis is essentially a disease of young people.
It rarely commences before the twentieth year, although
its occurrence before that period is not unknown. It
is far more frequent in women than in men, and the
statistics of various observers range from 61 to 50 per
cent. ; taking my own cases, I find that women are in a
majority of 5 to 1. Some explanation for this great
preponderance of women lies in the relative frequency
of anasmia and chlorosis in that sex, and to the
anomalies of nutrition peculiar to the puerperium. It
is not uncommon for otosclerosis to date from the-
occurrence of pregnancy.

A prominent feature in the condition is its heredit-xn?
nature. Denker, out of 306 instances, obtained a
history of heredity in 40.5 per cent. So far as can be
gathered, transmission would appear to have a ten¬
dency to take place through the female branches, and
it is a known fact that harmful embryonal influences
are more likely to affect the female than the male.
This fact of heredity, which can hardly be doubted,
supports Siebenmann’s contention that otosclerosis is
an abnormal post-embryonal development rather than-

Digitized by GoOgle

Dec, ii, 1907.

CLINICAL LECTURE.

The Medical Press. 62Q

a true disease, for, according to the laws of biological
heredity, it is supposed that diseases cannot be
inherited.

A number of agents have been suggested as exeiting
causes of otosclerosis, chief among them being gout,
rheumatism, syphilis, anaemia, pregnancy, and the
puerperal state, and severe chill. I need do no more
than mention most of these, but syphilis and preg¬
nancy require more than a passing notice. Habermann
and Gradenigo have been the strongest advocates of
syphilis, both congenital and acquired, as an essential
agent in otosclerosis, but, so far as I know, there is
no real supporting evidence. The aural manifestations
of syphilis are definite end well-known, whereas in
otosclerosis one sees no other evidences of the disease,
nor is specific treatment of any avail.

Pregnancy and parturition are not infrequently
assigned by patients as a definite cause of otosclerosis,
and the puerperal condition almost always results in a
decided increase in the deafness. This adverse in¬
fluence is probably due to the blood condition, which
may favour stagnation in the capillaries, and so bring
about the local bone death suggested by Gray as the
starting-point of the malady. The same remark applies
to gout, rheumatism and an®mia.

Coming now to symptomatology , the chief mani¬
festations of otosclerosis may be enumerated as deaf¬
ness, tinnitus, vertigo and paracusis Willisii (or hearing
better in a noise), together with several subsidiaiy
symptoms.

The characteristics of the deafness are its markedly
insidious onset and progressive nature. It is always
bilateral, although one ear may be affected long before
the other, even years. In the majority of cases the
hearing is affected very gradually, so that patients can
make no definite statement as to when the trouble first
began. Sudden onset, although it may occur, is dis¬
tinctly rare. The progress of the deafness is usually
slow, and the condition may remain stationary for a
variable, sometimes a long period. Again, a more or
less rapid and marked accentuation may occur, the
patient never recovering the ground thus lost.

Although I shall again refer to the deafness when I
speak of the results of functional testing, I may
mention here that, in pure ankylosis of the stapes, even
in the later stages, the whisper can still be heard in
the majority of cases, if only close to the ear, and
spoken speech can always be heard. Where the per¬
ception of loud speech is lost, pure stapes ankylosis is
no longer present, but there is superadded some ad¬
vanced change in the structural characters of the laby¬
rinthine capsule, or in the terminal nervj apparatus,
or the fenestra rotunda is also involved.

Subjective tinnitus is a frequent symptom in oto¬
sclerosis, and often precedes the deafness. In character
it may be buzzing, hissing, singing, humming, roaring,
rattling, or pulsating. Though usually constant, it
may, in some cases, be intermittent, and is occasionally
so intense as to drive the patient to desperation. In
one case of Denker’s it led to suicide. It is often found
that, when tinnitus is only occasionally prjsent in the
early stages of otosclerosis, it becomes constant Inter,
and it does not invariably disappear when the patient
becomes completely deaf.

Vertigo is not very common, and, when present, is
usually slight in character.

The peculiar symptom of hearing better in a noise,
or paracusis Willisii, is a remarkably constant and
early symptom in otosclerosis. I need not enter into
the various theories which have been advanced to
explain this symptom, but I would impress upon you
how frequently and early it occurs in otosclerosis; in
one lady under my care it was noted within six months
of the onset of the deafness. By most otologists it is
considered to be a most unfavourable symptom,
although Burkner believes that it is never present in
cases which are complicated with affection of the
sound perceiving apparatus, and therefore gives a com¬
paratively favourable outlook.

Pain, slight and deep in the ear, and a feeling of
tension in ths ear, are sometimes complained of. In¬
crease of deafness on straining to listen, due to the
inability of the intra-tympanic muscles—put into
vigorous action by listening—to put the fixed ossicles
In motion, is not infrequent.

On examination the tympanic membrane is usually
normal, or nearly so. The chief peculiarity to be noted
is a reddish reflex over the promontory or in the area
of the stapes This is, however, by no means present
in every case. It is due to hyperaemia of the mucous
membrane over the promontory or about the fossula
ovalis shining through the membrane. This reflex,
when over the promontory, is an unfavourable sign, as
it points to the extension of the bony pathological
process to the labyrinthine capsule.

The Eustachian tubes are patent, inflation giving a
large, full sound, and being unaccompanied by im¬
provement in either hearing or tinnitus.

It must, however, be remembered that otosclerosis
may be complicated with chronic middle ear catarrh,
which may alter the normal condition of the tympanic
membrane, middle ear, and Eustachian tube.

In uncomplicated otosclerosis the upper air passages
do not usually present any condition especially note¬
worthy.

Functional testing reveals the presence of what is
known as “Bezold’s triad of symptoms,” viz.:—(1)
increase of bone conduction ; (2) a markedly negative
Rinn^ ; and.(3) loss of low tones.

Increased bone conduction is found in uncompli¬
cated stapes fixation, but when, later, the bony laby¬
rinthine wall is the seat of foci of spongioid bone, the
bone conduction becomes diminished. All cases pre¬
senting Bezold’s triad of symptoms in association with
normal, or nearly normal, tympanic membranes, and
patent Eustachian tubes that have been subjected to
post-mortem examination, have been found to have
stapes ankylosis. When, however, the disease has so
progressed that the changes in the stapedio-vestibular
symphysis no longer preponderate, and foci of
spongioid change have become marked in the cochlear
capsule, the two conditions are opposed. The stapes
fixation increases the bone conduction and lenders the
Rmne reaction markedly negative, whilst the marked
spongioid processes in the labyrinthine wall diminsh
the bone conduction and decrease the negative Rinne.
Owing, however, to the fact that the region of the
stapedio-vestibular symphysis is the seat of election of
the condition, stapes fixation usually predominates. In
rare cases—in very early stages of otosclerosis—
the result of functional testing will be normal bone
conduction, reduced air conduction and positive Rinne.
In such cases the acoumeter is diminished in propor¬
tion to the loss of air conduction, spoken speech is
heard relatively well, and the whisper is reduced.

As the disease progresses, bone conduction may be
found normal, air conduction absent, and Rinne nega¬
tive, such cases standing midway between the increased
and diminished bone conduction stages of the con¬
dition. The greater proportion, however, yield the
result—bone conduction increased, air conduction re¬
duced, and Rinne negative. Here the greater the in¬
crease of bone conduction the greater proportionately
will be the loss of air conduction ; acoumeter and voice
will be diminished, whisper almost lost, and the lower
tone limit will be reduced by one or more octaves.

When the spongioid changes have progressed to a
stage when diminution of bone conduction prepon-
derates, both that and air conduction will be found
reduced, associated with a Rinne negative. Material
reduction of bone conduction may need a differential
diagnosis to be made from nerve deafness. This can
be done by considering the loss of the lower tone limit,
the comparative retention of high tones (as ascertained
by the Edelmann Gatton-pfeife), the increasing dura-
tion of air conduction as the number of vibrations in.
creases, and Gelle’s test.

The last-named test is, I think, certainly useful, in
spite of the adverse criticisms to which it has been
subjected. Its chief objection lies in its difficulty of
application. As a control test to Rinne’s reaction, it
possesses most value. Without further discussion, I
may formulate the following results and their signi¬
ficance :—

(1) If Rinne is negative high up in the scale (to C),
Gelle is also negative, and deafness is due to stapes
fixation.

(2) If Rinne is negative below or up to C, and posi¬
tive for higher octaves (C s ), the result of Gelle's test

__630 The Medical Press. ORIGINA

indicates whether stapes fixation is to be assumed
or not.

I have dwelt upon the results of functional testing
somewhat at length because I believe them to be im¬
portant, not merely from the diagnostic point of view,
but as indications for treatment. The small attention
that has been paid to tuning-fork tests by the majority
of British aurists is the chief blot upon British otology.

The course of the majority of cases of otosclerosis is
slow, but occasionally one meets with instances in
which a quickly progressive diminution in hearing,
with increasing tinnitus, leads to almost complete deaf¬
ness within a few months. In the ordinary slow pro¬
gress, exacerbations may occur, due usually to preg¬
nancy, excessive body chill, anxiety and the like.

From what I have said you will gather that prognosis
is the reverse of favourable. We are at present quite
unable to cure the condition. In a few cases relief
from the tinnitus can be afforded, or the otosclerosis
even brought to a standstill. Those cases in which the
reddish promontorial reflex, already alluded to, is
present usually progress rapidly and ultimately reach a
high degree of deafness.

Treatment does not promise much. I am not going
to discuss the numerous operations—radical mastoid,
removal of the stapes, or formation of a new opening
in the bonv labyrinthine wall—that have been sug¬
gested and practised with varying results, mostly the
reverse of encouraging.

Prophylaxis, in regard to the evil effects of preg¬
nancy and chill, should certainly be kept well in mind.
Conception in otosclerotic patients should be avoided,
and female descendants of otosclerotic persons should
be advised not to marry.

When otosclerosis is present, numerous drugs havo
been suggested for its treatment. Iodide of potassium,
in daily do9es of about 15 gr. in half a pint of water
immediately after food ; antipyrin and salicylic acid in
small doses; arsenic, iron, bromides, strychnine,
thyroid extract—all have been recommended and found
wanting. The drug which has received most universal
attention is phosphorus, which, according to Mirwa
and Stdtzner, retards the formation of normal
spongioid bone in the long hollow bones. It may be
given in oily solution or in glutoid or keratin capsules,
and is best administered in small doses given for a
long period of time. Caution is necessary, as it may
cause digestive disturbances.

As regards local measures, nearly all those hitherto
employed have been with the object of mobilising the
stapes. They resolve themselves into two groups—
intra-tympanic injections and passive movements. In¬
flation with air alone (by catheter or Politzer douche)
is useless, and may do positive harm. In place of air,
steam, nascent chloride of ammonium, vaseline, pilo¬
carpine, and solutions of pepsin have been suggested.
More recently the use of a fluid ointment containing
red oxide of mercury injected through the catheter
and combined with rapid otomassage has been advo¬
cated.

The best results hitherto recorded seem to have
accrued from the judicious application of otomassage,
and I am inclined to believe that any successful treat¬
ment of otosclerosis will be obtained by this means.

Rote.— A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture for
next week will be by Dr. Chantemesse, Profeeseur
Agrigt of the Faculty of Medicine of Paris. Subject:
" The Serum Treatment of Typhoid Fever (Antityphoid
Opsonisation) ”

On December 4th, Elisa Dehring. 50, a cook, lately
in service at Crediton Road, West Hampstead, was
before Mr. Paul Taylor charged with being accessory
to the murder of a married woman, 28 years of age,
who died in St. Mary's Hospital on August qth last,
as the result of an illegal operation. Mr. Symmons
prosecuted for the Treasury. Mr. Paul Taylor com¬
mitted the prisoner for trial at the Central Criminal
Court, not, however, on the original charge, but, at
the request of Mr. Symmons, for various other alleged
offences iti connection with the woman’s death.

PAPERS. Dec. ii, 1907.

ORIGINAL PAPERS.

THE COLOUR OF~ THE MUCOUS
MEMBRANES AS A GUIDE TO THE
CONDITION OF THE BLOOD, AND
AN INDEX OF THE NUTRITION OF
THE BODY.

By ALEXANDER HAIG, M.A., D.M., Oxox.,
F.R.C.P., Lond.,

Physician to the Metropolitan Hospital and to the Royal Waterloo
Hospital for Diseases of Children and Women.

Some years ago I produced a card of graduated
colours corresponding with those of the mucous mem¬
branes, the palest colour being that usually met with
in chlorosis or anaemia, and the darkest being that met
with in those who maintain a good standard of health
and nutrition on a uric-acid-free diet (a). The other
colours are intermediate between these extremes, and
to make the card more useful I placed under each
colour the numerical index of the corresponding blood
decimal— i.e., the decimal per cent, haemoglobin
divided by per cent, red cells. Now in chlorosis the
common decimal is about .5 or less, and that of the
deepest colour is more than a whole number— i.e., 1.1.

We thus get four colours for comparison with the
mucous membranes, and the numbirs corresponding
are .5, .7, .9, and 1.1, and in examining a case we can
enter it in our notes as any one of ihese, or, if it 1$
intermediate, then as .6, .8, or 1.0 (i).

I propose now to mention some of my results with
this card, to describe the best methods of using it, and
the extent to which it may be relied upon as an index
of blood condition and general nutrition.

It does not, of course, pretend to be more than an
approximate guide to the actual blood decimals, and
whenever the pale colours indicate distinct diseased
conditions, examinations of the blood itself should
always be made to supplement the information given
by the card, and also for the purpose of examining the
numbers of the various kinds of cells and their forms.

The whole object of the card is not to do away with
the necessity for blood examination, but to tell us, as
it does in two minutes, whether there is, on the one
hand, anything far wrong with the vital fluid calling
for further investigation, or, on the other, whether a
patient, whose blood decimal had been recorded six or
twelve months before, was keeping up a condition of
good and satisfactory nutrition, or whether that nutri¬
tion was improving or falling off.

The mucous membranes that are generally made use
of for the purpose of obtaining the approximate blood
decimal are those of the mouth and eyes.

It is well to have the patient seated on a chair, and
facing a good light, but not in direct sunlight, which
is apt to cause dazzling reflections. I may say that the
cards are not intended for use by artificial light, and
that if they are so used they will probably give results
that are from 10 to 15 per cent, too high.

A fairly good idea of the index may be obtained
simply by watching the patient smile ; the only objec¬
tion is that as the lips are drawn up, there is apt to
be some pressure on the gums, squeezing the blood out
of them so that the index may be too low.

The best way to examine the gums is to take the
lower lip and pull it gently down so as to expose the
lower gums without exerting any pressure upon them.

Having done this, place the colour card just below
them and slide it along to right or left till the nearest
tint to that of the gums is vertically below them.

It must not be expected that the colours will tone
absolutely in all cases. It is practically impossible to
produce artificially the exact tint of the blood as seen
in the mucous membranes, but you should obtain as
nearly as possible the tint or depth of colour visible
in the gums, and if it is intermediate between two
colours, mark it with an intermediate number.

In order that the result obtainable from the gums

(а) Cooler of this card can be obtained from Messrs. Bale and
DrmM.son, London. Price 1*.

(б) Note the number* on t 1 e cards at present obtainable hare, for
rea nos which I explain in a forthcoming new edition of “ Drlc Arid.'
been marked too low and should be altered as above for eomparimo
with ordinary atandard* of blood examination.

Digitized by G00gk

Dec. ii, 1907.

ORIGINAL PAPERS.

The Medical Peess 631

may be moderately reliable, there must be no irritation
of any part of the gums from dental periostitis or the
accumulation of tartar. Therefore, look at the general
tint of the whole gum surface, not at one spot.

But since the colour of the gums may be misleading
from some of these causes, it is always well to use
other mucous surfaces for comparison, and to enter
the result of such comparison rather than the colour
of any one.

The colour of the lips, as seen in their natural posi¬
tion, is always loo dark from the presence of pigment,
but the tint of the inner surface of the everted lip may
be used if this eversicn can be managed without
squeezing the blood out of it.

Again, if the tongue is clean, and it is p-otruded in
such a manner as to force the blood moderately into
the surface of its mucous membrane, this may give a
fairly reliable index.

As to the eye, the blood decimal may be read from
the lower lid simply by pulling it downwards (though
this is very often congested, and yields too dark a
colour), or, better, while gently fixing the lower lid,
make the patient look outwards, so as to expose the
mucous membrane covering the caruncle at the inner
canthus, and take the general tint of the surface thus
exposed.

In all cases it is the general tint or the average tint
of all these exposed mucous surfaces, rather than the
tint of any one of them, that is to be used in arriving
at the approximate blood decimal.

Now as to the use of this blood decimal when
ottained. It has long been my habit to note this in
all patients when they first come to me, and at each
subsequent visit, and the observation is so easily and
quickly made that it soon becomes a routine.

I thus get most valuable information as to the con¬
dition of the blood and general nutrition, and am able
to see at a glance whether a patient is improving,
standing still, or going back, as time goes on.

As a rule, middle-aged people living on an ordinary
mixed diet do not show a blood decimal above .7, or
at most .8, and, of course, those who come to a doctor
are not in the best of health, or they would not come.

But those who live on a mixed diet never have quite
such a high blood decimal as those who live on the
uric-acid-free diet, and while 1.0 and 1.1 are reached
by those who do well on this diet, and have been on
it for about three or four years, and especially by
children and young people whose nutritive processes
are active, there are practically no meat-eaters who
attain to 1.0, just as there are no meat-eaters who have
as quick a capillary circulation as those who swallow
no unnecessary uric acid.

Those who attempt to get on to the uric-acid-free
diet, but fail from one cause or another to take suffi¬
cient albumen, not only do not show an improving
blood decimal, but often present to us a great and
decided falling-off below even the level of the ordinary
meat-eater, because to alter diet without taking suffi¬
cient nourishment is to have low acility of urine and
high alkalinity of blood ; hence the blood is flooded
with uric acid from the old stores, and the blood
decimal rapidly deteriorates.

Such people have depression one day and rheumatism
the next, as the uric acid excess oscillates back and
forward from the blood to the fibrous tissues, and
from the fibrous tissues to the blood, and it is the
latter change that markedly brings down the blood
decimal.

This is well seen in the case of chlorosis, especially
if the chlorosis (as is often the case) has been preceded
by rheumatism.

It is the very same uric acid which in the girl of 13
causes rheumatism, and in the same person at 17
causes chlorosis, and between these two ages there is a
more or less constant alternation of excess of uric
acid in the blood, with increasing anaemia, and excess
of uric acid in the joints and fibrous tissues, with in¬
creasing rheumatism.

And the blood decimal will at once tell us which way
the pendulum swings, for with rheumatism at 13 there
is a much higher decimal (at first almost normal—say,
.q to 1.0), and with chlorosis at 17 there is a much
lower decimal tending to get even lower still if the
case is untreated.

When I see a case of chlorosis with a decimal of .5
or less, I never put that on to a uric-acid-free diet, as
to do so would aid the solution of uric acid in the
blood and make matters worse.

Here we must first cure the patient with iron and
any food she can best take to make sure of sufficient
albumen (without which neither good blood nor any
other tissue can be made), and when the decimal has
got to .7 or .9, then slowly alter the diet, taking great
care that the proper quantity of albumen is not on any
account allowed to be missed.

For similar reasons the gouty old squire type of
patient (who leads a healthy out-door life and is
troubled by nothing except occasional gout in his big
toe) is the one who shows, as a rule, the best decimal
for the meat-eaters, and may even get up to .9. For
he, like the rheumatic girl of 13, is exactly the person
who has most uric acid in his joints and fibrous tissues,
and least in his blood.

And this is a favourable condition for the blood,
which shows a relatively high decimal.

But when this man breaks down from advancing
years, or breaks his leg in a motor smash, or is other¬
wise laid up, there comes his bad time, and all the
uric acid stored in his tissues in previous years begins
to pass into his blood, and his decimal falls to .7, .6,
or even lower, according to the amount of uric acid
passing through the circulation, and the length of time
it continues to be present in the blood in excess.

The blood decimal of the ordinary mixed feeder is
about .6 or .7, and if he alters his diet you must be
content if it does not fall off in the first six or nine
months.

By the end of twelve months it may have begun to
improve slightly ; in the second twelve months there
should be more decided improvement, and by thirty
or thirty-six months it should be .9 or 1.0 if nutrition
is being properly kept up (»'.«., if sufficient albumen
is being taken).

And this is where the great value of the colour card
shows itself. It would be absurd to examine a patient’s
blood at every visit. If it has been examined at the
first visit and found normal except for deficiency of
colour, and if colour has been improving on the re¬
formed diet, it is unnecessary to examine the blood at
each visit, and there are few patients who would care
for the trouble involved.

But with the card one can feel confident that one is
not overlooking any serious blood disease, and if the
decimal is improving one knows with practical cer¬
tainty that nutrition is satisfactory.

Again, the card is of great use in the treatment of
anaemia and chlorosis by iron or other drugs ( e.g .,
iodide of mercury often more powerful than iron—see
case and fig. in “Uric Acid,” Ed. VI.) which clear the
blood of uric acid ; and it is because iron clears the
blood of uric acid it does good in chlorosis and
anaemia. If such troubles as dyspepsia or diarrhoea
prevent it acting on the uric acid and clearing it out of
the blood, then the blood decimal will not be found to
improve under its administration.

But under ordinary conditions the decimal improves
so much under the proper administration of one of
these drugs that if the card is used, say, once a week,
a quite visible improvement can generally be observed
and recorded. The improvement (except under iodide
of mercury) is often slow at first, but becomes more
marked in the third, fourth, and subsequent weeks.

For all these purposes the card is most usefui, but
it is a good thing to examine the blood also at the first
visit, as this ensures that nothing is being overlooked,
and also gives us an opportunity of comparing the
result with the reading given by the card.

On the other hand, if the colour does not stand still
on the new diet, but falls lower and lower, wo may infer
either that the patient is not doing the diet correctly
{».£., has not left off all the poisons), or that he is not
taking sufficient albumen.

For the blood will not improve if nourishment is
deficient (nothing can be made out of nothing), and
this is so even if drugs are being used. The blood
decimal will not improve on iron if nourishment is
deficient, or if dyspepsia prevents its full and com¬
plete utilisation. Dyspepsia may also hinder recovery
by preventing the absorption of the iron.

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632 The Me dical Peess .

If we follow these facts carefully it soon becomes
evident that the cause of anaemia is the presence of
excess of uric acid in the blood; and that its cure by
drugs (iron, mercury, copper, etc., all of which form
insoluble compounds with uric acid) is the clearing of
such excess out of the blood, though the cure is often
temporary enough, as the urate is only driven into the
fibrous tissues (where it may cause various amounts of
pain as evidence of its whereabouts), from which it is
practically certain to return into the blood at some
future time when the retentive effect of the metals has
passed off; and that its prevention is the keeping of
the body moderately free from any large quantities by
means of the uric-acid-free diet.

All this and much more, which I have no time to
mention, is rendered sufficiently obvious by the steady
routine use of the blood decimal card.

A little practice soon gives all reasonable accuracy
as to the results recorded, and the card is a boon to
the busy practitioner, who can carry in his waistcoat
pocket a means of testing in a moment the blood con¬
dition of numbers of patients, when lack of time would
quite prevent him from drawing a sample of blood and
estimating both cells and haemoglobin with instru¬
ments. But he can always fall back on his instruments
when the colour card reveals the presence of very
abnormal conditions.

I say again the card gives only the approximate
blood decimal, but its constant use reveals many in¬
teresting facts as to the causation and concomitants
of anaemia and chlorosis, and their relation to uric
acid and rheumatism, and the effects of treatment by
drugs or diet in prevention or cure.

DIPHTHERIA AND SCHOOLS, (a)

By JAMES NIVEN, M.A., M.B.,

Medical Officer of Health, Manchester.

The subject may conveniently be divided into two
parts, the first concerning itself with the question
whether elementary schools have caused an increase
in the prevalence of diphtheria and the manner in
which it spreads in schools ; the second, with the mode
in which the spread of diphtheria in schools may be
combated, and the relation of such action to the pre¬
vention of diphtheria generally.

It does not follow because diphtheria spreads in
elementary schools that the incidence of the disease
must be increased by increased attendance at school.
This problem has for a long series of years been studied
by Sir Shirley Murphy, in a manner calculated to
give an answer to the question raised. From a com-
arison of the death-rate from diphtheria and mem-
ranous croup at school ages, and at younger as well
as more advanced ages, in the decade preceding the
Elementary Education Act, 1870, which made attend¬
ance at school compulsory, with the death-rate from
these conditions at the same age groups in the decades
following and in the quinquennial period 1901-05, he
shows that the diminution of the death-rate at school
ages has been less than that occurring at other ages,
or the increase has been greater at that period of life.

The incidence of diphtheria has, in fact, been
shifted so as to fall more than formerly on children at
school ages. Nor can this conclusion be said to be
invalidated by the greater precision which has been
attained in respect of diagnosis in recent periods, as
Sir Shirley shows.

Granted, however, that so much has been clearly
made out, it does not necessarily follow that a greater
total incidence of diphtheria has thereby been pro¬
duced, since, unless it can be shown that school life
has a special tendency to produce outbursts of
diphtheria such as would not occur in the ordinary
course of life erf children not attending school, all
that has occurred may have been merely a shifting of
incidence and not an increase of the total number of
cases. It might be supposed, for example, that, if
school children remained at home, and were infected,
as a number of them no doubt would be, the younger
ones being more in contact with those still younger

than themselves would infect them to a greater extent
than before, and the older ones being, perhaps, at
work would increase the amount of diphtheria amongst
their seniors. Nor are there wanting occasions on
which the closure of schools has seemed to produce
such a result.

Sir Shirley Murphy has been led to consider the
effect of school holidays on the incidence of diphtheria,
and he has shown that the autumn holiday produces
a decided diminution in the reported number of cases,
both of diphtheria and of scarlet fever, amongst
children at school ages, a diminution which is not
necessarily experienced either at younger ages or
amongst older persons. Here, again, there can be no
doubt that the effect of school attendance in summer
is arrested by the advent of holidays, but it is not
certain that the improvement at school ages is entirely
real, or that, even if it were, the effect of the holidays
at that season is not a more important factor than the
interruption of school life.

It will be seen that, even after Sir Shirley’s refined
and elaborate analysis, the question of the effect of
school life on the spread of diphtheria in the com¬
munity admits of further study. I have, therefore,
referred first to the careful investigations made by the
staff of the Local Government Board into particular
outbreaks of diphtheria, in the period preceding the
discovery of the diphtheria bacillus, and in the sub¬
sequent period before it had come to be considered a
necessary part both of investigation and administration,
as well as to Sir Richard Thorne’s work, which
summarises these and other reports.

From these sources we learn that the manner in
which outbreaks of diphtheria are preceded and
accompanied by slight sore throats, plainly of a
diphtheritic nature, was clearly made out. The part
played by other infectious diseases, and particularly
by scarlet fever, in causing diphtheria was emphasised.
The infective power of special cases, and the persist¬
ence of infective power in particular cases, were
recognised. The effect of rhinitis in causing infection
was not, and could not be, so clearly defined, as it
has subsequently become. But the influence of the
school was in some instances sharply defined, and it
was shown by Mr. Power, in one outbreak, that the
children at school were living in an infected
atmosphere, similar to that existing in households
invaded by diphtheria. Mr. Power also emphasised
the manner in which diphtheria introduced, on more
than one occasion, into the village school, by cases
with slight or without clinical symptoms, appeared to
gather intensity as one child after another was
attacked. On another occasion, school children
apparently became affected in the course of scrambling
play along with other infected children, but in a
manner independently of school life. On a third
occasion where a day-school was severely invaded, the
disease spread especially amongst the children living
in a particular part of the district.

It appears evident that the aggregation of children
in elementary schools must have the effect of diffusing
diphtheria in a number of instances sufficient when
taken together to affect the total incidence of the
disease, and that the power of the schools to affect the
total incidence of diphtheria will be greatest in
sparsely-populated rural districts.

It has appeared to me that it would be advantageous
to study more closely the behaviour of diphtheria in
relation to schools in the city of Manchester, a study
for which I possess a number of apposite facts.

Premising that the cases may, with few exceptions,
be regarded as diphtheria, owing to the careful
bacteriological and clinical sifting to which they have
been subjected, I give the facts as follows.

As regards the number of cases accepted finally as
diphtheria in individual years from 1897 to 1906, and
the aggregate numbers accepted, at each year of life
up to ten, in the aggregate a great increase is shown
in the number of cases at age three, which is the year
of maximum incidence. A small decline takes place at
ages four and five, and a marked drop at age sir.
Now, in Manchester, the numbers attending school at
age three are not much over one-third of the numbers
attending at age four, and the numbers attending at

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(a) Abstract of Paper read before the 8 econd International Cong reel
on School Hygiene, London, 1907.

Dec, ii, 1907.

ORIGINAL PAPERS.

The Medical Peess. 633

age four do not greatly exceed one-half of the numbers
attending at age five.

Hence the year of maximum incidence precedes the
years of school life. It is, however, the year in which
children will first be brought into intimate intercourse
with each other and with school children in the
course of play out-of-doors. I have already mentioned
one instance in which the scramble of play appeared
to have a special influence in the diffusion of
diphtheria.

A study of the facts for individual years appears to
show that as the wave of diphtheria rises the number
of cases increases most markedly at school ages and
at younger ages, the increase in adufts following later.
Further, as the wave rises year by year there is a
tendency for the age of maximum incidence to advance
to Uie fourth year, and in exceptional cases to the
fifth. In every year there is a marked drop in the
number of cases in the sixth year of life. The
influence of school is thus a special one, and is most
marked when . the total incidence of diphtheria is
greatest—that is to say, when more opportunities are
given for its manifestation. This is a result which
Sir Shirley Murphy had also arrived at by his method
of examining the subject. The great drop at age six
is probably due to the widespread establishment of
immunity.

Next, there is the number of cases for ten years of
diphtheria occurring in the separate elementary schools
of Manchester, quarter by quarter. That the significance
of this statement may be understood, it is necessary
to premise that the number of public elementary
schools in 1906 was 177, and the number of children
on the books 109,765, the average attendance being
about 90 per cent. It will be seen that diphtheria
affects particular schools in two forms, either as
special outbursts or in the form of a low and steady
persistence.

The latter form is greatly influenced by the number
of scholars and by the amount of the disease present
in the district. The outbreaks or flare-ups, however,
which take place in particular schools are more or
less independent of these circumstances and constitute
the true school influence. They are due, no doubt, to
the aggregation of susceptible children in the infant
departments of the schools affected, subjected to some
particular cause of a temporary character.

It is probable that this cause is the presence of
some child or children possessing the power to
produce copious discharges, rich in diphtheria bacilli,
while themselves not suffering. Many such cases have
been found, particularly among cases of diphtheritic
rhinitis, whether post scarlatina or otherwise, but the
tonsils also are affected in a similar manner.

The tendency of such flare-ups to last only a limited
period, and to bum themselves out, provided no more
children are meantime introduced into the class, is a
noteworthy circumstance.

It cannot be doubted that such flare-ups, which are
a special product of the aggregation of susceptible
material, do add to the diffusion of diphtheria in the
community. The degree to which they do so is to
be measured by the number of such flare-ups and the
number of cases occurring in course of them. Yet it
is not to be forgotten that similar occurrences would,
though less frequently, take place independently of
elementary schools.

Another interesting mode of considering the question
is the comparison of the death-rate from diphtheria in
the three main divisions of Manchester at ages o—3,
4—14, and above 15. It will be seen that while the
death-rates at ages o—3 and above 15 do not differ
widely in the three divisions of the city, the death-
rate in North Manchester is between two and three
times as great, at school ages, as the corresponding
death-rate for the Manchester township. This is the
more remarkable inasmuch as the Manchester township
is the poorest portion of the city, and, on the whole,
possesses the poorest schools. It might be inferred that
school diphtheria pursues a course of its own, inde¬
pendent of that followed by diphtheria at other ages.
As we have seen, this is true only partially, and the
figures require explanation. It is, however, partially
true.

This comparison leads us to observe that the sanitary
condition of the schools appears to have, upon the
whole, little to do with the occurrence of these out¬
breaks, which are, in a measure, fortuitous, and de¬
pendent apparently on the aggregation of children not
yet immunised, and on their opportunities for infecting
each other. It has been suggested to me by my
assistant, Dr. Goldsmith, that the absence of play¬
grounds in the centre of the city may be the essential
fact, a suggestion which chimes in with the conclusion
to which I had already come that the scramble of play
was probably the most important fact in the diffusion
of diphtheria. Nevertheless, crowding together in the
schoolroom and the use of common articles must also
contribute.

I have also analysed the cases of diphtheria occur¬
ring in a particular year—an analysis which, while
establishing some degree of exchange of infection
between school and younger children, again appears to
show that diphtheria in school children is largely
spread in school, and diphtheria in persons outside
school is largely spread independent 01 school.

It is, however, very difficult to arrive at a secure
position. It is manifest that diphtheria is one of those
diseases in which the slight or latent cases far out¬
number the discoverable cases. This is probably true
also of enteric fever, pneumonia, and cerebro-spinai
fever.

All these different lines of investigation, then, go to
show that diphtheria finds in the earlier period of
school life a favourable occasion to extend itself, and
that, in fact, it is in this manner widely diffused.

Some facts given by Dr. Graham Smith in his excel¬
lent paper in the Journal of Hygiene , Vol. II., go to
show that about rne-half of school children and a
much higher proportion of adults may have harboured
diphtheria on a membrane sufficiently invaded to have
allowed the system to absorb toxin in small quantities,
and so to elaborate a protective anti-toxin. Moreover,
when diphtheria has definitely invaded a school, the
proportion of harbourers is always high.

Further, Dr. Graham Smith shows that the propor¬
tion of persons in the poorer districts of an urban
community harbouring the Hofmann bacillus is gene¬
rally high, and I would suggest that in this circum¬
stance may be found the explanation of the compara¬
tively low incidence of diphtheria on the poorer dis¬
tricts. It is not suggested that there is not a pseudo-
diphtheritic bacillus, but that the “short ” or “sus¬
picious ” bacillus is frequently a true diphtheria
bacillus, and in all probability the so-called Hofmann
bacillus has frequently been a diphtheria bacillus. I
understand from Professor Delcpine that he recognises
the short form of the diphtheria bacillus by its rapidity
of growth on Loeffier’s serum, by its cultural charac¬
ters, by the arrangement of the bacilli in cultures, and
by the development of involution forms. There
appears to be a considerable margin of doubtful forms,
which may be capable of slowly producing immunity.
No doubt Professor Cobbett’s work is valuable, in
giving more precision to the observation of morpho¬
logical differences. At the same time, the facts seem
to point to a widespread production of immunity,
especially in the poorest districts, thiough bacilli of
comparatively low virulence. It would be highly in¬
teresting to know whether a similar difference exists
in different parts of other large towns.

How, now, are we to deal with the occurrence of
diphtheria in school? It appears impossible, usefully,
to separate this question from the allied one, how we
are to deal with diphtheria generally. It is now ad¬
mitted that all cases of suspected diphtheria should be
examined bacteriologically, and it may be added that
swabs should be taken from both throat and nose. It
is further generally admitted that, while bacteriological
confirmation should be sought in all cases, medical
practitioners should inject antitoxin on the appearance
of suspicious signs and symptoms without delaying to
ascertain the result of bacteriological examination.
Nevertheless, swabs are not and cannot always be care¬
fully taken, and the conditions are not always favour¬
able to the taking of swabs which will yield true
results.

Further, unless the public health bacteriological
examinations are made by experts, with great experi-

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ORIGINAL PAPERS.

Dec. ii, 1907.

634 The Medical Press.

ence, there is a decided risk of cases being classified
as not diphtheria which should not be so classified.
On both acoounts, there is a real danger that the estab¬
lishment of bacteriological examinations may lead to
the spread of diphtheria, owing to a false sense of
security being produced in respect of infective persons.

No serious case of throat illness, presenting signs
of diphtheria, should be entirely rejected simply on
bacteriological grounds, although the absence of
diphtheria bacilli should cause caution to be exercised
in placing such persons in the same ward with clear
cases of diphtheria, for the sake of thi latter.

The clinical diagnosis, then, still remains as neces¬
sary as ever, and bacteriological examination must be
regarded as only an aid, especially in the absence of a
staff such as the Public Health Authority in New York
has provided.

In the circumstances of public health administration
holding in this country, it is very desirable that all
cases of diphtheria should be removed at the earliest
possible moment after the commencement of symptoms.
If this cannot be done, a serious responsibility rests
on the medical practitioner who omits to administer
antitoxin within the first three days of illness.

No further principles of action can be laid down
applicable to all authorities, nor does it seem desirable
that they should be. If, under any system of adminis¬
tration, there is very little diphtheria in the district,
and schools are not invaded, it would be better to con¬
tinue on existing lines, until a necessity arose for
acting otherwise. Quieta non movere. If diphtheria is
present in the district at a moderately high level, more
action is called for. In that case, bearing in mind
the necessity of submitting all specimens to a bacterio¬
logical expert with large experience, and versed in
public health work, swabs should, when possible, be
taken by an officer of the sanitary authority from the
throat and nose of members of any family who have
been exposed to infection, and should be submitted to
bacteriological examination.

Cases harbouring diphtheria bacilli should receive a
prophylactic dose of antitoxin, and may usefully be
removed to an isolation hospital to be kept under
observation until free from bacilli on three negative
swabs. No child attending school from such a family
should be allowed to return to school while harbouring
bacilli. Breadwinners may be allowed more latitude.
But even breadwinners should not go to work while
harbouring bacilli, without being required to use pre¬
cautions in the way of antiseptic gargles, and nasal
douching of a gentle character with antiseptics.

Cases isolated in hospital are, usually, not discharged
except after three negative swabs have been taken. But
Dr. Newsholme’s practice appears to be a good one—
viz., to exclude diphtheria convalescents from school
for six weeks after discharge from school and recovery
at home. Apart from the question of infection, such
children are often weak, and susceptible to other forms
of disease—a consideration which might well be taken
into account by school authorities m connection with
other forms of disease. There are considerable diffi¬
culties in the way of obtaining three negative swabs
from children treated at home, and on this account
also Dr. Newsholme’s plan appears a good one.

The Action of Certain Salts of Formic Acid
on THE

CIRCULATORY AND MUSCULAR
SYSTEMS, (a)

By ALEXANDER GOODALL,M.D.,F.R.C.P.Ed.,
and ISABEL MITCHELL, B.Sc.

Dr. Goodall first referred to the extensive use
which was at present made of formic acid and its
salts in therapeutics, and to the very laudatory
terms in which they had been advocated, particu¬
larly by French writers. He thought that some of
the assertions as to the scope of formic acid were
extravagant, and noted that Dr. Ker and Dr.
Croom, who had written a paper on the use of these

(«) Abstract of Paper read before the Edinburgh Medlco-Chlrunrlcal
Society, December 4tb, 1907.

remedies in diphtheria, were much more cautious in
their statements than Huchard had been. He had
thought it, therefore, important to investigate the
physiological action of the formates by experiments
on animals. In the work he has made use of
ordinary physiological methods, and as he had
found that formic acid was too irritating to admit
of its use, he had employed the salt of sodium,
potassium and calcium.

Effect oti Blood-pressure .—In the case of all these
salts the only action observed was a depressant one ;
that is, the <irug, as soon as it produced any notice¬
able effect at all, was toxic. Sodium formate had
little action of any kind, except in strong solution,
and the fall in blood-pressure was usually tern
porarv. Potassium formate was more powerfully
depressant, and was fatal in strong solutions.
Calcium formate was depressant in dilute solutions ;
in stronger solutions the blood-pressure was raised
again. Formic acid was purely depressant. In the
case of sodium, potassium, and calcium, the action
of the metallic ion preponderated over that of the
formate. The Na-ion was inert; the Ka-ion was
depressant; and the Ca-ion raised the blood-pres¬
sure. The next series of observations were made
on the vessels of the isolated heart, with much the
same result; potassium formate was rapidly toxic;
sodium formate transiently so, and calcium for¬
mate stimulating. Their actions on the vessels
were also tested by counting the rate at which drops
fell from a divided artery of a frog when the circu¬
lation was perfused with solution of formate. All
the salts caused a transient vaso-constriction fol¬
lowed by a longer period of vaso-dilatation. Sodium
formate caused least vaso-constriction and most
vaso-dilatation; potassium formate caused most
vaso-constriction and least vaso-dilatation, while
calcium formate was intermediate between the two.

The action on skeletal muscle was investigated
on ordinary muscle, never preparations. " The
general effect of the formates was greatly to
lengthen the latent interval, and to induce fatigue
more quickly. Some experiments on man were
also undertaken. In doses of several grammes
no subjective sensations whatever were experienced.
Tracings were taken by means of the ergograph.
Some of the observers practised with the ergograph
until a uniform tracing was secured; others took
simply a tracing before and after formates. It is
well known that in using the ergograph great im¬
provement is manifested in the errors after a little
practice. In the case of the two subjects who prac¬
tised formates seemed to diminish the output of
work. In the observer who did not practise ihe
ergograph, tracing after formates was slightly
better than that taken before the drug was ad¬
ministered. Records made by the dynamometer
showed no improvement after formates. Lantern
slides of the various tracings made were shown,
and fully confirmed the statements made by Dr.
Goodall. The conclusions were that formates were
almost useless drugs; in all probability they were
rapidly converted into carbonates in the tissues.
Sodium formate was practically inert. Calcium
formate might find a sphere of usefulness as a
readily absorbed and not unpleasant calcium salt,
and be given in cases of hasmorrage, such as hae¬
mophilia in which the action of the Ca-ion was
desired.

Lord Strathcona presided over a special meeting
at Saffron Walden, held in aid of the Kssex Asylum
for Idiots, Colchester. A resolution was unanimously
passed that the meeting approved of a special effort
being made in the district to raise ^5,000 for the pur¬
pose of building an isolation hospital near the asylum
for the treatment of tuberculosis and other infectious
diseases.

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Dec. ii, 1907.

OPERATING THEATRES.

The Medical Press. 635

OUT-PATIENTS’ ROOM.

KING’S COLLEGE HOSPITAL.

Poll's Fracture.

By Peyton Beale, F.R.C.S.

Amongst the out-patients was a man, aet. about 50,
who was complaining of considerable oedema of the
right foot, very marked trophic disturbances evidenced
by eczema over the region of the lower end of the
fibula, wasting of the muscles of the lower part of the
leg and foot, with inability to bear weight on the
latter. On feeling the fibula it was evident that he
had suffered from a Pott’s fracture, and from his
history it appeared that this had occurred about
18 months ago. He said that his leg had been put up
in splints, and he had been admitted to a hospital,
where he remained for six or seven weeks. The log
and foot were then put up in plaster, and this was
removed about six weeks subsequently. On examina¬
tion there was a great amount of thickening about the
lower three inches of the fibula, including the external
malleolus; the patient had a flat foot, with very
marked eversion of the foot; the skin over the lower
end of the fibula was thin and eczematous, and there
was a small ulcer commencing just above the mal¬
leolus. Mr. Beale said that this state of affairs was
found very commonly after Pott’s fracture in oldish
people. There were, of course, many varieties of
fractures of the lower end of the fibula. The fracture
nearly always occurred at the weakest part of the bone
at a point about three inches above the tip of the
malleolus, the upper end of the lower fragment being
displaced inwards; this resulted in an outward dis¬
placement or eversion of the foot. The different varie¬
ties of the lesion were mainly due to the injuries which
took place at the inner malleolus as to whether this
was fractured or whether the internal lateral ligament
was ruptured to a greater or lesser extent. Accom¬
panying fracture there was commonly considerable
effusion of blood, and when the blood clotted and sub¬
sequently became organised, it caused blocking of
lymphatics and veins, often leading to considerable
oedema. He ventured to think the following line of
treatment was the best to adopt in order to obtain the
best results: for the first two days an evaporating
lotion should be applied to the leg and foot, the
patient lying in bed with the foot raised; then a
Dupuytren’s splint should be used. This is applied on
the inner side of the leg, its upper end being fixed
below the knee ; a large pad is inserted between the
splint and the leg about three inches above the internal
malleolus ; the foot is then securely bandaged to the
forked lower end of the splint, so as to fix it in a
position of marked inversion ; the splint should be le-
moved twice daily, and the foot and leg massaged
from below upwards. If for any reason there is an
objection to the Dupuytren’s splint (by its use alone
it may sometimes be difficult to counteract backward
displacement of the foot), a back splint with a foot
piece may be employed. The foot piece shoulci be at
right angles to the splint, but should be fixed “on the
skew ” in such a way that when the sole of the foot is
applied to it, it keeps the foot in a position of marked
inversion. Such a splint is found to give great com¬
fort to the patient, and most effectually prevents the
eversion and flat foot which are found so commonly
to occur after Pott’s fracture.

As regards this particular case, the only thing to be 1
done now was to carefully strap the foot, inverting it
as far as possible, and apply massage to the leg daily ;
the strapping should be renewed as the oedema
diminished. Of course, proper dressings would be
applied to the ulcer and eczematous skin before the
strapping was put on. The patient would also be given
a tonic containing iron, quinine and magn. sulph.

OPERATING THEATRES.

WEST LONDON HOSPITAL

Case Illustrating One of the Complications
Following Iliac Colostomy. — Mr. Swinford

Edwards operated on a woman, ast. 54, who had
been admitted with advanced carcinoma in the upper
rectum. A careful examination showed that the dis¬
ease was fixed to the sacrum, and, as the stenosis was
considerable, Mr. Edwards thought that a colostomy
should be performed without delay. The patient was
somewhat obese, and the abdominal wall was flaccid
and pendulous. The operator made the ordinary inci¬
sion, but on account of the adipose tissue it had to be
of greater length than usual. After the various mus¬
cular layers of the abdominal wall had been split in
the direction of their several fibres, the peritoneum was
opened. The colon was easily found, and as the
mesentery was sufficiently long, there was also no diffi¬
culty in bringing a knuckle well out through the
wound. The parietal peritoneum was next sewn with
interrupted sutures to the edge of the skin wound. A
glass rod was now passed through the mesentery trans¬
versely across the wound, resting on the abdominal
wall on each side of the incision. In this way the
posterior wall of the bowel was on a higher level than
the surface of the skin, thereby ensuring, as the
operator pointed out, a good spur. The bowel was now
fixed to the margin of the wound with several inter¬
rupted silk sutures, passing, where possible, through
one of the longitudinal bands. Several appendices
epiploicae were ligatured and removed, the ligatures in
a good many instances being used afterwards as
sutures, thus anchoring the bowel yet further to the
abdominal parietes. The bowel was not opened, and
after a layer of protective matter had been placed over
the operation area, the usual dressings, consisting of
gauze and cotton wool, were applied, a many-tailed
bandage being put on over all.

The subsequent history of the case was as follows:
Mr. Edwards opened the bowel on the third day by
slitting it up from end to end—that is to say, in the
long axis of the gut. On removing the dressings, the
glass rod was found loose in them, having slipped
from under the gut. The bowels acted after a lapse
of another two days, and all went well until ten days
after the operation, when the patient, being troubled
with a bad cough, felt something occur under the
dressing, after a violent fit of coughing. Thinking
that there was an action of the bowel, a nurse was
called, and on exposing the wound found that a large
knuckle of small intestine had prolapsed by the side of
the artificial anus at the upper part of the wound. The
house surgeon was communicated with, and, as Mr.
Edwards’s colleague, Mr. Bidwell, happened to be In
the hospital, he was asked to see the case. It appears
that the bowel had been prolapsed a sufficient time to
allow a coating of lymph to form. The gut having
been carefully cleansed, was returned, and four or
five deep silkworm gut sutures were passed in through
the upper part of the wound, including the walls of
the colon, and, in order to afford greater support, they
were passed through all its coats, thus effectually pre¬
venting any further prolapse. Four days after this
second operation, it is satisfactory to record, the patient
appeared none the worse for this accident. Mr.
Edwards remarked that it is well-known the chief risk
in colostomy is prolapse of the abdominal contents.
He had never known, however, this accident to occur
so late as in this case. In his opinion the following
reasons conduced to the contretemps : (1) a large pendu¬
lous and flabby abdomen ; (2) the employment of a
glass rod instead of sutures; (3) the union of the
parietal peritoneum to the skin ; and lastly (4) the
occurrence of undue muscular expulsive efforts due to
the cough. In this case Mr. Edwards said he used
a glass rod in order to get a better spur than even
could be got with a deep suture. He sutured the peri¬
toneum to the skin, a method which he largely prac¬
tised in former days, but which he has since aban¬
doned in the majority of cases. He did this on the

636 Th e Me dical Pkess. TRANSACTIONS

present occasion in order to cut off the subcutaneous
fat from the wound, hoping thereby to prevent fat
necrosis and suppuration, which are of somewhat
frequent occurrence after the operation of colostomy
in the obese. In any future case where he judged
that it was advisable to suture the peritoneum to the
skin, he would substitute for the glass rod a deep
mesenteric stitch, passing through the mesentery and
both lips of the wound. Should this method not
appear to sufficiently raise the colon, a glass rod might
be used in addition. Practically, he remarked, he
always used the deep suture, as by this method the
large opening into the abdomen is converted into two
small openings. This undoubtedly prevented any pro¬
lapse of the abdominal contents, even should no peri¬
toneal sutures be placed into the gut.

TRANSACTIONS OF SOCIETIES.

ROYAL SOCIETY OF MEDICINE

Necrological Section.

Meeting held Wednesday, December 4TH.

The President, Dr. C. E. Beevor, in the Chair.

Dr. J. S. Collier read a paper on
CERTAIN PECULIARITIES OF INTRA-CRANIAL GCMMATA IN
RELATION TO THE EFFECT OF ANTI-SYPHILITIC
TREATMENT.

He first gave an account of the case of a middle-aged
man who had developed additional symptoms (optic
neuritis, hemianopia, etc.) actually during the time he
was being energetically treated for a gumma. Recourse
was then had to operation, and a small, very fibrous
gumma was removed. Dr. Collier pointed out that
gummata should be sharply divided into two classes—
(1) rapidly growing diffuse growths presenting clinic¬
ally two characteristic features—acute onset and
general symptoms (headache, vomiting, and early optic
neuritis). These cases respond well to anti-syphilitic
remedies. Many of them are really cases of acute
hydrocephalus due to syphilitic ependymitis. (2)
Slowly growing tumours characterised clinically by
the presence of facial symptoms (epilepsy, etc.), and
by the late development of optic neuritis and other
general symptoms. This late development of general
symptoms was probably due to changes in the vicinity
of the gumma. The present case belonged to this
group. Many of these cases also responded well to
medicinal treatment, but some did not. He emphasised
the fact that the cases not responding to medicinal
treatment usually belonged to the second group, and
could be localised so that operative treatment was
clearly indicated.

Sir Victor Horsley concurred in all Dr. Collier's
remarks, and narrated a case throughout similar to the
one described by Dr. Collier.

. Dr. Purves Stewart raised the question of the dura¬
tion of medicinal measures, and stated that examina¬
tion of the cerebro-spinal fluid for lymphocytosis was
important, as sometimes this sign was present—indi¬
cating a syphilitic nervous affection—when no other
symptoms revealed the presence of the lesion. Thus
treatment should be continued not only until the
symptoms disappeared, but also until the lympho¬
cytosis subsided.

Dr. Farquhar Buzzard agreed with Dr. Collier that
some cases even of the second group recovered with
medicinal treatment.

Drs. F. E. Batten and Gordon Holmes read a
papier on

the nervous system of a dog suffering from ataxia
AND INVOLUNTARY MOVEMENTS.

The animal has had choreic movements, failing vision
and smell, apathy and marked mental deterioration.
At post-mortem was found : cell infiltration of the peri¬
vascular region, the cells being lymphocytes and
plasma cells. The changes were strongly reminiscent
of those found in general paralysis of the insane,
except that the ganglion cells were but little altered.

OF S OCIET IES._ Dec. 11, .907,

Sir Victor Horsley pointed out the similarity of
the changes to those found in rabies.

Dr. T. Grainger Stewart read a paper on
FOUR CASES OF TUMOUR OF THE FOURTH VENTRICLE.

These cases were very difficult to recognise, and one
had chiefly to rely on the absence of signs indicating
positive or cerebellar disease. He laid stress on the
sudden onset of the symptoms, the fact that there was
giddiness which increased on movement, and on the
slow, coarse nystagmus, equally marked in both
lateral directions; death was often sudden.

Dr. David Fbrriee discussed the symptomatology.

Dr. F. E. Batten referred to a case in a child with
whom vomiting was the only symptom.

Dr. S. A. K. Wilson also referred to a case. It was
characteristic of these lesions that the symptoms till
near the end were only general.

Dr. Farquhar Buzzard read a paper on
a case of tubercle of the sixth nucleus on one

SIDE.

The patient, a woman aet. 42, had had signs of
tumor cerebri, and then died of tuberculous menin¬
gitis. At the autopsy was found degeneration in the
posterior longitudinal bundle on the opposite side to
the lesion of the sixth nucleus. According to Bruce
this bundle does not cross the middle line in its course,
and this case might be adduced as indicating that It
reached the opposite third nucleus by crossing imme¬
diately on leaving the sixth nucleus. It was not con¬
clusive, however, for the degenerated fibres might have
originated, not in the sixth nucleus, but in Deiter’s
nucleus.

Sir Victor Horsley was of opinion that the de¬
generated fibres certainly came from Deiter’s nucleus,
which in his opinion was to be regarded as the centre
regulating conjugate movement, and not, as previously
thought, the sixth nucleus.

ROYAL ACADEMY OF MEDICINE IN IRELAND.

Section of Pathology.

Meeting held Friday, November 22ND, 1907.

The President, Dr. A. R. Parsons, in the Chair.

VILLOUS TUMOUR OF THE BLADDER.

Dr. Boxwell stated that the patient from whom the
specimen was taken was a young man, aged about 34,
who had been perfectly healthy until about 12 months
previous to his admission to hospital. The chisf
symptoms on admission were hasmaturia with pain on,
and increased frequency in, micturition. The urine
was found to be alkaline, full of pus, and in addition
contained triple phosphates, epithelium, and a con¬
siderable amount of blood. The appearance of the
man, and the fact that he had lost his voice, suggested
that the trouble was of tuberculous origin, but no
tubercle bacilli could be found in the urine. He was
too ill to be operated on, and even attempts to wash
out his bladder were always attended with great pain.
He died a fortnight after admission to hospital. At
post-mortem the base of the bladder was found to bi
occupied by several large villous masses, the largest
being situated at the mouths of the ureters ; the bladder
wall was thickened, and the ureters greatly dilated
The kidneys showed the ordinary septic changes fol¬
lowing cystitis.

Mr. L. G. Gunn spoke on the subject.
carcinoma following ulcer of duodenum, with

SECONDARY DEPOSITS IN LUNGS.

Dr. Boxwell exhibited specimens with microscopic
slides. The organs were obtained from a man aet. 60.
He had been suffering for some years from attacks of
jaundice, sometimes with slight vomiting, but never
had much pain. An exploratory laparotomy was per¬
formed, and the gall-bladder was found to be dis¬
tended, and a hard mass could be felt in the duo¬
denum, while the pancreas was found filled with small
hard nodules. The patient made no definite progress,
and died in a week. At post-mortem it was found that
there was something like an ulcer occupying the

Digitized by GoOgle

Dec..,,, ,907._ TRANSACTIONS OF SOCIETIES. The Medical Peess. 637

ampulla, just at the entry of the common duct, with a
fair amount of new growth of a cancerous nature
around it. Nodules were also scattered through the
lungs; these were found to be carcinomatous, while
the nodules in the pancreas were merely necrotic
masses. The liver was simply jaundiced; there were
no secondary deposits in it.

CANCER OF THE BLADDER.

Mr. L. G. Gunn exhibited a specimen showing exten¬
sive cancer, filling practically the whole interior of the
bladder. The patient was a man who presented all the
appearance of a very acute inflammation of the
bladder. When the patient was first seen the disease
was too far gone to allow of operative interference
beyond giving relief, by draining; the tumour was then
about the size of a small tangerine orange. The man
lived about two months, and in that time the bladder
had filled up. The tumour was a very cellular car¬
cinoma, and was unusual in not having any symptoms
of haemorrhage.

THROMBOSIS OF ARM WITH GANGRENE.

Dr. O’Carroll described a case of gangrene in a
widow, set. 39, who entered hospital in July last com¬
plaining of cramps in the fingers of her left hand. The
day after admission a slight bluish tinge was seen,
especially about the wrist, and she was unable to lift
the forearm. Nothing in her history gave any clue to
the cause of the condition. Her heart was found to be
rather weak, with some slight softening of the first
sound. The only objective defect to be found was a
small quantity of albumen in the urine. Her chest
was small; she was thin, and had a ruddy blue face.
The day after admission pain was complained of in
the right hand and arm, and a slightly black hue was
found about the right wrist. Within a few days the
circle moved up the left arm, while the right hand
cleared up. The left hand gradually dried up, and
became perfectly rigid, and in about three weeks the
dryness and mummification had reached the junction
of the upper and middle third of the forearm. The
arm above this became swollen and tender, and pre¬
sently a line of demarcation occurred, and sank in
about a fortnight to a depth of about half an inch.
The patient was given two or three minutes of
anaesthesia, and the arm was taken off above the elbow
joint. The stump healed perfectly, and she left hos¬
pital much better in general health.

Mr. H. Stokes referred to a somewhat similar case.

Professor White said he remembered quite well the
case referred to by Mr. Stokes, which was so like that
which Dr. O'Carroll had so graphically described. In
it the gangrene was undoubtedly due to the condition
of the vessels of the arm, which were rigid, and their
lumina almost obliterated.

favour of the view that the tumour started inside the
bone. The upper portion of the internal aspect of the
tibia was completely destroyed, which simply meant
that the tumour in making its way out destroyed the
bone. The so-called expansion of bone simply meant
that while the bone inside was being infiltrated and
destroyed, new bone was being formed outside. A
time always arrived when the new bone was not formed
in sufficient quantity to cover the more rapidly growing
tumour.

Mr. L. G. Gunn also spoke, and Dr. Harvey replied.

LARYNGEAL SPECIMENS.

Professor White showed and demonstrated a few
interesting old specimens from the College of Surgeons’
Museum.

(a) Cases of Hanging. —In two specimens obtained
about 80 years ago the same lesions were present. In
each case the thyroid cartilages and os hyoides are
widely separated from each other—the intervening
muscles, etc., having been almost completely torn
across. The epiglottis was torn away from rest of
larynx, and ascended with os hyoides and tongue into
floor of mouth. In Vol. V. of the old Dublin Hospital
Reports, a short description of these specimens is
given. It would appear that the omo-hyoid, sterno¬
hyoid, and steyno-thyroid muscles were lacerated in
such a fashion that only a few shreds held the torn
portions together. The right sterno-mastoid was ecchy-
mosed, contused and broken; while the left sterno-
mastoid was but slightly bruised. The rope knot was
to the left side. The skin alone intervened between
the rope and the interior of pharynx. The cervical
vertebrae and spinal cord were uninjured.

(b) Suffocation. —The specimen in this case showed a
large lump of meat, almost three inches in length,
firmly wedged in the pharynx and oesophagus, and
completely closing the superior opening into larynx.

(r) Ulceration of Tracheotomy Tube into Aorta. —No
history attached, but apparently the condition for
which the operation of tracheotomy was performed was
an acute one, as no disease of the larynx is recog¬
nisable. At a period long after the operation, but
some time antecedent to death, some unskilful person
attempted to replace the tube, but thrust it instead
between the sternum and trachea, with the result that
ultimately the lower end of tube ulcerated into crch
of aorta. Judging from the appearance of the wound
in the trachea, some time must have elapsed before this
occurred. From the time the tube was put in the false
position, the patient must have breathed in the ordinary
way, as the tracheal wound was quite blocked by the
tube in front.

EDINBURGH MEDICO-CHIRURGICAL SOCIETY.

SARCOMA OF TIBIA.

Dr. G. Harvey showed a specimen of sarcoma of
the tibia occurring in a married woman set. 55. He
exhibited at the same time several microscopic slides
and X-ray photographs of the tumour. The latter
showed certain points which were not evident in the
specimen—viz., (1) that the fibula was free from the
growth, (2) that there was no great expansion of the
medullary cavity, but (3) there was great rarefaction
of the head of the tibia, and (4) that the articular sur¬
face of the tibia was enlarged at its external margin.
The growth did not appear to infiltrate the muscles
very much, but rather pushed them in front of it.
Microscopically, the tumour was in parts an ossifying
chondro-sarcoma. In other portions round cells in
alveolar grouping were to be seen. Two interesting
questions arose: First, was this alveolar arrangement
due to a segregation of cells into cartilage spaces, with
partial absorption of the cartilage?—and might this be
the general explanation of alveolar sarcomas, using the
term in the descriptive sense? Second, did the sarcoma
start in the centre of the bone or outside? From the
appearances of the radiograms in conjunction with the
fact that the tumour cells appeared to be grouped
about the perichondrium, he inclined to the view that
the growth originated outside the bone, probably from
the cartilage of the point.

Professor White said he thought the appearances
seen in one of the X-ray photographs were strongly in

Meeting held December 4TH, 1907.

The President, Dr. James Ritchie, in the Chair.

Dr. W. G. Aitchison Robertson gave a demonstra¬
tion of the method of sterilising milk by Buddisation.
He referred to a previous communication concerning
the state of the milk supply of Edinburgh, and said
that the condition of matters had in no way altered
for the better during the two years which had since
elapsed. Budde’s method of sterilising milk had
proved commercially successful in Denmark, and a
company had been formed to supply Buddised milk
in Edinburgh. He did not himself believe that in
the minute quantities which were required to destroy
the germs in milk such preservatives as formalin or
boric acid were deleterious, but any objection which
existed to their use did not apply to Budde’s process.
He had found the germ content of Edinburgh milk
higher than the standard of good quality in many
cases. Buddisation consisted in adding peroxide of
hydrogen (pure 3 per cent, solution) to milk at a tem¬
perature of iao° F. The enzymes, which are
present in milk as well as all other living substances,
decomposes the peroxide of hydrogen and sets free
nascent oxygen, which acts as a germicide. In order
completely to sterilise milk, .03 to .035 per cent, of
hydrogen peroxide is added. This quantity is com-

638 Thf Medical Press. TRANSACTIONS OF SOCIETIES.

Dec. 11, iqo;.

pletely decomposed by the milk, and consequently
there is no disagreeable taste. Milk so treated wiU
remain sterile for a number of days. Mr. Budde, who
was present, gave details of his process, and samples
of the milk were on view, stored in the automatically
stoppered bottles in which it is supplied commercially.

Dr. Alex. Goodall and Miss Isabel Mitchell,
B.Sc., read a paper on

THE ACTION OF CERTAIN SALTS OF FORMIC ACID ON THE
CIRCULATORY AND MUSCULAR SYSTEMS,
a full abstract of which will be found on page 634. 1

In the discussion that followed,

Dr. G. A. Gibson remarked that, from the results ;
of clinical observation, he could not doubt that formic !
acid had a marked effect in raising the blood pressure.
This he had frequently demonstrated in cardiac dis¬
ease by means of the Riva-Rocci sphygmanometer. He
was also convinced that in chorea the drug had a
valuable tonic action on the muscles. Moreover, he
believed that it was of use as a tonic. He had fre¬
quently noticed that patients who had felt the benefits
of formic acid asked for more of the same tonic, 1
though they were ignorant of its composition.

Dr. C. B. Ker also spoke favourably of its use in
diphtheria. The mortality rate had diminished slightly
since they had begun to use it systematically in the
fever hospital, and the incidence of post-diphtheritic
paralysis had diminished. Possibly the lessened num¬
ber of cases of post-diphtheritic paralysis was due to
the action of formic acid on muscular tissue. At
present, in spite of Dr. Goodall’s destructive criticism, j
he was inclined to go on using a remedy which was
giving him good results. It was generally said that
formic acid was apt to disagree, but he had noticed
that in cases of cardiac vomiting, when nothing else
could be retained except a little iced brandy, formic
acid was well borne. In his cases diuresis had not
been noticed.

In his reply Dr. Goodall spoke of the difficulty of
reconciling clinical and physiological discrepancies.

He had made no observations on the action of formalin
on the metabolism, because he understood that the
subject was being worked out elsewhere at present.

Mr. J. W. Struthers read a paper on
THE VALUE OF NOVOCAIN AS A LOCAL AN.ESTHETIC FOR
SUBCUTANEOUS USE.

Novocain was a synthetic local anaesthetic which had
already found many supporters, and the claims made
for it were, he thought, .well founded. After trying it
in about 85 cases, he could say that it had proved
uniformly satisfactory, and equal to, if not better
than, cocaine and eucaine. It was soluble, stable,
and sterilisable, and compatible with adrenalin. He
preferred to make up a stock solution in bulk which
was boiled each time before use. For infiltration
anaesthesia he used a solution of 1.400, with 1 minim
of commercial adrenalin solution added to every 2
drachms. This solution produced anaesthesia in about
10 minutes, and it lasted for from one to three hours. \
For inguinal anaesthesia, produced by injecting novo¬
cain in the neighbourhood of large nerve trunks, a
stronger solution (2 per cent.) was employed, with 1
minim of adrenalin added to every drachm. The
maximum dose of the weaker solution was 6 ozs. ; of
the stronger, $ oz. A number of operations, such as
avulsion of the nails, amputation of the fingers, !
cleansing lacerated wounds, incision of whitlows, etc.,
which had been satisfactorily performed under novo¬
cain, were referred to.

Mr. George Chiene and Mr. Wheeler (Dublin)
discussed the paper, the former pointing out the great
advantage of local anaesthesia in minor surgery.
Fatalities from the anaesthetic were relatively far more
common after minor operations, therefore general
anaesthesia should as far as possible be dispensed with.
Mr. Wheeler confirmed Mr. Struthers’ estimate of the
great value of novocain, and described his method of
employing it. He injected it into the true skin, and
found that anaesthesia was almost immediately pro¬
duced.

In reply, Mr. Struthers said that while anaesthesia 1
was almost instantaneous when the injection was made |
into the true skin, he preferred to give it sub- [
cutaneously, which delayed the action somewhat.

Dr. Alexander James read

notes on cases of tuberculous ax.emia.

The condition had first been described by Trousseau;
its characteristic was that along with the symptoms
and appearance of anaemia there was found an almost
normal appearance of blood. He gave notes of two
cases in which the patients had complained for some
time of pallor, palpitation, and breathlessness in
exertion. They both looked markedly anaemic, but
on examination of the blood an almost normal count
was found. On further investigation evidences of
phthisis were discovered. It was argued that the
existence of chronic anaemia, without alterations in the
blood, was suggestive of tuberculosis. Possibly, the
anaemic condition was a factor in the development of
the tuberculous diathesis. It was possible that the
appearance of anaemia was actually due to a diminu¬
tion in the total volume of the blood, and was
associated with a condition of hypoplagia of the
vascular system. Trousseau held the view that in
these cases treatment of the anaemia was not very
safe; he compared the need for care in giving of iron
to these patients with the caution which must be
exercised in checking leucorrhceal discharges, and in
operating on fistula in tuberculous patients. It seemed
to him that haemorrhage from the lungs might
develop on the administration of iron. With this old-
fashioned view Dr. James to some extent agreed, and
he quoted an example of the occurrence of signs of
tuberculosis after treatment of an anaemia of ihis
description with arsenic.

Dr. Gulland discussed Dr. James’s paper.

Dr. Alexander Bruce read a paper on
UNUSUAL SEQUEL-® OF HERPES ZOSTER (?) POSTERIOR
POLIOMYELITIS.

The patient in question had suffered from a severe
attack of herpes zoster, followed after a short interval
of time by a sensation of numbness, which passed up
one lower extremity and down the other. Then followed
muscular weakness of the right leg, with exaggeration
of the deep reflexes and an extensor plantar response,
and loss of pain and thermal sense with conservation
of the lactile and muscular sense below the level of the
herpetic zone. The secretion of sweat was also
abolished over the affected limb. These symptoms—
dissociated anaesthesia, muscular weakness, and
exaggeration of the reflexes—subsequently spread to the
left leg, and these gradually cleared up altogether.
The sequence of events was suggestive of hysteria, but
Dr. Bruce gave reasons for supposing that they were
due to a haemorrhage or other vascular lesion at the
base of the posterior cornua, first on one side, and
then on the other, a condition of posterior poliomyelitis

CENTRAL MIDWIVES’ BOARD.

Meeting held Thursday, November 28th, iqo;.

The President, Dr. Champneys, in the Chair.

After a brief discussion as to the correctness of the
designation of “midwife,” and of the inability of the
Act to suppress the practice of so-called “maternity
nurses,” it was agreed by the Board—(</) That the
Home Secretary’s proposal to extend the system
adopted for reporting convictions of midwives within
the area of the London County Council to the whole
of the Metropolitan Police District, if desired by »he
other County and County Borough Councils therein,
be accepted, with thanks ; (b) that it be suggested to
the Home Secretary that this system might with advan¬
tage be extended to the whole of England and Wales:
(c) that the Home Secretary be furnished with par¬
ticulars as to those Local Supervising Authorities who
have not complied with Section 8 (5) of the Midwives
Act, 1902, up to the present time.

A letter was read from Dr. W. P. T. Daniel, of 273.
Cable Street, London, E., forwarding a copy of a
resolution adopted at a meeting of medical men re¬
siding in the parish of St. George’s-in-the-East, and
neighbourhood, declaring their intention, after Novem¬
ber 30th, not to proceed to any case of parturition.

CORRESPONDENCE.

Dkc . u , 1907.

etc., occurring in the parish, on the requisition of a
midwife, unless a minimum fee of one guinea is
guaranteed either by the Guardians or by the Central
Midwives’ Board.

It was agreed—(<z) that a copy of the correspondence
be sent to the Privy Council, pointing out the diffi¬
culties and dangers of the situation, and suggesting
that a copy of the Local Government Board’s circular
on the subject should be forwarded to every medical
practitiorer in England and Wales; (£) that the
Board’s action in the matter be communicated to Dr.
Daniel, and that he be informed that the Board has
no power to pay fees in such cases.

THE FEES OF MEDICAL MEN SUMMONED BY MIDWIVES.

Mr. Ward Cousins opened a discussion on the
matter, reporting the question which had been put to
him by the Royal College of Surgeons, as to what the
Board was doing with regard to the question of the
fees of medical men summoned to the assistance of
midwives. He thought it was time the Board took
some definite action. The whole efficiency of the Act
was blocked by the absence of such official payment,
and the consequent attitude of doctors. The Chair¬
man said he thought the Board had done a good deal ;
it was out of their power to pay doctor’s fees, or
compel anyone else to pay them ; but the importance
of the matter had been constantly urged by them
before the authorities, and he pointed to the recent
circular issued by the Local Government Board, and
sent to all the Local Supervising Authorities as a result
of this agitation. He had great hopes from this cir¬
cular, but it was quite new, and he thought it highly
probable that a great many practitioners did not yet
know of it. Dr. Stanley Atkinson said that St.
George’s-in-the-East was the only parish in London
which had objected to complying with the suggestion
of the Local Government Board.

Letters on the same subject had been received from
Dr. E. Rowland Fothergill, Hon. Secretary to the
Wandsworth Division of the Metropolitan Counties
Branch of the British Medical Association, and from
Dr. J. \V. Hembrough, County M.O. for Northumber¬
land. It was decided that the latter should be for¬
warded to the Privy Council.

At the request of the Local Supervising Authority
for the Worcestershire County Council, it was agreed
that Birmingham be constituted one of the Provincial
Examination Centres during the pleasure of the Board.

Letters had been received from the Clerks to the
Guardians of the Ashton-under-Lyne and Gateshead
Unions, inquiring the reasons of the Board’s refusal
to approve their Union Hospitals as Training Schools
for Midwives.

It was agreed that the Guardians be informed that
the decisions were arrived at after a full consideration
of all the facts bearing on the matter, and that it is
contrary to the practice of the Board to give reasons
for its decisions in such cases.

At their own request the names of 12 women were
removed from the roll, on the grounds of old age, ill-
health, or inability to comply with the rules.

Vacancies on the list of examiners to the Board were
filled by the appointment of:—(1) J. P. Hedley, M.B.,
B.C. (Cantab.), M.R.C.P., Obstetric Tutor and Regis¬
trar, St. Thomas’s Hospital; (2) Eardley Holland,
M.D., B.S. (Lond.), F.R.C.S., Obstetric Registrar and
Tutor, King's^ College Hospital, Assistant Surgeon for
Diseases of Women, Metropolitan Hospital.

Applications for approval as Teacher were granted
to the following:—Rosa E. Bale. L.R.C.P., L.R.C.S. ;
W. Fordyce, M.B., F.R.C.P.E. ; F. G. Haworth,
M.B. ; G. F. B. Simpson, M.D., F.R.C.S.E. ; S. H.
Smith, M.B. ; and of Penrose Williams, M.R.C.S.,
L.R.C.P.

Five midwives were approved to sign Forms III.
and IV.

Dr. Stanley Atkinson was added to the Finance and
Office Committee.

In the Secreary's report of the October Examination
it appeared that out of a total of 461 candidates, 386
passed, leaving the percentage of failures 16.27. The
London Training Schools had sent up 128 candidates,
of whom 120 were successful. From the rest of the
training schools in England, Wales, Scotland and
Ireland there were 245 candidates, of whom 47 failed.

The Medical Press. 63 9

The number of candidates trained by private tuition
was 88, out of which 68 passed the examination.

The next general meeting of the Board will be held
on December 19th, at 2.45 p.ln.

CORRESPONDENCE

FROM OUR SPECIAL CORRESPONDLNTS
ABROAD.

FRANCE.

Pari*. Dec. 7th, 19*7.

Colloidal Silver.

After a silence of several years, colloidal silver is
once more placed on the tapis. Netter, in 1902, was
the first to bring it under the notice of French surgery
in an important communication made to the Medical
Society. It was spoken of for some time, and finally
fell into oblivion. Some medical men, however, con¬
tinued to use it. Recently, some articles of Victor
Henri and Iscovesco on colloidal silver, prepared by
electricity, once more drew attention to this agent, and
at the late Medical Congress several communications
were made on the subject, presenting it in a very
favourable light.

Silver can, like several other metals, such as mercury,
gold, be obtained in a colloidal state. The reduction
of salts of silver by different agents produces very
easily colloidal solutions, but chemical processes give,
all or them, impure products.

The electric preparation of colloidal silver, on the
other hand, according to the method of Br£dig gives
absolutely pure products. Faraday proved that if an
electric spark was given off in the air between two gold
wires, a metallic deposit was obtained under the form
of a very fine powder. It was by taking this principle
as a basis that Bredig prepared a large number of
colloidal metals.

The metallic solutions thus obtained, says Dr.
Milian, are coloured more or less ; they are clouded
and yet leave nothing on the filter, nor with an
ordinary microscope can any solid deposit be detected.
With a powerful lens, however, a large number of
brilliant particles can be seen, moving with great
rapidity, and which are the metallic granules in sus¬
pension in the water.

One of the most important properties of these pseudo¬
solutions is that of giving a precipitate by an electrolyte
of no matter what kind, provided it is employed in
sufficient quantity ; thus chloride of sodium precipitates
a solution of colloidal platinum, and nitric acid pre¬
cipitates silver colloidal. •

Colloidal silver, called by Crede collargol, appears
under the form of small black grains easily crushed.
It is employed in ointments, subcutaneous or intra¬
venous injections.

The strength of the ointment is 15 per cent. It is
utilised in the form of frictions like mercurial oint¬
ment. The skin being previously washed, the ointment
is rubbed in for about ten minutes. These frictions
possess a certain activity of absorption, but they are
insufficient in grave cases. Subcutaneous injections
should never be employed, as the solution (1—25) is
absorbed very slowly, leaving hard nodules which take
several days or weeks to disappear. The same might
be said of intra-muscular injections.

Intravenous injections should be always preferred.
Here absorption is rapid and complete. When the
injection is properly made it leaves 110 trace, and its
action is rapid and powerful.

The solution may be that of colloidal silver dis¬
solved in water (1—100), but Dr. Milian prefers to
employ electrargol, that is to say, collargol prepared
by the electric method, as it is more active and more
fluid.

The instrument employed is a syringe holding two
drachms, as it may be necessary to inject that amount.

The bend of the elbow, where the veins are most
visible, is the region to be chosen for the injection, and
the preliminary preparations are those for blood
letting : a bandage around the middle of the arm to

Digitized by GoOgle

640 The Medical Press

CORRESPONDENCE.

Dkc. 11 , 1907

arrest the venous circulation, antisep9y of the part by
soap and hot water, and finally, with proof spirit.
The operator, his hands being also rendered aseptic,
seizes the needle, and only the needle between the
thumb and index of the right hand, while with the
left hand he fixes the vein by pressing on it with the
thumb, he inserts it obliquely and gently into the vein.
He knows he is in it by a drop of blood flowing out
of the needle when he continues to push it in parallel
to the vein. Then, holding the needle in the horizontal
position, he fixes on to it the syringe and slowly injects
the contents. No resistance should be felt during the
injection, which if experienced, would result either
from the needle being blocked up or that the liquid
had penetrated into the cellular tissue. In either of
these cases the operation should be stopped, the needle
withdrawn and re-inserted into another vein.

These injections, made with the usual antiseptic pre¬
cautions, are without danger; they are better borne
than intra-muscular injections, and give truly wonder¬
ful results.

Asthma and Atropine.

Some 70 years ago, Trousseau recommended atropine
in the treatment of grave cases of asthma, but this
treatment fell into disuse, and yet deserves to be
brought under notice again.

In a case of asthma of 20 years, for which different
treatments had been applied in vain, including injec¬
tions of morphia, atropine produced a prompt and
durable effect.

The subjective condition improved, sleep returned,
and the catarrh ceased. The treatment lasted six
weeks. A quarter of a milligram was given twice a
day at first, and gradually increased to two milligrams
a day.

Certain very rebellious cases were not benefited, and
sometimes troubles of accommodation and dryness of
the pharynx were observed, but the heart was never
affected. Naturally, the antispasmodic properties of
atropine explain its action.

GERMANY.

Barilo. Dec. 7th 1907.

At the Medical Society, Hr. W. Braun spoke on
Penetrating Wounds of the Gastro-Intestinal
Tract.

Last summer he had shown patients treated by him¬
self in the Friedrichshain Hospital; first, two children
with punctured wounds of the abdomen, victims of a
crime that had aroused a great deal of excitement.
One child, three years of age, had three penetrating
wounds of the abdomen, from which intestine pro¬
truded, and in which the intestine was wounded in ro
less than eight places. In the other case, a child of
five, the omentum protruded, but the intestines them¬
selves were intact. To these were added four patients
with gunshot wounds of the abdomen. In one case,
that of a young girl, the bullet had penetrated from
behind, had wounded the lower pole of the right
kidney, and had then passed through the stomach,
duodenum, and liver. The stomach and bowel were
closed by suture ; the kidney had to be extirpated on
account of the continued bleeding that could not be
arrested. Another patient who had severe injuries of
the gastro-intestinal tract inflicted on the same occa¬
sion died. Two boys, aged 6 and 15 respectively,
recovered.

The surgical experiences of the last war showed that
in the case of abdominal wounds received from fire¬
arms in the field, expectant treatment gave the best
results. The best war results were, however, wretched
as compared with those obtained in a state of peace.
Here it was decidedly better to treat at once, and the
sooner the better. Undoubted signs of injury of in¬
testine, such as vomiting, blood in the stools, or escape
of faecal matter from the abdominal wound, were not
necessary, and in the cases shown were not present;
but, on the other hand, symptoms of peritoneal irri¬
tation, such as nausea and abdominal tension, were
present in every case. Where there was a possibility
of a penetrating wound of the abdomen, the case
should be attacked at once, provided the patient was
in a properly equipped hospital. On widening the

track of the wound, whether of knife or bullet, one
can easily see whether the peritoneum was wounded
or not, and in any case no harm would have been
done.

Immediately on the infliction of the injury, spasm,
of the bowel took place; that at first closed the bowel
and prevented the escape of faecal matter; paralysis,
of the bowel did not take place till later, and then the
escape of faeces was facilitated. Therefore, operation
should not be delayed till the first shock was passed.
Waiting might be very fateful for the patient, for the
reasons that, first, the danger of peritonitis would
be the greater the more abdominal contents had
escaped, and, next, that suture of a well-contracted
bowel was much more reliable than that of a paralysed
one.

At the Otological Society Hr. Wagner showed *
child in whom during the course of an attack of in¬
flammation of the middle ear symptoms present in the
fundus oculi were the main cause for chiselling the
mastoid. The patient, a girl, gave the impression of
being very ill, although both pulse and temperature
were normal, and there was no tenderness over the
mastoid. In the fundus oculi both the arteries and
veins were engorged, and there was papillitis on the
left, but no papillary stasis. At the operation a peri¬
sinuous abscess the size of a small hazel nut was
found, and which was undergoing considerable pres¬
sure. After the operation the papillitis became still
worse, but the vascular engorgement receded at once.
Kfirner attributed this papillitis to a meningo-ence-
phalitis.

Hr. Oertel related a case of

. Serious Injury to the Skull.

The head of a little boy, set. 3, was crushed between
a mangle and the wall. The left side of the face at:
once became paralysed. A considerable quantity of
blood escaped from the nose, mouth, and right ear for
the next two days. After that, watery fluid came from
the same ear, and a fortnight later pus flowed pro¬
fusely. The external auditory canal was narrowed up
to a small slit, out of which pus flowed when the child
cried. Pressure on the mastoid, which was tender,
also caused pus to flow from the opening.

An operation showed that a fracture had taken
place in the lower portion of the squamous
bone, and that a sequestrum, the size of a sixpenny
piece, lay in the posterior wall of the auditory canal
and was only connected with the other bony parts
by a narrow bridge of osseous structure. The removal
of the sequestrum led to speedy recovery from the
traumatic mastoiditis. The left-sided facial paralysis
was also beginning to disappear.

AUSTRIA.

Vienna, Dec. 7 ta. 1907.

Osteopathy.

Goldreich showed a child with an uncommon form
of osteopathy due to syphilis, as was presumed at the
May meeting, when he showed the child before treat¬
ment in the morbid state. At that time the differential
diagnosis resulted in designating the case one of in¬
hibited ossification, or osteogenesis imperfecta remoWy
depending on hereditary syphilis. At that time the
ossification of the cranium was quite rudimentary,
while there was inflammatory hyperostosis of the long
bones which strengthened the syphilitic view. The
same virus was considered active in stopping the
growth of the flat bones of the cranium by some of the
members, while others argued the opposite—that in¬
flammatory hyperplasia was the rule in the bones of
the head as well as the bones of the limbs. A more
exhaustive examination revealed osteochondritis in the
shoulder-blades and the elbow-joints, with pseudo¬
paresis of the right arm.

After that examination the child was put on anti¬
syphilitic treatment, with magical results, putting
beyond doubt the proof that the affection was entirely
due to the syphilitic virus.

The cranial defects soon closed, and the inflamma¬
tory hyperostosis of the long bones disappeared. It
was subsequently discovered that the father had
l suffered from syphilis.

ized by G00gle

Dec. ii, 1907.

CORRESPONDENCE.

The Medical Peess. 641

Spieler said he had a similar puzzling case two years
ago, which he recorded in the Zeitschrift, and diag¬
nosed it as probably due to hereditary syphilis.

Hochsinger said he had no doubt that the case was
one of hereditary syphilis, as osteogenesis imperfecta,
hyperostosis, etc., were peculiar to congenital syphilis.

Escherich thought that those belonging to osteo¬
malacia were of a similar origin.

Cerebellar Tumour.

Marburg presented a case that originated a year ago
in disturbance of vision, pain in the head of a rheuma¬
toid character, unsteady gait, great increase of
cranium, and a general growth of fat throughout the
body. There was also congestion of the papilla and
ataxia present. The tumour seemed to be located
about the anterior portion of the superior vermiform
process, causing dropsy of the third ventricles and
degenerative changes in the hypophysis, the latter
morbid condition accounting for the adipositas uni¬
versalis, which has amply been demonstrated in cere¬
bral changes.

Hochwart drew attention to the happy, gay, uncon¬
cerned state of the patient’s mind, which he said was
characteristic of cerebellar tumours.

Poliomyelitis.

Zupper next brought in a six-year child, with
paralysis of both arms, including the shoulder muscles,
with the exception of the levator scapulae, trapezius
and serratus magnus. All the muscles of the arms
were paralysed with the exception of the flexor carpi
ulnaris and flexors of the fingers. On the right hand
the flexor of the thumb was also intact.

From this state it must be assumed that the lesion
in the anterior horns of the cord cannot extend above
the fifth, sixth, and seventh cervical vertebrae; but it
must be noted the supra- and infraspinatus are involved
in the general destruction, which have part of their
origin in the fourth segment. This is worthy of note,
as the phrenic nerve has its origin in the fourth seg¬
ment, and remains perfectly entire. Another freak
may be observed in the musculus serratus magnus,
which arises in the fifth segment and is functionally
entire. This case forcibly demonstrates how difficult
it is to locate lesions of the cord with any approach
to accuracy. Zappart said the prognosis was very un¬
favourable, even by orthopcedic means, although by
a form of arthrodesis in fixing the shoulder and elbow,
the boy could be made to raise the one hand to the
mouth by the assistance of the other.

Moszkowicz thought a good deal could be accom¬
plished in this case by means of surgical-orthopoedia,
and exhibited a similar case he had operated on to
demonstrate his assertion.

Abnormal Displacement.

Hochsinger interested the members with an unusual
displacement of the heart below the ribs altogether,
where the apex beat could be seen on the left side in
the abdomen, while the upper margin of the cardiac
area was delineated between the fourth and fifth ribs ;
towards the right the margin was two finger-breadths
outside the sternum. Systolic and diastolic murmurs
were found at all the ostia.

It appears that after an attack of endo- and peri¬
carditis rheumatics, a mediastinal pericarditis super¬
vened, fixing the pericardium to the anterior costal
wall. The valvular defects and concretions subse¬
quently caused hypertrophy and dilatation, but being
fixed in its upper margin left no other retreat for the
expansion than downwards and to the left in the
abdomen, pressing the diaphragm before it into the
abnormal position as seen in the patient.

HUNGARY.

Budapest, Dec. 7th, 1907

Physostigmine in Intestinal Paresis.

Not so long ago atropine was praised highly in all
cases of intestinal obstruction depending upon pairesis
of the intestines. However, the director of the First
Internal Clinic in Budapest, Prof. Koranyi, holds that
physostigmine is much more suitable for such cases.
Similar opinion was expressed also by Dr. Dollinger,
Professor of Surgery. The latter gave in one instance

where operation was refused and atropine given with¬
out the slightest effect. The patient was getting weaker
and weaker, but after a subcutaneous injection of half a
milligrame of physostigmine, rapid improvement set in.
In some cases it will be necessary to give as much as
one milligrame. The drug is not suited for children,
but does good service if given by mouth for nervous
flatulency and atonic meteorism.

The Efficaciousness of the Erysipelas Serum.

Dr. Rev^rf having applied the antitoxic therapy in
cases of erysipelas, describes the results of his investi¬
gations in the Orvosok Lapja. He used the blood
serum obtained from patients convalescing from ery¬
sipelas. The doses used were generally 10 to 30 c.c.,
sometimes 68 to 90 c.c., hypodermically. Nine cases
were thus treated, including erysipelas of the face. As
the result of this form of medication, headache, deli¬
rium, and hallucinations disappeared. The appetite
improved, and the temperature fell in the mijority of
cases. Whenever albuminuria was associated with
erysipelas, the antitoxin caused the disappearance of
the former.

On the Internal Treatment of Appendicitis.

Dr. Sz&k&cs settles the confusing diversions of
opinion as to the proper time for operation in appen¬
dicitis in a simple manner. In mild cases he merely
applies linseed poultices and administers 0.50 gr. of
collargol, 100 c.c. of water, a tablespoonful every
half hour. In more severe cases the dose is increased
to 1.0 gr. in 100 water, and Cred6 ointment is applied
locally. The drug also may be given per rectum where
vomiting interferes. Sometimes a cure follows even
where peritonitis has already set in, and of a large
series of cases only two were lost since the peritonitis
had already advanced too far when the patients were
seen for the first time. Surgical intervention is only
indicated where there is general peritonitis, and in
these cases it is advisable to establish an artificial anus,
and also to give large doses of collargol. This drug is
harmless even if applied in very large doses.

The Sterility of Women.

Dr. Backer discussed the various forms of sterility
in women at the last meeting of the Royal Inter¬
hospital Association. He cautioned his colleagues
against the tendency to go ahead with the treatment of
sterility on the assumption that it is due to the woman.
In every case, he believes, the husband should be ques¬
tioned as to his virile power, and a careful examina¬
tion of his sperma should be made. This search for
spermatozoa should be made several times, and at
rather long intervals, during which time the person is
to abstain from intercourse, since it is well-known that
a temporary azoospermia occurs after repeated coitus.
Dr. Backer read a report concerning 483 cases of
sterility, in 58 of which absence of spermatozoa has
been found. In nineteen of these cases the wives had
been under treatment. Furthermore, he found in 37
instances persistent oligo-spermia, and 13 times necro-
spermia.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

Treatment of Incipient Insanity. —Dr. Urquhart,
the superintendent of James Murray's Royal Asylum,
Perth, has written a letter to the Scotsman strongly-
supporting Dr. Clouston’s appeal for the establishment
of wards for the treatment of mild mental disorder.
He instances the experience of the Albany Hospital,
N.Y., in which on the petition of some physicians, a
psychiatic pavilion was erected in 1902. It is a two-
storeyed building containing 24 small rooms, 6 day
rooms, and 2 dormitories, and since it was opened
1,031 patients have been admitted. Of these, 596 have
returned to their homes recovered or improved, 316
have remained stationary, and 86 have died. More
than half the patients were returned to their homes
without the formidable apparatus of legal procedure,
and the institution has become a general hospital
turning none who are sick from its doors.

642 The Medical Press.

CORRESPONDENCE.

Dec. 11, 1907.

Proposed Model Hospital for the Scottish
Exhibition. —In connection with the National F.xhibi-
tion, which is to be held in Edinburgh next year, a
letter was read at the last meeting of the Managers of
the Infirmary, stating that it was proposed to have a
home nursing section in connection with the woman s
section of the exhibition. Lessons will be given in
home nursing and the use of disinfectants. A request
was made that the lady superintendent of the infirmary
should be permitted to co-operate with the Exhibition
Committee in arranging this exhibit. The letter was
remitted for consideration.

Edinburgh Medico-Chirurgical Society. — An
interesting meeting of this society was held on Wednes¬
day last, when Dr. Aitchison Robertson gave a
demonstration of the method of sterilizing milk by
Buddisation; Mr. Budde, who was present, gave
details of the process, and exhibited samples thus
dealt with. The reading of papers followed, that by
Dr. Goodall and Miss Mitchell on “The Action of
certain Salts of Formic Acid on the Circulating and
Muscular Systems” evoking considerable discussion.
An abstract of this paper will be found in another
column under the heading of “Original Papers.” Mr.
J. W. Struthers subsequently read a paper on “The
Value of Novocain as a Local Anaesthetic for Sub¬
cutaneous Use,” Dr. Alexander James one on “Tuber¬
culous Anaemia,” and Dr. Alexander Bruce one on
“Unusual Sequelae of Herpes Zoster.” A report of the
proceedings will be found under the heading of
“Transactions of Societies.”

Some Outstanding Effects of Tuberculosis, Professor
Symmers; (11) Sanatorium Life Illustrated, Dr.

Howard Sinclair. The exhibition was privately
visited by her Excellency the Countess of Aberdeen,
who made a special journey from Dublin for the pur¬
pose. She was conducted through it by the Honorary
Secretaries, Drs. Thos. Houston and John Macllwaine,
to whom no small share of the credit for its success
must be assigned.

Dr. Richard Barnett. —One of the oldest medical
men in the district passed away last week in the
person of Dr. Richard Barnett, who died in his sleep
on his 79th birthday at his residence at Holywood,
co. Down. Dr. Barnett studied in Edinburgh, where
he graduated in 1849, and subsequently practised as
a dental surgeon in England and the south of France,
returning to his native city, Belfast, about 40 years
ago, and practising here till his retirement in 1900.
He was a singularly shy and retiring man, but came
prominently before the public in two capacities, as a
rifle shot and as a chess player, in both of which he
obtained champion honours, as has his only surviving
son, Mr. R. W. Barnett, a well-known member of the
English Bar and of the Irish rifle team at Bisley.
He was highly respected by his medical colleagues,
and was fox many years a vice-president of the Ulster
Medical Society.

LETTERS TO THE EDITOR.

BELFAST.

Queen’s College. —The successful attainment of
the objects for which the Better Equipment Fund was
raised was marked by an interesting ceremony at the
College last week, when a fine bronze tablet com¬
memorating the services to the Fund of the Rev.
Thomas Hamilton, D.D., President of the College, was
unveiled. The unveiling was done by Mr. Justice
Dodd, an old classmate of Dr. Hamilton’s, and the
chair was taken by the Right Hon. Thomas Sinclair.
References to the University question were made by
both these gentlemen, and hopes were expressed that
the College might before long become autonomous.

Lurgan and Public Health. —A largely attended
meeting was held in Lurgan last week, when it was
decided to start a local branch of the Women’s Health
Association of Ireland. The inauguration of the new
society will take place in connection with the visit of
the Tuberculosis Exhibition to the town. Dr. Agnew,
the Medical Superintendent Officer of Health, ad¬
dressed the meeting.

Medical Inspection of School Children. —At the
first meeting of the Public Health Committee of the
Belfast Corporation, Dr. Henry O’Neill brought up
the question of the desirability of having a system of
medical inspection of school children in Ireland
similar to that which is now coming into operation in
England.

The Tuberculosis Exhibition. —In the course of
the past fortnight, during which the Tuberculosis
Exhibition was open in Belfast, it was visited by over
43,000 persons, and has proved in every way a great
success. In the mornings and afternoons parties cf
visitors were conducted through the various rooms by
young medical men who had volunteered for the duty ;
then afternoon lectures on sick-room cookery were
given by a lady, and a series of evening lectures were
delivered to crowded audiences. These lectures were
as follows:—(1) Tuberculosis in Children, Dr. John
McCaw ; (2) Surgical Tuberculosis, Professor Sinclair ;
(3) Tuberculosis the Scourge of Ireland, Sir Robert
Matheson; (4) Some Aspects of the Tuberculosis
Problem in Ireland, Dr. David Lawson ; (5) Stuffy
Rooms: their Cause and Cure, Mr. Wm. Davidson,
Belfast Technical Institute; (61 Tuberculosis in
Animals, Professor Mettam; (7) How to Keep Our
Homes Healthy, Mr. A. Savers, Belfast Technical
Institute; (8) the Fight against Tuberculosis: what
Other Countries have Done, Professor Lindsay ; (gl the
Prevention of Tuberculosis, Dr. Wm. Cal well; (10)

“THE BROWN DOG” DISTURBANCES.

Sir, —In your comment of November 27th re the
“ Brown Dog ” and the students, you state the dog
“was destroyed in a perfectly legal and regular
manner.” Allow me to correct this assertion. Accord¬
ing to the Act of Parliament, “the animal must be
killed immediately the object of the experiment is
obtained.” When this unfortunate dog, after an
interval of two months, was opened a second time to
ascertain if inflammation had been set up by the first
operation, the object was obtained. But the dog was
not killed ; on the contrary, it was handed ever, with
wounds clamped with forceps, to a second vivisector,
who performed upon it a severe operation lasting an
hour. Even then it is a matter of doubt what further
use may have been made of its mangled body, for at
the trial a third person and also the laboratory boy
both claimed to have despatched it. This may be
“regular,” alas! but it is certainly not legal.

I am, Sir, yours truly,

Frances E. White.

December 6th, 1907.

[We spoke simply of the death of the dog. It was
killed in as legal and regular a manner as a bullock
is killed in an abattoir. The plea about the second
experiment done on the dog is beside the point alto¬
gether. It is mere juggling with words to make out
that the demonstration given on the animal while it
was under the anaesthetic and before it was killed was
a transgression of the Home Office regulations. Would
the anti-vivisectionists have preferred another dog to
have been used instead?—E d.]

To the Editor of The Medical Press and Circular.

Sir, —My attention has been called to a paragraph
or two in an article in your issue of November 27th,
i.e., that “Animal experimentation provides the children
of their borough” (i.e., Battersea) “with the only
means ” (sic) “whereby they can efficiently be helped
to recover when attacked by diphtheria.” If you will
take the trouble to look the matter up, carefully and
without bias, you will find that some of the highest
authorities, and perhaps, even especially vivisec-
tionists, have by their expressed opinions traversed
this misleading statement in your article. The rest of
your article does not much concern me; but, in
closing, I may say that your “ Bullock ” remarks will
cause some astonishment in farming circles, proceed¬
ing from a pardonable want of knowledge of farming
pursuits, operations, and objects. As regards your

ized by GoOgle

Dec. ii, 1907.

CORRESPONDENCE.

The Medical Press. 643

assertions about the different experiments on and death
of the “ Brown Dog ” and the libel case to which you
allude, it would be well not to confuse the two issues,
and you might look this also up at the same time as
you do the use of diphtheritic serum and certain farm¬
ing operations.

Yours very faithfully,

George W. F. Robbins, Secretary.

Battersea General Hospital,

December 9th, 1907.

[We really cannot take Mr. Robbins seriously; to
traverse his statements would be to do so. His advice
to us to look up the literature of antitoxic serum in
the treatment of diphtheria is a very poor joke. So,
too, is his criticism of our knowledge of the
castration of male animals on farms, and also
of our delinquencies in the English language.
With regard to the slander case in question, we are
satisfied that a jury should have expressed their
opinion of the veracity of anti-vivisection statements
by awarding Dr. Bayliss ^2,000 damages, and that
the anti-vivisectionists proceeded to commemorate the
occasion by putting up a public monument. A more
striking testimony to the sense of truth and justice
possessed by the organisers of the movement is hardly
needed.—E d.]

WHO INTRODUCED TRYPSIN?

To the Editor of The Medical Prks9 and Circular.

Sir,—T he letter from Dr. Shaw-Mackenzie, published
in your last issue but one, contains a challenge as to
the origination of the trypsin treatment of cancer that
it will be impossible for the scientific world to ignore.
The gentleman mentioned either is or is not the
originator of the method. His statements are clear,
and he has published the documentary and other evi¬
dence on which his claim is founded. On the other
hand we have conflicting claims published for the most
part in lay newspapers by Dr. Saleeby, a medical
man, who asserts that Dr. Beard, a non-medical man,
was the first to advance the theory. Dr. Shaw-
Mackenzie states that he used trypsin and published a
description before Dr. Beard. The matter can hardly
be allowed to rest here, for some of our medical
journals seem to have assumed that the honours do
not rest with Dr. Shaw-Mackenzie. Surely no
honourable man would decline his challenge to sub¬
stantiate public statements as to the priority of claim.

Turning to another phase of the subject it seems
curious that we should turn to Germany for informa¬
tion on the trypsin treatment, and quote freely the
opinions of von Leyden on the point. We have ho
need for science “imported from Germany ” while we
have the original thing at home. Von Leyden is years
behind Dr. Shaw-Mackenzie in this matter, yet we see
von Leyden quoted copiously, while the prophet stands
neglected in our midst. At present the scientific
surgeons appear to be recognising that there is some¬
thing of truth in Dr. Shaw-Mackenzie’s patient
investigations. It seems only reasonable to ask that
the editors of medical journals should carefully
examine the facts of the case before they accept the
claims to priority on either side, especially when one
of the rival claimants happens not to be a medical man.

Yours faithfully,

Onlooker.

London, W., December 8th, 1907.

THE MIDWIVES ACT.

To the Editor of The Medical Press and Circular.

Sir, —It is probable that most of us who have any
knowledge of the ways and means of providing the
poor with the proper care required when their children
are being born will agree with the views expressed in
the leader in the Times (December 7th) ; and it is quite
clear that the Archbishop of Canterbury and Lord
Balfour are perfectly incompetent to deal with this
question. The Times seems to be at a loss to know
what is best to be done. Jt thinks that it will be
“necessary to appeal to Parliament for some modi¬
fication of the stringency of the Act.” It thinks that
“the period has passed for any more waiting upon

providence.” This question is one that should and
must be dealt with by our profession, and it would
be interesting if you would take it up in The Medical
Press and Circular.

I am, Sir, yours truly,

R. L.

PROPRIETARY MEDICINES.

To the Editor of The Medical Press and Circular.

Sir,—I heartily endorse every word contained in
Dr. Hamilton’s letter in your issue of December 4th.
In May last I communicated a paper on “The Passing
of the Prescription : some of its Causes and Effects,”
to the Therapeutical Society. The rules of that Society
prevented me from publishing this paper in one of
the weekly journals. At the present time it seems that
the majority of the profession are simply playing into
the hands of the manufacturers. As to these pro¬
prietary preparations, many of them are advertised in
the daily and weekly newspapers at the expense of the
profession, yet are largely ordered by the latter. Why
medical men are such fools in their own interests I
have never been able to understand. One thing, is
certain, that prescription-writing is greatly neglected
in these days. Students are lectured on rare diseases,
new and very often empirical modes of treatment, and
intricate laboratory methods, but when they receive
their diplomas they are often unable to recognise a
common case of varicella or of rickets, and much
less able to prescribe for 9uch conditions. To put it
broadly, the old-respected “ family doctor ” is going
out of fashion, and a new order of “medical man,”
equipped with little more than a price-list of drugs
put up in special forms, a book of recipes presented
to him by some enterprising manufacturer, has sprung
into existence. Such a state of matters is to be greatly
deplored, but so long as m ed i cal men prescribe pre¬
parations that are advertised in the newspapers, and
sold direct to the public, we cannot expect much else.

I am, Sir, yours truly,

James Burnet, M.D.

Edinburgh, December 5th, 1907.

MEDICAL LAW.

To the Editor of The Medical Press and Circular.

Sir,—-T he admirable editorials which appear with
due frequency, and the letters of well-informed corre¬
spondents in your journal, ought by this time to have
made your readers tolerably well acquainted with the
state of medical law. Every one of your readers ought
to know that very few clauses of the Medical Acts are
of any practical value; that the penal clauses are in
most cases useless; and that, when operative, there
exists no authority charged with the duty of putting
them in force. Prosecutions under Medical Acts never
take place unless carried out entirely by private persons
or by societies. It ought to be impossible under the
present law for a quack to recover fees for professional
services; but, as most County Court judges know
nothing about medical law, it is not at all surprising,
as in a case you report this week, to find a quack suing
for fees and gaining his case in such a court. Quacks
are, as a rule, too clever to need recourse to the law.
They mostly get paid in advance, or take care to
charge for “goods supplied,” not for services. The
goods may be a new nose, or an apparatus to make a
crooked nose straight, an electric belt, or a certain
cure for rupture in form of a truss; and if the patient
consent beforehand to pay the sum agreed upon, it is
probable that the law will in most cases help the quack
to obtain the money, however exorbitant the charge.
That medical law should remain in the shameful state
in which it now stands must seem to outsiders dis¬
graceful to the profession that tolerates it. Surely it
is the duty of the profession to bring their case before
the country and before Parliament. A Medical Law
Reform Society, properly organised, and including
the majority of those having valid claim to the title
of leaders in the profession, would attract a very large
amount of outside support. It would attract the sup¬
port of the whole scientific world, of whioh doctors
form so important a section; it would attract the sup¬
port of lawyers, and in time, either by means of a
Royal Commission or otherwise, the imperative neces-

Digitized by GoOglC

Dec. ii, 1907.

644 The Medical Press. SPECIAL ARTICLES.

sity for new enactments would be brought home tb
the minds of statesmen capable not only of construct¬
ing the necessary legislation, but of placing it speedily
upon the Statute-book. ,

I am, Sir, yours truly,

Common Law.

Lincoln’s Inn, December 6th, 1907.

QUACK METHODS.

To the Editor of The Medical Press and Circular.

Dear Sir,—I would draw your attention to two
pamphlets issued by “The Urillae Syndicate. 5 .’
Address, 31 and 32, King William Street, London,

E.C.

To the Parochial Clergy.

Rev. and dear Sir,—The Urillae Syndicate ventures
to send vou the enclosed sample of “ Urillae ” in the
anticipation. and hope that you will make use of it in
any suitable case coming under observation. in the
course of your visitation of the sick! It then goes
on— ......

No restrictions with regard to diet are required ; and
total abstinence is not. a sine qud non .

A further sample will be sent on receipt of a stamp,

Then comes a second paper.—The Urillae Syndicate
would deem it a great favour if particulars of cases
were forwarded to 31 and 32, King William Street,
London, E.C. Name, sex, age, address, occupation.

The above particulars will be treated as strictly
private and confidential, and will in no event be made
use of for advertising purposes.

1. Description of disease. . : ,

2. Duration of same. • 1

3. How soon relief from pain . was effected after

first dose of Urillae. . . • *

These, Mr. Editor, are the essential points of^these
two extraordinary leaflets. You will notice that
■quackery has reached another stage, viz., that.in which
vendors of quack preparations, are trying to create a
further order of quack practitioners. Surely it is high
time that we obtained, our Royal Commission, and
safeguarded the public against the experiments of
unqualified practitioners.

Yours truly.,

S. J. Russ.

Monkhams, Bedford.

OBITUARY.

CHARLES ROBERT DRYSDALE, M.D., Sr. And.,
M.R.C.P., F.R.C.S.

We record with sorrow the death of Dr. C. R.
Drysdale, who passed away on December 2nd, in his
78th year. For many years Dr. Drysdale was a well-
known figure in medical circles in London. He had'
been Physician to the Metropolitan Hospital, to ihe
North London Hospital for Consumption, the Far-
ringdon Dispensary, and to the Rescue Home. Dr.
Drysdale was well-known for the interest he took in
the limitation of families. He was ever outspoken on
the subject, and at the time of his death was President
■of the Malthusian League. With him passes from the
scene another of the links with the middle of last
century, for it is only just short of fifty years since he
took his first qualification.

ROBERT DE BRUCE TROTTER, L.R.C.P.Ed.,
L.F.P.S.Glas., I.L.

We regret to announce the death of Dr. Robert
de Bruce Trotter, of Perth, which took place at his
residence on December 3rd. For the past three or four
years Dr. Trotter has been ailing, but was in his
usual health at the beginning of the week, and the
end came rather suddenly. Born in Galloway 74
years ago, after receiving his elementary education,
Dr. Trotter proceeded to the University of Glasgow,
where he carried off many prizes. Subsequently he
started practice in Northumberland, where he was
for ten years prior to coming to Perth. In 1880 he
went to the Fair City, and rapidly built up an ex¬
tensive practice for himself. For twenty years he
discharged the duties of Medical Officer to the General
Post Office staff, Perth. In ambulance work he took

a keen interest, was one of the founders of the St.
Andrew’s Ambulance Association in Perth, and always
acted on its Committee. He was a former President
of the Perthshire branch of the British Medical Asso¬
ciation. Dr. Trotter was possessed of considerable
literary talent, and, besides being the contributor of
many miscellaneous articles, was the author of t*o
well-known books, “Galloway Gossip,” and a “Col¬
lection of Folklore ” about Galloway.

SPECIAL ARTICLES.

MEMORANDUM ON MEDICAL INSPECTION
OF SCHOOL CHILDREN.

The Board of Education have issued a Memorandum
[Circular 576] on medical inspection of 'children ia
public- elementary schools under section 1.3 of the
Education-(Administrative Provisions) Act, 1907, from
which we extract the following :—

Scope and Purpose of th« Act. —The Education
Act, 1907, in so far as it concerns the medical inspec¬
tion erf school children, is the outcome of a steady
movement of public opinion throughout the-entire
community. For some years past evidence has been
accumulating that there exists in certain classes of tbe
English people a somewhat high degree of physical
unfitnegs, which calls for amelioration,, and, as far
as possible, for prevention. , A consideration of the
gravity of t^ie need led to the conclusion that medical
inspection of school children is not .only reasonable.
’ but necessary as a first .practical step towards remedy,
and the Board desire at the outset to emphasize th^t
this new legislation aims not merely at a. physical or
anthropometric survey or at a record of defects dis¬
closed by medical inspection, but at the physical im¬
provement and, as a natural corollary, the mental
and moral improvement of coming .generations. Tbe
broad requirement? of a healthy life are comparatively
few and elementary, but they, are essential, and should
not be regarded as applicable only to the case of the
rich. , In point o£ .fact, if rightly administered, tbe
new enactment is econpmical in the best sense of tbe
word. Its justification is not to be measured ip term 1
of money, but , in . the decrease of sickness and
incapacity among children, and in the ultimate
decrease of inefficiency and poverty in after life
arising from physical disabilities.

The powers, and duties of a local education
authority under Part III. of the Education Act, 1901.
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 direct, 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 elemen¬
tary schools; provided that in any exercise of power-
under this section the local education authority may
encourage and assist the establishment or continuance
of voluntary agencies and associate with itself repre¬
sentatives of voluntary associations for the purpose.

Organisation. —The respective functions of tbe
Board of Education and the Local Education
Authorities are clearly defined by the Act. Tb*
duties thrown upon the Board consist in advising
Local Education Authorities as to the manner in which
they should carry out the provisions of the Act, and
in supervising the work they are called upon to under¬
take ; in giving such directions as may be necessary
regarding the frequency and method of inspection ir.
particular areas; and in considering and sanctioning
such arrangements for attending to the health and
physical condition of the children as may be sub¬
mitted to them by individual Authorities. The Board
will also collate the records and reports made by the
Authorities and will present an annual report to
Parliament. The duty of carrying out the actual
inspection has necessarily been entrusted by Parlia¬
ment to the Local Education Authorities, and not to
the Board. Each authority must, therefore, in due

Digitized by GoOgle

SPECIAL ARTICLES.

Dec. ii, 1907.

course appoint such Medical Officers or additional
medical assistance as may be required for the purpose.
Some time must inevitably elapse before all
Authorities have their arrangements in working order,
but it should be carefully borne in mind that, although
the work is begun gradually, the initial organisation
established by each Authority should admit of such
expansion as will secure the thorough and efficient
administration of the Act.

After careful consideration, both of the present con¬
ditions of local sanitation and of the developments
most likely to serve the economical and efficient
administration of this important branch of pubilc
work, the Board are of opinion that—

(a) In county areas the County Council, which is
the Local Education Authority, should instruct their
County Medical Officer, who will be responsible for
smooth and effectual administration, to advise their
Education Committee and to supervise the new work,
its actual execution being deputed wholly or partly
to suitable medical colleagues or assistants (men or
women), who either will be appointed specially for
the purpose under him or will be local Medical
Officers of Health, and to whom groups of schools
may be allocated. Where no County Medical Officer
has yet been appointed under the Local Government
Act, 1888, it would seem that the new duties in regard
to medical inspection of children now imposed on the
County Council will render it inadvisable any longer
to postpone such an appointment, since in no other
way will the Council be able effectually to secure
adequate control, economy, and efficiency in carrying
out their new work, which must obviously be guided
from the central county organisation.

( b ) In county boroughs the Town Council, which is
at the same time both the Local Authority for Public
Health and also the Local Education Authority,
should instruct their Medical Officer of Health to
advise the Education Committee and should make him
responsible for the new work or for the supervision
of such medical assistance as is needed to carry it out.
Where appointments of school medical officers already
exist, the Board do not suggest that they should be
disturbed, provided always that the officers arj com¬
petent and sufficient for the new duties and that the
arrangements for supervision by the Medical Officer
of Health are satisfactory.

(r) In non-county boroughs and urban districts
which are Local Authorities for elementary education,
the desirability of ultimately making similar arrange¬
ments, separately or in combination with contiguous
districts, should be kept in view, though for the time
being some variation may be requisite in accordance
with local needs and circumstances.

Generally speaking, the work of inspection should
be supervised by the Medical Officer of Health of the
Authority which appoints the Education Committee;
and when the work is obviously more than he can
undertake unaided it should be entrusted to one or
more medical officers working under his supervision.
When it is necessary to appoint officers for the purpose
of the Act, it is extremely important that persons of
suitable qualifications and experience should be
selected, even though they may not be called upon to
give the whole of their time to these duties, and it
should be noted that there are many cases in which
women are likely to be specially suitable. In making
such appointments preference should be given to
medical men and women who (1) have had adequate
training in State Medicine or hold a diploma in Public
Health, (2) have had some definite experience of
school hygiene, and (3) have enjoyed special oppor¬
tunities for the study of diseases in children. The
particular needs and circumstances of the area or
group of schools concerned should receive due con¬
sideration, and great care must be taken to see that
school hygiene really forms an integral and funda¬
mental part of the public health adminstration of the
district, and is not subordinated to other less im¬
portant sanitary questions.

Subsidiary Agencies. —The Board are convinced
that the work of medical inspection cannot be properly
accomplished by medical men without assistance. The
teacher, the school nurse (where such exists), and the

The Medical Press. 645

parents or guardians of the child must heartily co¬
operate with the school medical officer.

Character and Degree of Medical Inspection.—
From what has been said it will be clear that the
fundamental principle of section-13 of the new Act L,
the medical examinatipn and/supervision not only ot
children known, or suspected, to be weakly or ailing,
but of all children in the elementary schools, with a
view to adapting and modifying the system of educa¬
tion to the needs and capacities of the child, securing
the early detection of unsuspected defects, checking
incipient maladies at their onset, and furnishing the
facts which will guide Education Authorities in rela¬
tion to physical and mental development during school
life. The character and degree of medical inspection
will depend on the standpoint from which the subject
is viewed, the difficulty being, of course, to attain a
due sense of proportion and uniformity, particularly
as to fundamental points. Valuable to science though
the findings of a more thorough and elaborate medical
examination might be, it is the broad, simple neces¬
sities of a healthy life which must be kept in view.
It cannot be doubted that a large proportion of the
common diseases and physical unfitness in this country
can be substantially diminished by effective public
health administration, combined with the teaching of
hygiene and a realisation by teachers, parents, and
children of its vital importance. The spread of com¬
municable diseases must be checked ; children’s heads
and bodies must be kept clean; the commoner and
more obvious physical defects, at least, must be re¬
lieved, remedied, or prevented ; schoolrooms must be
maintained in cleanly condition, and they must be
properly lighted, well ventilated, and not over¬
crowded ; the training of the mental faculties must
not be divorced from physical culture and personal
hygiene.

Regulations. —The Board have decided, under
section 13 of the Act, that not less than three in¬
spections during the school life of the child will be
necessary to secure the results desired. The first in¬
spection should take place at the time of, or as soon
as possible after, admission to school; the second at
or about the third year (say, the seventh year of age);
and the third at or about the sixth year of school life
(say, the tenth year of age). A further inspection
immediately before the departure of the child into
working life.wouldbe desirable where practicable, and
in some areas it may be best for this to take the place
of the third inspection. Certain adjustments will be
necessary in working out any standard in practice, as
it will at once be evident that without such adjustment
the first year (1908) would b6 unduly burdened with
the inspection of the children newly admitted and of
all the children already in school.

Amelioration and Physical Improvement. —The
aim of the Act is practical, and it is important that
Local Education Authorities should keep in view the
desirability of ultimately formulating and submitting
to the Board, for their approval under section 13 (1) (b)
of the Act, schemes for the amelioration of the evils
revealed by medical inspection, including, in centres
where it appears desirable, the establishment of school
surgeries or clinics, such as exist in some cities of
Europe, for further medical examination, or the
specialised treatment of ringworm, dental caries, or
diseases of the eye, the ear, or the skin. It is clear
that to point out the presence of uncleanliness, defect,
or disease does not absolve an authority from the con¬
sequent duty of so applying its statutory powers as to
secure their amelioration, and to prevent, as far as
possible, their future recurrence or development. The
subject of specific medical treatment is, however, one
which will require subsequent consideration in the
light of the findings of medical inspection and the
collateral issues raised thereby, and it is clear that,
speaking generally, Local Education Authorities
will be unable to formulate and submit for the Board’s
sanction any comprehensive scheme for the further¬
ance of this object until they have considered the
results of their medical inspection in various
directions. '

This Circular is of a preliminary nature only, and
concerns almost entirely the work of the new Act at
its initiation.

646 The Medical Press.

MEDICAL NEWS IN BRIEF.

Dec. 11. 1907.

REVIEWS OF BOOKS.

SURGICAL INSTRUMENTS IN GREEK AND
ROMAN TIMES (a).

Dr. Milne is certainly to be congratulated on his
book, “Surgical Instruments in Greek and Roman
Times,” for it enlightens us on a subject on which up
to the present little or no collective work has been done.
As it is, his volume forms a high testimonial to his
skill and learning, and it will be a source of much
pleasure to those who delight in medical archaeology.
The task the author has undertaken is one which might
well have appalled anybody but a man of leisure, and
we can only say that it is highly creditable to the
industry of a practitioner that he should have been
able not only to pursue all the literary research neces¬
sary to the elucidation of the shape, sire, and purpose
of surgical instruments among the Greeks and Romans,
but also have managed to visit all the collections on
the Continent and photograph the actual specimens.
We doubt if there is anyone in a position adequately
to criticise Dr. Milne’s judgments as to the purpose for
which the instruments were designed; for ourselves
we may say that they strike us as sound and well
thought out, and in some cases where be differs from
other authorities, notably in the case of the lithotomy
knife described by Celsus, he carries us with him.
His explanation and design of this instrument are as
convincing as they are ingenious. To those unread in
medical lore it may be a surprise to learn how large a
surgical armamentarium the classical nations pos¬
sessed, and what a variety of operations they under¬
took; but perhaps the most striking thing is that
Hippocrates should have been probably the most
accomplished as Well as the earliest of the surgeons
of whom we have definite record. The photographic

E lates, 53 in number, which accompany (he text, are
eauti fully executed, but it is rather a pity that Dr.
Milne has not named the various instruments in situ.
That, perhaps, is more of a lazy man’s objection than
a really critical point, but we feel a slight actual
grievance in the fact that so scholarly a man as the
author should habitually use such a solecism as “a
forceps.” However, the book all through is a mine
of interest, and in the name of the profession we offer
our warm thanks to Dr. Milne for having made avail¬
able to his less fortunate brethren so fascinating a
mass of information.

TRAVELS THROUGH FRANCE AND ITALY (a).

The author being a medical man, suffering at the
time from a chronic lung affection that ultimately
carried him off, his letters possess a special interest
for medical readers, although, iu truth, he does not
seem to have practised the healing art, having achieved
a considerable measure of success in literature. Broken
down in health, and mercilessly pursued by political
enemies, he started in 1763 for Boulogne, en route for
Montpellier, which was then apparently the most
popular health resort in Southern Europe. On the
way, however, he met an officer who recommended
Nice, the climate whereof was “ faxouxably spoken of
with respect to diseases of the breast. ” Passing through
Montpellier on his way thither, he notes that “ the air
is counted salutary iu catarrhous consumptions from
its dryness and elasticity, but too sharp in cases of
pulmonary imposthumes ” (abscesses). Poor Smollett
saw everything en noir, and bitterly complains of things
in general and of French people and their ways in
particular. Needless to say that the author of “ Roderick
Random ” points his gibes with the skill of a master
hand, so that his narratives are interesting as well as
instructive reading. It will surprise many to find that
doctors as far back as the middle of the eighteenth
century talked of tubercles in the lungs and their
breaking down (page 97), wbich, being absorbed, render
the blood “acrimonious.”

(a) “Surgical Instrument* in Greek mnd Roman Times.” By
John Btewut Milne, M.A., M.D. Aberd. With illimMotions.
Oxford : .At the Clarendon Press. 1907 .

(a) Smollett’s “Travels through France and Italy ” Is a ascent
addition to the admirable series of “The world's Classic*,”
issued by the Oxford University Press.

Medical News in Brief

Disputed Claim.

Before Judge Parry in the Manchester County
Court, on December 3rd, Drs. Vipont Brown, J.
Darrington Willis, and Arnold Gregory, who practice
in partnership in West Gorton, sued a tram-driver
named T. C. Zlatano for ^3 5s. for attendance on
the defendant’s child. When the case was originally
before the Court the defendant said the reason he had
not paid the bill was because Dr. Gregory, wbo
attended his child, had been negligent.

Dr. Gregory, who attended the child from July
9th to July iSth last, said that upon the symptoms
he diagnosed the case as pneumonia, with the pos¬
sibility of meningitis suggested. By means of cold
baths, packs, and sponging, he succeeded in reducing
the temperature. Eventually the defendant called in
another doctor. Cross-examined, he denied that the
child was kept in bed without any covering until
July 18th on bis suggestion, and that it was un-
scious for more than two days.

Dr. Vipont Brc>wn said that in his opinion Dr.
Gregory’s treatment saved the child’s life. There was
not the slightest doubt that the child was suffering
from inflammation of (he apex of the light lung.

Dr. Reynolds agreed that the symptoms of the
child’s illness indicated pneumonia. The treatment
given by Dr. Gregory was the only proper one under
the circumstances.

Mr. Hislop submitted that the ministration of the
plaintiffs bad the result of leading the defendant's
daughter to the point of death.

His Honour: you must not say things like that,
because the evidence at present is that tne effect of
the treatment was to bring her back to life.

Mr. Hislop: I am suggesting he was grossly
negligent.

His Honour: You might just as well say a lawyer
is grossly negligent if he doesn’t win his case. If
that were so, 50 per cent, of the lawyers who come
here would he grossly negligent.—(Laughter). If you
like, you may suggest that Dr. Gregory did not use
a reasonable degree of skill and care.

Dr. A. W. Martin said he found all the symptoms of
meningitis. If there had been pneumonia, it was
only secondary.

His Honour: Are you prepared to say that in your
opinion Dr. Gregory did not treat the case with a
reasonable degree of care and skill?—All I can say
is that the treatment was not what I myself would
have adopted. I cannot say it was wrong or improper,
because each doctor has his own methods. He treated
it very much as nearly all doctors do.

Mr. Hislop: In face of this I don’t think I can
carry the defence any further.

His Honour: No, you cannot. You, too, are only
expected to tTeat your case with reasonable skill and
care.—(Laughter.) It was a hopeless case from the
first. There must, therefore, be judgment for the
plaintiff for the amount claimed, with costs.

Mr. Hislop pointed out that the defendant was a
poor man, and asked for time in which to pay.

His Honour: That is just like a defendant. He
first won’t pay the doctor, then he blackguards him.
and then saysj “I want his mercy and plenty of time.”
However, I don’t suppose Dr. Gregory has any vicious
feeling. He is bound to justify himself. So I shall
make a small order for payment at the rate of 10s. a
month.

•eatli wader aa AmmOMIc.

Dr. F. J. Waldo held an inquest on Saturday on a
man aged 38, who died at Guy’s Hospital while under
the influence of an an«sthetic. After the operation
was finished, the wife was asked to come and see her
husband, as another slight operation had been found
necessary, but before she could start she received
a telegram informing her that be had died.

John Sefton Cooper, house surgeon at Guy’s
Hospital, said deceased was being treated for cancer
of the tongue. He consented to the final operation
being performed, and Mr. Smith—a clinical assistant.

°gl'

PASS LIS I S.

The Medical Press. 647

Dec. 11, 1907.

though a fully qualified man—administered the
anaesthetic.

Henry J. Smith said he had been a qualified medical
man since June 1.

Were you appointed to give anaesthetics among your
duties?—Clinical assistants are supposed to give
anaesthetics when they are called upon to do so. The
witness added that there were eight anaesthetists in the
hospital who would deal with the worst cases. His
opinion was that death was due to a sudden dilata-
tion of the heart, caused by coughing.

Dr. Theodore Fisher, an expert pathologist, called
in by the Coroner to make a post-mortem examination,
said there was nothing in the organs to show that the
anaesthetic had anything to do with the death.

Mr. Philip Turner (acting resident surgical officer)
said that at the present time there was a large com¬
mittee sitting at Guy’s Hospital to inquire into the
whole question of anaesthetics. He believed that
surgeons, anaesthetists, and the governors were all
represented on that Committee.

The Coroner said, with regard to Guy’s Hospital,
that this was the thirty-eighth inquiry he had held
into the cause of deaths of persons who had died
while under the influence of anaesthetics.

The jury returned a verdict of death from mis¬
adventure.

London Hospital.

The quarterly Court of Governors was held on
December 4th, Mr. Sydney Hollartd presiding. The
Committee reported that the Queen, President of the
hospital, since the last meeting had sent a donation of
^666 13s. 4d. to the general funds of the institution.
In recommending for election two dental surgeons, the
Committee had considered it advisable that the depart¬
ment should be opened on every week-day instead of
only four times a week. While it was satisfactory to
note that the hospital was not in debt, the cost of the
upkeep was ,£100,000 a year, and the assured income
from investments and other funds was scarcely
£20,000. Without the promissory income there was a
balance of ,£40,000 a year which had to be raised.
Among the list of donations was an item of ,£200
vhich had been received from Messrs. Clarke and
Robinson, the owners of Demure, who won the Cesare-
vitch. Before the race the owners promised that
lonation in the event of the horse’s winning. In
noving the adoption of the report, the Chairman
eferred to this contribution, and hoped the laudable
xample would be copied by the Jockey Club and
ithers interested in racing. The motion was seconded
>y Sir F. Young, and adopted. The Chairman said
lext year would be their quinquennial appeal, which
le trusted would be responded to in a liberal manner.

t. Bartholomew’s Hospital—New Pathological Wing.

Lady Ludlow, who was accompanied by Lord
.udlow (treasurer of the hospital), laid the foundation-
tone of a new pathological block, which is to be
rected on a site adjoining that of the medical school,
nd facing Smithfield. The ceremony was attended by
lost of the members of the medical and surgical staff,
nd many other friends of the hospital. The Clerk of
le hospital, on behalf of the governors, read an
Idress to Lady Ludlow. The address stated that the
uilding was to be devoted to investigations in patho-
'gy and in pharmacology. The discoveries thus made
id the observations recorded would be of benefit to
atients, whether within the hospital or without,
iroughout the world. The address also alluded to
>e administration of Lord Ludlow, as treasurer,
hich, it pointed out, had been of the greatest benefit
St. Bartholomew’s, while his period of office would
s always commemorated by the many new buildings
ected. The new building is to be erected at a cost
• ^3°> 000 » and a special appeal is to be made for
at amount.

immittee of the London Ambulance Service.

The Committee appointed by the Secretary of State
>r the Home Department to inquire into the question
the ambulance provision for cases of accident and
idden illness occurring in streets and public places
the Metropolis met at the Home Office on December

6th, Sir Kenelm Digby (chairman), presiding. Evi¬
dence was given by Mr. Samuel Osborn, F.R.C.S.,
chief surgeon of the Metropolitan Corps of the St.
John Ambulance Brigade, the Hon. Sydney Holland,
chairman of the London, Poplar, and Tilbury Hos¬
pitals, and deputy-chairman of the London and India
Docks Company, Mr. F. W. Higgs, M.B., B.S., acting
resident medical officer, St. George’s Hospital, and by
Dr. Henri Nachtel, of Paris. Any communications
on the subject of the inquiry may be addressed to the
Secretary, Mr. A. L. Dixon, Home Office, Whitehall,
S.W.

Notification of Blrtbo Act la Dublin.

At the last meeting of the Corporation of Dublin,
the Lord Mayor moved the adoption of the Notification
of Births Act. Dr. McWalter opposed the adoption,
and suggested that the question be deferred for twelve
months, as it would entail extra expense on the Sanitary
Department and was of doubtful utility for the con¬
ditions prevailing in Dublin, where excessive infantile
mortality was mostly due to mere poverty. The con¬
sideration of the question was eventually deferred for
one year.

Public Medical Service la Blruilnrbam.

Another meeting of Birmingham doctors was held
last week at the Medical Institute for the purpose of
considering the proposals for the establishment of a
public medical service. After prolonged discussion
the meeting decided that it would not be advisable
to establish the proposed service in Birmingham, the
voting being 27 for and 60 against.

PASS LISTS.

University of London.

The following candidates have passed the M.B.,
B.S. Examination: —

Honours.—Richard H. C. Gompertz, B.Sc. [a, d,
University Medal), T. S. Higgins, B.Sc. (£), James L.
Lawry (d), Elizth. H. Lepper (i), Alfred Richard¬
son (a), Clare O. Stallybrass (c, d), Leonard H.
Wootton, B.Sc. (d), Andrew J. M. Wright (a, d).

{a) Distinguished in Medicine.

(b) Distinguished in Pathology.

(c) Distinguished in Forensic Medicine and Hygiene,
(rf) Distinguished in Surgery.

Pass.—Samuel H. C. Air, Edgar Alban, Ardeshir P.
Bacha, Laurence Ball, Frederick J. F. Barrington,
Walter R. Bristow, Thomas E. A. Carr, Herbert S.
Chate, B.Sc., Meyer Cohen, Walter F. Corfield,
Ernest M. Cowell, Davis W. Daniels, Eleanor Davies-
Colley, Eric J, De Verteuil, Carel C. A. De Villiers,
Reginald L. E. Downer, Kenneth E. Eckenstein,
Marmaduke Fawkes, Charles H. Fielding, Vera Foley,
Arthur Fothergill, Ernest C. Hadley, John Hadwen,
B.Sc., Eric H. R. Harries, Claud S. van R. Harwood,
Herbert Hawker, Geo. M. W. Hodges, Edward H.
Hugo, Douglas W. Hume, John P. Johnson, Henry T.
Jones, Edgar H. Kettle, Clement Lovell, Eleanor
Lowry, Emily M. S. Mecredy, Humphrey Nockolds,
Evelyn H. B. Oram, Basil T. Parsons-Smith, Walter
Patey, John G. Phillips, Jeffrey Ramsay, Samuel S.
Rendall, Russell J. Reynolds, William Scarisbrick,
B.Sc., Shantaram R. Shirgaokar, Marie Simpson,
Eliza M. Smith, Horace E. R. Stephens, Robert Y.
Stones, Arthur A. Straton, Reginald S. Townsend,
Alfred G. Tresidder, Harold S. Vivian, Cuthbert G.
Welch, Ruth H. Western, Henry Whitehead, Harold
W. Wilson, John Black F. Wilson.

The following have passed in one of the two groups
of subjects: —

M.B., B.S. Examination.—Group I.—Charles A.
Basker, Janet M. Fishe, Susie E. Hill, Laura G.
Powell, Mona D. Roberts, Frederick G. Sergeant,
Thomas G. S. Smith, John J. Suckling, Cuthbert F.
Walker.

Group II.—George N. Bartlett, Stanley J. A. Beale,
Alfred Bernstein, John W. Bride, Herbert R. Davies,
Clara Eglington, Frederick P. Fisher, Charles T.
Hawkins, Maurice J. Holgate, John B. Martin,
Alexander M. Pollard, Ethelbert W. Squire, Hugh
Stott, Arthur L. Yates.

Dii

, y Google

648 The Medical Press.

WEEKLY SUMMARY.

Dec. 11. 1907.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT MEDICAL LITERATURE.

Para-Nephritic Abscess. —Halsey reports a case of
this rare affection, the patient, a man of 22, contracted
3 gonorrhoea eight weeks before admission. He was
also under treatment for syphilis, which he had got
about a year previously. Four weeks before admission
pain began in his back, at first on the left side and
later on, as the pain became more severe, spreading
to the right side also. In the four weeks he had lost
seven pounds weight. His inguinal and femoral
glands were very much enlarged, those on the left
side were exquisitely tender. There was no rigidity
of the recti muscles, but deep pressure in the left
hypochondrium caused pain. His temperature was
104, his pulse 116, urine showed no casts, no albumin,
no indican, cystoscopic examination of the bladder
revealed nothing abnormal. Ten days after admission
to hospital he developed spasm of the left psoas
muscle, which prevented him completely extending
the left thigh, and soon after a slight bulging appeared
in the left lumbar region, just below the ribs, and it
was thought that a retro-peritoneal abscess was
present. By an incision at the outer edge of the
erector spinae muscle a large amount of pus was
evacuated, the kidney could be felt above the abscess,
which was behind the peritoneum and external to
the psoas muscle, and evidently external to the peri¬
toneum. The patient’s recovery was uneventful. It
is interesting to note what was the probable course
of the infection in this case, while the ureter and
bladder were free from infection, the lymph glands
were undoubtedly the path by which the infection
travelled to the deep lumbar glands, those lying upon
the psoas muscle being obviously the most vulnerable.
Enlarged because of the syphilitic infection, the super-
added gonorrhoeal infection was too great, and an
abscess formed ; in reality this might be called a bubo
inferior to the left kidney. The complete absence of
any kidney irritation is also worthy of note. G.

Treatment of Tumours of the Central Nervous
System. —Oppenheim (Berlin Monograph , 1907) says
the prognosis of brain tumours is far more unfavour¬
able than the prognosis of tumours of the spinal cord.
In the former cases, the author noted only 11 per cent,
of recoveries, and over 50 per cent, of failures, which
must be designated as the results of operation. The
surgical treatment of tumours of the spinal cord had
resulted in permanent cures in about 50 per cent, of
the cases so treated. The prognosis in the author’s
cases was made considerably worse by the fact that a
proportion of 44 per cent, of his brain tumours
belonged to the group of tumours of the posterior
cranial fossa, and the prognosis in such cases is
always unfavourable. From his statistics it appears
that in only about one case out of ten carefully
selected cases of brain tumour is operation likely to
result in permanent and complete cure. The author
believes that in the near future the surgical treatment
of tumours of the spinal cord will be employed far
more frequently, and that in consequence the prognosis
will be greatly improved. Exploratory laminectomy
should be done far oftener than it is, as it affords the
only true means of recognising operable tumours in
many cases where a positive diagnosis is prevented by
the symptoms being very obscure. In such cases it
is nearly always necessary to incise the dura, and the
operator should never hesitate to do this,'Indeed in
most cases it is clearly indicated. The author believes
that the operation of laminectomy is attended with
comparatively no danger, and from observations made
on his own cases at a considerable time after such
operations, it seems that the patient suffers little or
no weakness or inconvenience from the removal of
several of his laminae. G.

Frequency of Micturition in Women. —The Hospital,
July). In women of middle age frequency of micturi¬
tion is by no means uncommon. Inquiries should
always be made in such cases if the frequency is by
night as well as by day. In some cases of prolapsed
uterus the frequency is markedly present in the day¬
time, but almost absent at night when the patient is
lying down. All such cases of frequency come under
one or other of the following headings:—(1) Those
cases which depend on some change in the urine; (Jj
those cases which depend on some condition outside
the bladder; and (3) those cases which depend 03
some actual disease of the urinary tract from the
kidney downwards. The most common cases are those
which depend on some change in the urine, such as
excess of urates, or excess of phosphates, and hypera¬
cidity. In such cases diet, digestion, and a sedentary-
occupation are often responsible for the condition,
and when they are remedied relief from the frequency-
will follow. The common lesions outside the bladder
are tumours on the fundus of the bladder, early
pregnancy, prolapse of the uterus, unilateral pelvic
cellulitis, and pelvio-peritonitic adhesions. For such
conditions citrate of potassium, hyocyamus and chloro¬
form will often be of use. The third group of cases
may require the cystoscope for their diagnosis,
although even here the cystitis can be discovered by
careful urinary examination. It is well to bear in mind
that mild cases do not call for lavage of the bladder.
Besides prolapses, vaginal discharges or dirty
catheters may cause cystitis. Calculus, tuberculous
ulceration, malignant growths, papillomata and
varices at the neck of the bladder are rare, and require
the cystoscope for their differential diagnosis. Stone
in the kidney, renal growths, Bright's disease,
diabetes, movable kidney, pyelitis, pyonephrosis, and
tuberculous disease of the kidney may all cause fre¬
quency, and must be borne in mind ; repeated and
careful examinations of the urine and kidneys will in
most cases enable a diagnosis to be formed. G.

Case of So-called Traumatic Asphyxia. —Beatso.i
(Glasgow Med. Journ., Nov., 1907) reports a case of
traumatic asphyxia in a man aet. 24. He had been
crushed antero-posteriorly by a pit cage, and his
shoulders driven downwards and forwards into the
abdomen and pelvis. There was intense congestion
of the head and neck, almost petechial in character,
but not affected by pressure. There was considerable
oedema around the eyes and mouth. Sub-conjunctiva!
haemorrhage was considerable, and there was a larse
sub-lingual haematoma. There was also a probability
of some haemorrhage into the orbit, as there was some
ptosis. There was no fracture. In three days the con¬
gestion and discolouration began to fade, and by the
eighth day this was only present in the forehead, where
it now yielded to digital pressure. There was dis¬
colouration around the eyes and nose, as in ecchv-
mosis. In a short time all the discolouration had dis¬
appeared. S.

Movable Kidney from a Surgical Standpoint. —Billing-
ton (Brit. Med. Journ., Nov. 30th, 1907) describes an
operation for movable kidney which he has employed
with success 70 times. The skin incision is parallel
to the erector spin®, and starts a little above and
just behind the tip of the twelfth rib. The kidnev is
brought out into the loin. All adhesions, which are
often of great density, should be cut with a scissors
curved on the flat, so as to leave the kidney attached
by its pedicle only. A triangular piece of kidnev
capsule is raised from the kidney. The apex of this
flap of capsule is taken from the upper pole of the
kidney. The base is left attached, and extends from
the hilum to the centre of the convex border of the-

ized by G00gle

Dec. ii, 1907.

kidney. Two stout strands of silkworm gut are now
passed beneath the unraised capsule in the way de¬
scribed by Goelet. The free ends of the silkworm gut
sutures and the apex of the loose piece of capsule are
clamped with a pressure forceps, and the kidney re¬
placed in the loin. The upper part of the anterior sur¬
face of the quadratus lumborum is cleared, so that
the kidney, when fixed in position, shall be against
the muscle itself. The final fixation is now proceeded
with. A pair of closed Spencer Wells forceps is forced
through the muscles of the eleventh intercostal space
immediately behind the tip of the twelfth rib, and
made to seize the apex of the triangular piece of loose
capsule. The kidney is pushed up from below until
the base of the denuded area is on a level with the
lower border of the twelfth rib. The loose strip of
capsule is then drawn taut, and fixed by means of
fine silk to its own base. In this way the kidney is
suspended by a loop of its own capsule, which passes
completely round the rib. Both ends of the two silk¬
worm gut stitches already mentioned are made to pass
through the ligamentum arcuatum externum, and
through the skin about one inch above the skin inci¬
sion. They are tightened and tied over a gauze pad.
The skin stitches are removed at the end of a week,
but the supporting stitches are left in for three weeks.
The patient is kept in bed for a month, and then pro¬
vided with a light belt or an elastic webbing bandage
applied in the form of a spica which is to be worn
for six months. S.

A Simple Operation lor Uncomplicated Oblique
Inguinal Hernia. —Chiene (Brit. Med. Joum ., 16th
November, 1907) describes an easy and quickly per¬
formed method of operative procedure for the above
condition. It can readily be done under a local
anaesthetic. The author has employed it in 16 cases
during the last 18 months with very satisfactory results.
The skin incision is made half an inch above and
parallel to the middle third of Poupart’s ligament, the
centre of which corresponds to the position of the
internal abdominal ring. The external oblique is
divided in the direction of its fibres, and the cremasteric
muscle fibres are divided in the same direction. The
internal oblique and tranversalis are retracted upwards
and outwards, and the tranversalis fascia divided in
the same direction as the external oblique. The neck
of the sac is thus exposed at the internal ring. It
is freed from the cord, opened and divided. The neck
is ligatured and fixed to the under surface of the
abdominal wall above and external to the internal
abdominal ring, the rest of the freed portion being cut
off. The split fibres of the external oblique are then
sutured by the oveT-lapping method. In some cases
the divided cremasteric fibres require a stitch to bring
them together. The internal oblique and tranversalis
therefore are left untouched, and the sac, with the
exception of a small portion at the internal ring, is
left in situ. S.

The After-History of Two Cases of Inter-Scapulo-
Thoracic Amputation for Sarcoma. —Thomson (. Edin¬
burgh Med. Journ.y November, 1907) details two cases
showing the sad contrast of the after-history in
sarcoma of the shoulder to the brilliant immediate
results that follow the extensive operation. Case 1. A
miner, aet. 20, six months before operation was struck
on the left shoulder while working in a pit. On
admission to hospital there was a prominent swelling
in the deltoid region, and marked wasting of the
scapular muscles and the biceps. The movements of
the shoulder joint were limited, and there was some
grating of the articular surfaces. The limb and shoulder
girdle were removed on August 8th, 1901. On dis¬
section the tumour was found to have taken origin from
the periosteum of the upper end of the humerus. It
had involved the shoulder joint, which was full of
blood, and had spread to the substance of the scapular
muscles, especially the infraspinatus and teres minor.
The growth was a mixed celled sarcoma. The patient
made an excellent recovery, and remained perfectly
well for the greater part of two years. Soon after that
the patient complained of pain in the left thigh and
leg, and a tumour rapidly formed in Scarpa's triangle.

The Medi cal Press. 649

On admission to hospital the disease had already made
such rapid progress that radical operation was out
of the question. The patient died on May 31st,
1904, a little less than three years from the time~ the
disease first appeared in the shoulder. Case 2. A girl,
ast. 14 years, had suffered from pain in the left shoulder
for three months. About a month before admission
to hospital on February 27th, 1907, a swelling had
been noticed, which had increased rapidly. On 3rd
March, 1907, the operation was carried out according
to Kocher’s description, except that the inner half of
the clavicle was evulsed from the epiphyseal junction.
The tumour was found to be a chondro-sarcoma
opening from the upper end of the humerus. For two
or three days after the operation the patient was
bright and well. Then she developed a troublesome
cough, and died on March 27th with malignant disease
of the pleura. S.

General Miliary Tuberculosis Diagnosed by Choroidal
Tubercle. —Cargill and Mayor (Trans. Ophthal. Soc. y
1906) record an interesting case in which the finding
of tubercle of the choroid in one eye and a neuro¬
retinitis in the other solved the diagnosis between
typhoid fever and general miliary tuberculosis. For
six weeks before admission the patient, aet. 21, had
been unwell, and for a month had been confined to
bed with headache, feverishness and constipation. On
admission (Dec. nth, 1905) he had the “typhoid
appearance,” temperature 100.6°, pulse 100, respira¬
tions 24. No physical signs in lungs, heart, or ab¬
dominal organs. No spots. Widal’s reaction was
negative. Opsonic index for t.b. was 1. No tubercle
bacilli were found in the sputum or blood. After
admission the temperature varied from 98° to 103°.
On December 18th, 1905, the eyes were examined
ophthalmoscopically, and choroidal tubercles were
seen in one eye and neuroretinitis in the other. Three
days before death, on February 20th, 1906, tubercle
bacilli were found in small numbers in the
sputum for the first time. An autopsy le-
vealed general miliary tuberculosis, the tubercles
being found in the meninges along the arteries, over
the surface of the liver, pancreas, kidneys, and
suprarenals. The lungs were thickly studded with
large and small foci. Although general tuberculosis
was the most likely diagnosis in this case, the
ophthalmoscope afforded nine weeks before death the
only physical signs which gave any certainty. The
detection of choroidal tubercle is, of course, most
helpful in diagnosing the general condition, but it
is evidently rare, as Osier says he has “never known a
diagnosis made on their presence alone.” M.

Children’s Sanatorium.

To aid the Children's Sanatorium for the Treat¬
ment of Consumption, Holt, Norfolk, an exhibition
of pictures and calendars, organised by Miss K. M.
Wyatt, whose father is hon. secretary to the institu¬
tion, and a number of friends, was held on Saturday
in the rooms of the Royal Female School of Art,
Queen Square. Pending the collection of funds with
which to provide permanent accommodation, tempo¬
rary buildings have been erected at Holt, and a num¬
ber of cases have already been treated and discharged
as ‘‘apparently cured.” These temporary premises,
are large enough to receive 15 children, but owing
to lack of funds, only 11 cases at a time have been
dealt with. To erect the permanent building at
present contemplated about ^5,000 is required—the
site has already been purchased—and of this sum

1,000 is in hand. The Holt Sanatorium was the first,
and until recently the only, establishment for the
treatment of consumptive children. The exhibitors
on Saturday included Mary Countess of Ilchester,
Lady Maxwell-Lyte, Miss Gloagh, Miss Ii. R. Stone,
Miss Woodward, and Miss K. M. Wyatt. All the
work shown, which included some embroidered fancy
articles by Miss Thomas, was for sale, and a sum of
over ^40 was realised.

Owing to the prevalence of measles, all the infants'
schools in Chester have been closed.

WEEKLY SUMMARY.

zed by Google

650 The Medical Press. NOTICES TO CORRESPONDENTS. Dec. ii, 1907.

NOTICES TO
CORRESPONDENTS, fife

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Nescis.—W e have frequently suggested that medical men should
adopt the practice of asking for half the confinement fee at the
time the engagement is booked. It is not unusual, and is per¬
fectly legitimate. The oontract, of course, is equally binding on
both sides in such an event, but the obligation is thus assured.
The circumstances are annoying, but if you put the patient in
the County Court you might quite well lose the case, as you
were absent when wanted, and another practitioner was so
obviously needed.

Facie*.— Freckles may be treated—if necessary—by drugs that
cause exfoliation of the epidermis. A good application is a 1 per
cent, solution of perchloride of mercury in alcohol; it should
be continued from day to day till the required irritation is
produced; 50 percent, resorcin in zinc paste (Unna) is also use¬
ful, but would require the patient to remain indoors.

A DISCLAIMER.

To the Editor of The Medical Press and Circular,

StR,— I was lately oonsulted about his eyea by the editor of
a provincisd newspaper. On his return home, being evidently
unacquainted with the rules of the medioal profession, he in¬
serted in his paper a paragraph praising my skill as an oculist.
I wish to say that the paragraph in question was written and
inserted entirely without my knowledge, consent or approbation.

Yours faithfully,

SXAUHAN P. MacEnRI.

(John P. Henry.)

32, Lower Leeeon Street, Dublin,

December 8th, 1907.

Aqua best. —The name Still's disease is applied to a oondition
allied to the rheumatoid anthritls (so-called) of young people.
Still's disease is a disease of children, and is accompanied by
enlargement of the spleen and lymphatic plands.

Db. K. C. T. (Hampstead).—We greatly regret that the inser¬
tion of a news paragraph should have given colour to any sus-

S icion that we approve of the treatment in question. We have
ealt with it several times in the Medical Pres* and Circular,
and thought our readers were well acquainted with our views.
Although there are unfortunately well meaning philanthropist*
connected with it, there is an " inventor ” in the background
who is frankly interested in the sale of the remedy.

4 p.m.: Lecture:—Mr. Fairbank: Congenital Dislocation of the
Hip and its Treatment.

Fbidat, December 13th.

Rotal 8 ociKTr or Medicine (Clinical Section) (20 Hanover
Square, W.).—8.30 p.m.: Exhibition of Cases by Dr. E. Reid.
Prof. W. Osier, Mr. T. H. Openshaw, Dr F. P. Weber, Dr.
W. E. Wynter, Dr. W. Pasteur, and Dr. F .' f. Poynton. The
patients will be in attendance at 8 p.m.

Socibtt or Art* (John Street, Adelphl, W.C .).—8 p.m.:
8 haw Lecture:—Prof. T. Oliver: Industrial Poisons—Lead and
Phosphorus, with Special Refcrenoe to the Manufacture of
Lucifer Matches.

Societt fob the Study of Disease in Children (11 Chan doe
Street, Cavendish Square, W.).—5 p.m.: Special Meeting. Dis¬
cussion on Inherited Syphilis (opened by Mr. C. Lucas). Followed
by Dr. Adamson, Dr. L. Guthrie, Dr. O. Carpenter, Mr. G.
Pernet, Mr. 8 . Stephenson, Mr. A. H. Tubby, and others.

Tuesday, December 17th.

The Medico-Legal Societt.—The Rotal Asiatic 8ociett (22
Albemarle 8 treet, W.).—8.15 p.m.: President, the Hon. Mr. Justice
Walton: 1. Narration of Cases and Exhibits of Medico-Legal
Interest; 2. “ The Radical Cure—Certification of Inebriates ":
T. Claye Shaw, M.D.

Rotal Society of Medicine (Therapeutical and Pharmaco¬
logical Section) (Apothecaries’ Hall, Blackfriars, E.C.).—
4.30 p.m..- Dr. James McKenzie: The Action of Digitalis on the
Human Heart.—Dr. William Soper: Reminiscences of an Appren¬
tice Fifty Years Ago.

^ppointmeniB..

Cross field, H. V., M.B., C.M.Glatg., Clinioal Assistant to the
Chelsea Hospital for Women.

Qbf.ex, Philip, M.D., M.R.C.S., L.R.C.P., Clinioal Assistant to
the Chelsea Hospital for Women.

Henry, F„ M.B., Ch.B.GIasg., Medioal Superintendent of the
Highfield Infirmary, Liverpool.

Legoett, William, M B., Ch.B., B.A.O.Dub., Senior Assistant
Physician at Montrose Royal Aaylhm.

Murray, John, M.B., B.Ch.Dub., F.R.C.S.Eng., Surgeon to the
Middlesex Hospital.

Pollabd, Arthur Haig, L.R.C.P., M.R.C. 8 ., House Physician
to the Cheltenham General Hospital.

Stuabt, Eppie Gordon, M.B.Edin., Assistant Resident Medioal
Officer at the Sheffield Union Infirmary.

Tatlob, Gordon, M.B., M.S.Lond., F.R.C.S.Eng., Assistant Sar-
geon to the Middlesex Hospital.

UaamatB.

Birmingham City Asylum.—Junior Assistant Medical Officer.
Salary, £150 per annum, with board, lodging, and washing.
Applications to the Medical Superintendent.

Suffolk District Asylum, Melton,—Second Assistant Medical
Officer. Salary, £160 per annum, with board, furnished apart¬
ments, attendance, and laundry. Applications to the Medical.
Superintendent.

Bristol General Hospital.—Senior House Sargeon. Salary, £180
per annum, with board, resldenoe, etc. Applications to tbs
Secretary, W. Thwaites.

Stockport County Borough.—Medical Officer of Health. Salary,
£450 per annum. Applications to Robert Hyde, Town Clerk,
Town Clerk’s Offioe, Stookport.

Leeds City.—Assistant Medical Offloer of Health and Chief In¬
spector of Nuisanoes. Salary, £300 per annum. Applications
to Robert E. Fox, Town Clerk, Leeds.

Great Northern Central Hospital, Holloway Road, N.—Patho¬
logist; and Curator. 8 alary, £100 per annum. Applications
to L. H. Glenton-Kerr, Secretary. (See Advert.)

^ectinga ai the Societies, Hectares, ice.

Wkdnesdat, December 11th.

British Balneological and Climatological Societt (80 Han¬
over Square, W.).—5.30 p.m.: Paper:—Dr. Edgecombe (Harro¬
gate) : Blood Pressure in Spa Practice.

• MEdical Graduates’ Colleoe and Polyclinic (23 Chcnies
Street, W.C.).—4 p.m.: Mr. T. P. Legg: Clinique. (Surgical.)
5.15 p.m.: Lecture: Dr. L. Guthrie: Preoocioua Development.
THUR8DAI, December 18th.

Rotal Society or Medicine (Obstetrical and Gynecological
Section) (20 Hanover Square, W.).—7.45 p.m.: Specimens will be
shown by Dr. C. H. Roberts. Dr. P. Horrocks. Dr. J. Oliver,
Dr. H. T. HScks, and Dr. Lewers. Paper:—Dr. W. E. Fothergill:
The Supports of the Pelvic Viscera, a Review of some Recent
Contributions to Pelvic Anatomy with a Clinical Introduction.

Habveian Society of London (Stafford Rooms, Titchborne
Street, Ed gw a re Road, W.).—Papers:—Mr. L. Paton : The Diag¬
nosis and Treatment of Some Forms of Simple Conjunctivitis.—
Mr. W. F Fedden: Congenital Talipes.

Ophthalmolooical Societt or the United Kingdom (11
Chandos Street, Cavendish Square, W .).—8 p.m.: Card Cases:
Mr. R. J. Smyth, Mr. S. Mavou, etc. 8.30 p.m.: Papers:—Mr.
S. Snell and Mr. E. Nettleshl’p.

North-East London Post-Graduate College (Prince of
Wales's General Hospital. Tottcnhnm. N.).—2.30 p.m.: Gyneco¬
logical Operations (Dr. Giles). Clininues:—Medical Out-patient
(Dr. Whiting); Surgical Out-patient (Mr. Carson); X-Rav (Dr.
Pirie). 3 p.m.: Medical In-patient (Dr. O. P. Chappel).
4 30 p.m.: Lecture:—Dr. A. Q. Auld: Varieties of Cough, their
Diagnosis and Treatment.

St. John’s Hospital for Diseases of the Sein (Leicester
Square, W.C .).—6 p.m.: Chesterfield Lecture:—Dr. M. Dockrell:
Fungous Diseases of the Hair: III.. Kuvus; IV., Leptothrix.
Hospital for Sice Children (Great Ormond Street, W.C.).—

jBirths.

Cutcliffe. —On Dec. 6 th, at Court Green, North Tawtoa, Devos,
the wife of Montagu Cutcliffe, L.R.C.P., M.R.C.S., of a
daughter.

Kinodon.— On Dec. 5th, at Nelson Street, King’s Lynn, the wife
of J. Renorden Kingdon, M.R.O.S., L.R.C.P., of a daughter.

Sawter.— On Dec. 6 th, at 14, Farqithsr Road. Edgbaston. Bir¬
mingham, the wife of James E. H. Sawyer, M.A., M.D., of
a daughter.

4Harmgt0.

Hill—Barbee. —On Deo. 5th, at the Pariah Charoh of Llanfor,
Merioneth, Charles Alexander Hill, M.A., M.B., of 13, Rodnrr
Street, Liverpool, to Ethel Oonatanoe, third daughter of the

late Richard Barker, of Huyton. _

Veblet—Noryoi.*.— On Nov. 16th, at the Parish Chnreh, Halfway
Tree, Jamaica, Reginald Charles Veriefr, M.B., Ch.B.,
M.R.C. 8 ., L.R.C.P., B.Sc.(Edin-). son of the late Jam« L.
Verier, of Jamaica, to Helen, fourth daughter of the late
Robert Norfolk, J.P.

Seaths.

rtbdale. —On Dec. 2nd, at 28, Carson Road, West Dulwich,
Charles Robert Drysdale. M.D., M.R.C.P., F.R.C.S. Consult¬
ing Physioian to the Metropolitan Hospital, aged 78.

RAH am— On Dec. 5th. at 14, Old Cavendish Strecv LondoB,
George Herbert Graham, M.D., late of StorriBgton.

eaffreson. —On Dec. 1 st, at Rouxrill* Orange River Colony,
South Africa, Alfred Ernest Jeaffreson, M.B., B.C.Cambndgr
M.R.C.S., L.R.C.P.London, formerly Assistant Physician of
Bridewell Royal Hospital.

zed by G00gk

The Medical Press and Circular.

“SALUS POPULI SUPREMA LEX."

Vol. CXXXV. WEDNESDAY, DEC. 18, 1907. No. 25.

Notes and Comments.

The An advertisement which appeared in
“ Standard ” the Standard has been sent to us.
and Medical It is headed, “ Appendicitis and
Butchery. Medical Butchery,” and proceeds on
this wise :—“Why be slain by costly
operations when a certain cure can be obtained by
natural means? A few years ago no such disease
could be found in the medical vocabulary, and there
is a VERY GREAT use for the appendix the igno¬
rance of whiclf is a disgrace to the medical profes¬
sion.” After this opening we are not surprised to find
a lot of mystic bunkum about “ magnetic auras,”
“vital force,” “nervous breakdown,” and so on,
and a statement that “ all this can be stopped
by scientific magnetic force from a gifted healer.”
This endowed individual is “Professor" W. H.
Edwards, “ who has been publicly tested in every
variety of disease," “ and who positively undertakes
to relieve every kind of internal inflammation, often
mis-called * appendicitis,’ without operations of the
surgeon’s knife.” After reflection, we have little
hesitation in saying that we consider this adver¬
tisement the most offensive concoction that we
remember to have read, and to label it as a disgrace
to the Standard, or any other paper claiming re¬
spectability. Under the old management it would
have been impossible for such an impudent libel on
the medical profession or any other body of men to
find its way into the advertisement columns of the
Standard, but apparently times have changed, and,
with them, manners.

With “ Professor ” Edwards we are
not much concerned. Gentlemen of
Qaantam his kidney are sufficiently numerous,
Mntatas. and more than sufficiently offensive
to medical practitioners who abide
by a code of honour and rules of
decency. But that a responsible journal of the type
of the Standard can so far forget what is due to
any recognised profession as to print in large letters
such an abominable insult as “Appendicitis and
Medical Butchery” is a more serious matter. It
shows, we think, a very rapid and abysmal fall
from what was till recently considered becoming
and decent, and we would advise medical men who
read journals which degrade themselves in this way
to write to the editors by way of protest. In the
absence of decided action or expression of feeling
these insults have gone from bad to worse, till
“ Medical Butchery,” in speaking of ordinary sur¬
gical proceedings, is not considered too outrageous
for a journal appealing to the better educated
classes to publish in the ordinary way.

The Papers hostile to medicine and
“ Dally News ” national science, such as the Daily
and Student News and the Star, had another
Disturbances, innings last week through the re¬
newed “ Brown Dog ” disturbances.
The Daily News is frankly delighted. “ We wel¬

come these demonstrations,” it says, “ because they
are favourable to the anti-vivisectionist cause.” As
in the same article it is asserted that some of the
demonstrators were drunk—a suggestion we have
not seen put forward elsewhere—the joy that ani¬
mates a nominally temperance paper such as the
Daily News would be hard to understand, if
we did not realise that no weapon is too tar¬
nished and no blow too foul if thereby medical
men and science are to be hit. Student rows
are common in all University towns, whether In
Scotland, Ireland, Wales, Oxford, or Cambridge,
and people accustomed to the presence of students
recognise them to be irresponsible creatures, who
are not always wise, not always rational, and, alas 1
not always possessed of discriminating taste. The
police in University towns, as a rule, understand
student-nature, and practice the art of restraint
with good sense and good temper; the London
police have so little experience of student manifes¬
tations that they regard them much as the Russian
police do demonstrations at the universities in that
bureaucratic country. It is utterly irrational, of
course, for students at the same time to protest
against an offensive monument and to turn it into
a joke; the phenomenon can only be explained on
the well-known principle of “ turning to mirth all
things on earth, as only boyhood can.”

But if a mob of strikers, labouring
under a sense of injustice, break the
PmioDopny of w ;. n< j ows 0 f Government offices or
Strikes. smash the railings in Hyde Park,
the statesman, while condemning
the excesses, seeks for the cause of the trouble, and
endeavours to adjust it. Breaking windows, smash¬
ing railings, and parading effigies of dogs, are
stupid and reprehensible methods, but they gener¬
ally indicate a grievance, and they do not
necessarily indicate the offenders to be possessed
of a larger dose of original sin than their fellows
who have not a grievance. There are many
gentlemen of the highest respectability holding
exalted positions in the State who, in their younger
days, have been guilty of blatant excesses. Every
man of middle-age can point out a dozen well
within his own knowledge. So that to found any
argument on the present regrettable street-rows is
not only unfair but plainly the outcome of spite
looking for a reason to justify its existence. This
is all the more evident when it is remembered that
the very papers that are now using the incidents
under notice for their own purposes, were a few
months ago doing all they could to mollify the dis¬
gust excited in the public mind by the unwomanly
tactics of the “ Suffragettes,” and only retreated
from that attitude when they found they had burned
their fingers and that the demonstrations of these
Amazons were directed personally at the leaders of
their own political party. We do not remember

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LEADING ARTICLE.

Dec. 18, 1907.

these journals welcoming the demonstrations as
being fatal to the cause of women’s suffrage, or as
showing what sort of order in the country would
be the probable result of the success of the move¬
ment

But the vapourings of the Daily
Snobbery News are outdone by the lucubra-
and tions of the Star. This journal is,
Abase. perhaps, the most persistent reviler

of medicine, and what it is pleased
to call the “ medical priesthood,” that we have to
contend with. As it is very ably edited and has a
large circulation among the working-classes, the
injury it does to Che poor in the way of sowing
distrust of medical advice is doubtless very great.
Considering that its advertisement columns are
filled with the most offensive announcements of
quack medicines, and its revenue is therefore
largely dependent on the money extracted from the
poor by their sale, any pretence of serving the
public interest by denouncing medical methods is
calculated to strike an observer as the most
unctuous hypocrisy. The student disturbances are
a god-send to the Star. It begins a leader on them
by sympathising with the police, a force which it
usually delights in denouncing, and which a non¬
medical witness described in this particular in¬
stance as behaving “ like a lot of savages.” It then
toadies to the older universities by congratulating
them on their refusal to join the “ medical larri¬
kins ” in “ the riot,” and proceeds sarcastically to
inquire “at what stage in his evolution does the
medical hooligan become the humane scientist?”
Finally, it winds up its article with a quotation,
adapted from something Robert Louis Stevenson
wrote about the art students of Paris, and applies
it “ to the cads of medicine ” Surelv gutter journa¬
lism, under the transparent guise of righteous
indignation, here reaches its nadir.

For every reason we are glad to
“Un-English, think that this painful chapter of
libellous, and incidents is likely soon to be closed,
provocative.” A member of the Battersea Borough

Council, Mr. Runeckles, has given
notice that he will move at the next meeting of that
body that, “as a matter of good sense and
good taste, the un-English, libellous, and provo¬
cative inscription of ' Little Brown Dog Memorial ’
be removed.” We sincerely hope that the Borough
Council of Battersea will accept the motion. As
we have said before, the inscription is not onlv
calculated but is obviously designed to stir up ill-
feeling, and on every ground such a cause of offence
should be removed. Mr. Runeckles is taking a
dignified and statesmanlike step, and we trust the
Council will dismiss from their minds all prejudice
and prepossession and accept the motion.

LEADING ARTICLE.

DABBLING WITH HUMAN AILMENTS.

The coroners of the United Kingdom have un¬
doubtedly a great power in their hands as regards
the suppression of the evils of patent medicines and
unqualified medical practice. To their honour be
it said that the matter has engaged their attention
both collectively in their society discussions, and
individually in many conspicuous instances. For
the full position of this tragedy is to be found in
the dead bodies of the patent medicine vendors’
victims who are thus brought before the public as
grim evidence of the cupidity of their fellow-men.
The single article of so-called teething powders is
answerable every year for the deaths of a great

number of infants. Yet the trade goes merrily on,
and the proprietors of these poisonous and scientifi¬
cally worthless nostrums amass large sums of
money out of the credulity of the poorer classes.
Then there is the noxious class known as herbalists,
whose names are not infrequently connected with
illegal operations. Two recent cases of public
censure of such persons by coroners for quackery
may be cited. In the first, Mr. S. Brighouse,
County Coroner, held an inquest upon the infant
son of a collier named Cawley, living in Ashton-
in-Makerfield. The child, previously healthy, was
taken ill when about ten months old. The mother
began treatment with a “ Fenning’s tooth powder,"
an unknown quantity, and a dose of castor oil.
Next morning the unfortunate child appeared a
little better and she gave another dose of castor oil,
but the day after she went to Mr. Hill, a herbalist,
of Ashton, and obtained a bottle of mixture and a
powder. Next day the child died before the arrival
of a medical man, who was not summoned until
that stage of the proceedings. In evidence it was
shown that Mrs. Hill examined the child, and six¬
pence was paid for advice, medicine, and powders.
As a matter of fact, the child died from bronchial
pneumonia; no attempt had been made to take the
child’s temperature, so that the data for a proper
diagnosis were defective. It appeared that the
Hills had dosed the unhappy infant with syrup of
rhubarb and antifebrin. With regard to the
latter drug, it is not necessary to remind medical
readers of the risks attending the use of so power¬
ful a drug. Of the many deaths that have
followed its use some at least have been amongst
young persons, and its administration to infants
requires the exercise of the highest and most re¬
sponsible medical skill available. The fact that
ignorant persons can openly avow in a public Court
that they have prescribed antifebrin shows the
impotence of the Medical Acts to protect the safety
of our countrymen against the machinations of
unqualified medical practice. The woman herba¬
list had the brazen audacity to state she had used
antifebrin for the past twelve years. In accord¬
ance with the wish of the jury, Mr. Coroner
Brighouse gave this precious pair a sound rating
for “ dabbling ” with human ailments about which
they knew nothing. There the matter ends, but
surely the police, had they a mind to it, could prose¬
cute this Hill and his wife for obtaining money-
under false pretences. The attention of Parliament
might well be called to this incident by any Member
who is sufficiently interested in the safety of the
community, especially of its rising generation. Die
second case to which we would refer briefly was
divulged at Brighton on October 10th. The
Coroner, Mr. J. E. Bush, held an enquiry into the
death of a young woman who had died shortly
after being discharged from the Sussex County
Hospital, where she had been under treatment for
leukaemia. Her case was regarded as hopeless,
and her friends called in a local herbalist of the
name of Stokes. This man visited the poor girl
at home, and gave her medicine “ for the kidneys,
liver, and nerves,” in spite of which treatment he
admitted having been surprised at her sudden col¬
lapse and death. He claimed, however, that he
had kept her alive for eighteen days. This man
had the impudence to boast he had been “practis¬
ing ” for over fifty years, and had cured cases given
up by doctors, and even doctors themselves. The

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653

Coroner wound up with the usual formal censure
of the herbalist, at the wish of the jury. Such
practices, it is needless to remark, will need more
drastic handling than the mere delivery of a public
remonstrance. “ Hard words break no bones ” is
essentially a motto for quacks. It is to be hoped
that the movement recently set on foot by the
General Medical Council will result in some short
and sharp legislation to rid society of such cruel
harpies and parasites as herbalists and other
quacks of the same kidney.

CURRENT TOPICS.

Suggested Royal Commission on Scarlet
Fever.

It may be still remembered that three years ago
The Medical Press and Circular took up strongly
the position that a Royal Commission, or other
authoritative inquiring body, should be appointed to
investigate the relation of isolation hospitals to the
spread of scarlet fever. By means of papers con¬
tributed by medical men having special knowledge
of the position, and by editorials, the matter was
placed before the public, and although some support
was received, the matter, on the whole, was not
warmly accepted. We realised that the isolation
hospital was such a convenience in many ways
that, as regards scarlet fever, any steps that seemed
to infringe its prerogative would be certain to meet
with opposition; but we held then, and hold as
strongly to-day, that the problem is a great and
puzzling one calling for a large and independent
investigation, considering the magnitude of the
sums invested in maintaining scarlet fever patients
and the poverty of the results achieved. We have
returned to the subject over and over again, but the
fruit, though long in ripening, has yet to be
gathered. That step, however, is appreciably
•nearer. On December 5th, Professor W. R. Smith
submitted a motion to the Metropolitan Asylums
Board to the effect that in view of the continued
prevalence of scarlet fever, notwithstanding the
extensive isolation accommodation which has been
provided, the Local Government Board be asked
to cause an inquiry to be instituted into the cause
of the disease, and whether any, and if so, what,
further means can be adopted for its prevention.
Professor Smith said that medical science had not
yet discovered the cause of the disease, and by an
inquiry the burden on the ratepayers might be re¬
duced. Personally, he thought the matter ought
to be submitted to a Royal Commission. That
motion was adopted unanimously.

The Extinction of the Eskimos.

One of the ironies of so-called civilisation is the
way in which contact with its vices secures the ex¬
termination of primitive tribes. The case of the
rapidly disappearing Eskimos is pathetic in the ex¬
treme, and it is pleasing to record that one of their
strongest friends and champions is an English
medical man, Dr. Grenfell. In former times the
natives of the frozen country of Labrador wrung
a livelihood out of their barren surroundings by the
aid of native weapons and by dint of hard and
adventurous living. Now, as a matter of fact,
they are being rapidly exterminated from the face
of the earth by the continued ravages of hunger
and disease. Armed with modern weapons of

civilisation, they have killed off the herds of musk
ox merely for the sake of their skins. In that way
they have destroyed their main source of food-
supply. Then, again, they are being decimated
by syphilis, introduced by the crews of the whaling
ships. Whole tribes are said to have been
destroyed, in some instances under terrible circum¬
stances. It seems clear that the countries that send
the whalers are morally responsible for this result.
Why should not the wanton spread of syphilis be
a punishable crime? Canada has forbidden the
export of musk ox skins, so that the natives should
not exterminate them for the sake of the hides.

It would be well if the legislation of that Dominion
would deal with the evil of syphilis in an equally
prompt and decisive manner.

Slums and Coroners.

The Truro Coroner has taken a step that bids
fair to have somewhat far-reaching consequences.
In a case under investigation in which death was
attributed to bad surroundings, the Coroner called
in some prominent members of the sanitary ad¬
ministration of the town, and after requesting them
to inspect the premises concerned, called them as
witnesses. It would be hard to imagine a more
dramatic and effectual way of bringing home to
those responsible for the local sanitary welfare a
conviction of their own shortcomings. Were object-
lessons of this sort to become general, we venture
to predict that the terrible evil inflicted upon the
community by the owners of slums would be
speedily abated. For one thing, it is obvious that
evidence of the kind would have an Inestimable
value Ln tenants’ actions for damages for injury to
health and life through insanitary premises, of
which several have been successfully conducted in
recent years. As irremovable and independent
Crown officials, the coroners are almost the only
persons able to fight such strongly-vested private
interests as those interested in slum property and
patent medicines. The owners of bad houses have
long ago recognised the advantage of being
strongly represented on local governing bodies. It
is not likely, however, that they would survive
many pillories in the Coroner’s court. It is to be
hoped that the example of the Truro Coroner may
be followed by his brethren throughout the United
Kingdom.

Indian Hospital Assistants’ Journal.

We have received a copy of a new medical
journal which gives us peculiar pleasure, namely,
the All-India Hospital Assistants’ Journal. The
hospital assistants have formed an Association
which, in their own words, “aims at the scientific,
moral, and material progress of our class,” and the
journal is the organ through which the members
scattered over the vast peninsula are kept in touch
with one another and instructed. That the hospital
assistants desire improvement and are capable of
forming such an Association and editing such a
journal must give great satisfaction to those who
sympathise with the native aspirations in India,
and wish to see a happy, well-governed, and pros¬
perous people in that Empire where England has
such vast responsibilities. The surest path of
progress is through the practice of self-culture and
the assumption of responsibility, and we warmly
congratulate the hospital assistants on their enter¬
prise, which, if wisely carried out, will be a source

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654 The Medical Press.

CURRENT TOPICS.

Dec. 18, 1907.

of help to the officers of the Indian Medical Service
under whom they serve, just as the organisation of
professions and trades at home is of assistance both
to the members and those with whom they come
into contact. The number of the journal before us
speaks with appreciation of the Indian Medical
Service, and the official approval of the movement
is testified to by the patronage of highly-placed
officers. In connection with the movement against
quackery which The Medical Press and Circular
is constantly keeping alive, it is interesting to us to
read in a paper by Mr. P. S. Ramchandrier, of
Ahmedabad, the following passage“ I do not
like to omit what I have to say about your duty
to put down the charlatan in the stations you will
be in charge. This is most rife in India. It is
wonder to me how this benign Government which
takes superb care to prevent any ordinary man not
to practice law without professional course in a re¬
cognised institution, allows scot-free men veneered
with sanctimonious theories of medicine to practice
their arts on slaughtering the ignorant and poor
agriculturists. What is not done by the ruling
power, people like us can to a certain extent do for
ourselves.” An autocratic Government like that of
India ought to grapple with the question soon and
strongly; it is not beset with the difficulties met
with in this country. It strikes the British reader
curiously to read of a concession granted to the
assistants. “ Hospital assistants are not required
to fire a revolver course ” runs a new regulation.
Perhaps the quacks will be glad too. But, revol¬
vers or no revolvers, we stretch out the hand of
welcome to our native fellow-subjects.

Infantile Mortality at Huddersfield.

The endeavours of the municipal authorities of
the borough of Huddersfield to cope with the evil
of infant mortality have jvithin the past year or
two attracted much public interest. By virtue of
a special Act which came into operation exactly a
year ago, the Corporation has had, during the past
twelve months, special powers it did not previously
possess, and it is interesting to note the effect of
the working of this Act. Under it all births have
to be notified to the health authorities within forty-
eight hours, and it appears that 94 per cent, of all
the births have actually been so notified. All the
exertions of the health authorities are in the defi¬
nite direction of helping the mother to nurse her
child in her own home. On the notification of each
birth, a medical woman, assistant to the medical
officer of health, calls at the address given, and if
advice as to infant management is needed, she
gives it. Ladies, who act as honorary visitors,
give their help, and, where necessary, continue to
supervise the care of the infant. No dole of any
kind is given, either by the visitors or by the muni¬
cipal authorities. The results have been better
than anyone could have hoped. The infant mor¬
tality rate for the first nine months of the year has
been 85, whereas for the corresponding period of
last year it was 138, and the mean for ten years was
135. Comparing the mortality in Huddersfield with
that in other towns a great difference appears. In
the third quarter of the year the infant mortality
rate in the seventy-six towns of the Registrar-
General’s list was no; that of Huddersfield was
62. We congratulate the municipal authorities on
their magnificent success, and we wish that other

towns would follow their example. It is stated
that the pecuniary expenditure for this saving of
infant life has not exceeded ^400 a year 1

Appendicitis and Plum-pudding.

What is the relation of plum-pudding to appen¬
dicitis? Lest the question should shroud the Christ¬
mas season with an appalling gloom, we hasten to
say that there is no appendicitis in plum-pudding.
The grotesque theory still propounded by some kill¬
joys that pips in the pudding cause appendicitis is
a hoary turnip-headed scarecrow. So far from
upsetting the digestion, there can be nothing finer,
more digestible, nourishing, toothsome, and sus¬
taining than good, wholesome English plum¬
pudding made from a sound recipe. Let mothers
take this kindly medical advice to heart. It is not
the plum-pudding that hurts the child, but rather
the stuffing with fruit and comfits and lollipops
and candies and other of the rich cates that cluster
round the merry Yuletide. Let a healthy youngster
abstain from these things between meals, and let
the meals be plain, then there will be no need to
shun the plum-pudding on Christmas Day. For it
is clear to the plain man as to the ’pothecary that
plum-pudding hath its scientific as well as its grossly
material and fleshy aspects. It is from our love
and veneration of this finest of old English dishes
that we would point out to our fellow-country¬
men of all ages, all sexes, and all temperaments,
how to enjoy to the utmost the brief but all-
conquering season of its advent. We lay it down
as a law of the Medes and Persians that no plum¬
pudding has half the heavenly savour of that served
up in Christmas week decked with a sprig of berried
holly and wreathed in lambent flame. So mote it
be to all of us!

The British Medical Association and its
Charter.

We have before now commented on the question
of the British Medical Association petitioning for a
Royal Charter, and we have advised the members
to exert due caution before committing themselves.
For several months a warm debate on the subject
has been in progress, and at the present time a
referendum is being taken to settle the question.
The official journal, which is working hard for the
Charter, in this week's issue makes a quotation
from the legal adviser of the Association which
may or may not help towards that object. Mr.
Beaufort Palmer says that if the Association were
under a charter instead of being, as at present,
governed by the Companies Acts, it “ would be freed
for all practical purposes from the trammelling
rules of the Courts in regard to what is and what
is not ultra vires.” In other words, the property
and interests of the members would not be so-
securely safeguarded as at present. This might be
a very serious matter, as it would be difficult to
rectify an unwise action. The members will be
wise to watch any further developments which
would emancipate the governing body “from the
trammelling rules of the Courts.” Incidentally, we
may notice that the debate on the question has
brought about a curious position in the Association,
in that the Council and the representative meeting
have found themselves in disagreement, and the
duel system of government of the Association estab¬
lished a few years ago has not worked well.

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Dec. 18, 1907.

PERSONAL.

The Medical Press. 65 5 .

The Reform of the Irish Poor-Law.

The Chief Secretary for Ireland has during the
past week informed an influential deputation
which waited upon him that the Irish Government
were drafting a measure dealing with Poor-law
reform, that it had first place on their list, and that
it would be proceeded with as soon as ever time
could be found for it. Further, he stated that the
recent report of the Viceregal Commission would
furnish a basis for the proposed legislation. As
our readers know, one of the most important recom¬
mendations made by this Commission was the
conversion of the existing Poor-law Medical Service
into a State Medical Service. This proposal was
cordially supported by the Irish medical Col¬
leges, the Royal Irish Academy of Medicine, the
Irish Medical Association, and other kindred
organisations. The necessity for some such step
has been fully recognised, and almost its only
opponents are the various local boards which would
lose opportunities of patronage. Human nature
being what it is, such opposition is only natural,
and surely it ought not to be allowed to weigh
against a measure so urgently demanded in the
interests of the Irish poor. Mr. Birrell, in his reply
to the deputation, referred to the fact that so many
of the recommendations of the Commission were
contentious. He, however, above all men, should
not shrink from what he considers necessary,
because he must by this time know that nothing in
Ireland which is worth anything is free from con¬
tention.

Defaulters under the Midwives Act.

The working of the Midwives Act is now
advanced far enough to warrant some sort of con¬
clusion as to its future progress. The “Association
for Promoting the Training and Supply of Mid¬
wives ” is already appealing to the public for a vast
sum of money to enable the training of midwives to
be conducted on a national scale. Where the matter
will end is a subject for speculation, but there appears
to be a not altogether remote prospect that eventu¬
ally medical men will find themselves faced with
the competition of an army of pseudo-medical prac¬
titioners. At present the fear is more than justified
by the terrible roll of indictments against 33 mid¬
wives presented last week before the Central Mid¬
wives Board. Several women were accused of
administering medicines other than a simple
aperient without entering the fact upon a register.
One woman is stated to have administered a vaginal
douche with a syringe previously used to give an
enema. A number of cases of drunkenness were on
the list. Failure to report puerperal fever occurred
in many instances, and often nurses continued
attendance on other labours while infected from a
puerperal case. Neglect to call in medical men
formed a large proportion of offences; in the
majority of instances the midwife failed to seek such
assistance for puerperal fever; but there were
several cases of ruptured permanent or retained
placenta in which she apparently considered the
advice of a medical man superfluous. It will, of
course, be argued by the supporters of the Act, that
these cases simply prove the need of special training
and of rigid supervision. While that may be ad¬
mitted it nevertheless seems no less clear that the
contentions of the medical men are being amply
justified when they asserted that certificated mid¬
wives would infallibly regard themselves in many
cases as entitled to carry on a sort of hybrid quack
medical practice under the aegis of their diploma.

PERSONAL.

Dr. Robert Maguire has been installed as Master
of the University of London Lodge of Freemasons.

Dr. John C. S. Rashleigh, of Par Station, Corn¬
wall, have been nominated a Sheriff for that county.

Dr. Thompson, of Feeny, has been placed on the
Commission of the Peace for the County of London¬
derry.

The award of the Nobel Prize for Medicine has, as
anticipated, been made to Dr. Laveran, of the Pasteur
Institute.

Dr. James MacLachlan has been re-elected Provost
of the Dornoch Town Council for a further period of
three years.

It is announced that Lord Cromer has accepted the
office of honorary vice-president of the Liverpool
School of Tropical Medicine.

On his retirement from the Liverpool Royal In¬
firmary, Mr. Rushton Parker’s students, past and
present, are presenting him with his portrait in oils.

Dr. William Berry has been presented with a silver
tea service in recognition of his twenty-five years’ ser¬
vice as Honorary Secretary to the Wigan Medical
Society.

Professor Moritz Schmidt, of Frankfort, who
recently was the recipient of the title of “ Excellency ”
in recognition of his services to laryngology, has, we
regret to hear, recently died.

The annual dinner in connection with the Medical
School of the Birmingham University was held at the
Grand Hotel on December roth. The chair was
occupied by Dr. J. W. Russell.

Dr. Charles James Sutherland has been promoted
to be a Knight of Grace of the Order of the Hospital
of St. John of Jerusalem. A similar distinction has
been conferred on Lieut.-Colonel E. J. Hunter.

Dr. Arthur J. Hall, Physician to the Sheffield
Royal Infirmary, has been appointed Lecturer on
Practical Medicine in the University of Sheffield,
rendered vacant by the resignation of Dr. W. Tusting
Cocking.

The medical men of Old Withington have presented
Dr. Railton with a silver rose bowl on the occasion
of his retiring from the office of Medical Officer of
Health of the district, which post he had held for

35 years. -

Dr. Alexander James was entertained at dinner by
numerous medical friends on the occasion of his retire¬
ment from active service as Physician to the Edinburgh
Royal Infirmary. Dr. Underhill, President of the
Royal College of Physicians, occupied the chair.

With the advent of the New Year Dr. A. Wynter
Blyth will cease to hold the post of Medical Officer of
Health of Marylebone, still retaining, however, that
of local Public Analyst. His successor in the medical
officership is Dr. Meredith Young, Medical Officer of
Stockport.

The Right Hon. the Earl of Meath, K.P., P.C.,
H.M.L., Co. and City of Dublin, with the approval
of his Excellency the Lord-Lieutenant of Ireland, has
been pleased to appoint Mr. William Askin Shea, of
“ Elmville,” 5, Garville Avenue, Rathgar, and 28,
Westland Row, to be a Deputy-Lieutenant of the City
of Dublin, in place of Charles E. Martin, Esq., D.L.,
deceased. Commission dated December 7th, 1907.
Mr. Shea is a J.P. of the City of Dublin and Vice-
Chairman of the South Dublin Poor Law Board of
Guardians and Registrar of the Incorporated Dentrtf
Hospital, Dublin.

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656 The Medical Press.

CLINICAL LECTURE.

Dec. 18, 1907.

A Clinical Lecture

ON

FRACTURES AT THE WRIST, (a)

By IYARCY POWER, FJLCS^ng.,

Surgeon to and Lecturer on Surgery at St. Bartholomew's Hospital f Surgeon to the Bolingbroke HospkaJ,
and Consulting Surgeon to the Victoria Hospital for Children, Chelsea.

[Specially Reported for this Journal.]

Gentlemen, —I propose to talk to you to-day about
fractures at the wrist, illustrating my remarks by skia¬
graphs, for which I am indebted to our X-ray depart¬
ment, which is so excellently managed by Dr. Lewis
Jones and Dr. Walsham, though I am the more
especially indebted to Mr. J. M. Flavelle for the
trouble he has taken in selecting from the common
stock so splendid a series of illustrative plates. If I
had chosen this subject ten years ago I should have
spoken of it as “Fractures of the Lower End of the
Radius,” and when I used to teach you the elements
of fractures and dislocations more than twenty years
since, we merely called it “Colies’ fracture.”

By taking advantage of successive advances in
physics and surgery we have achieved very satisfactory
results in diagnosis, and where we used to employ a
specific name we are now obliged to reconsider the
nomenclature and sub-divide the injuries at the lower
end of the wrist into a variety of groups, which may
be thus tabulated :—

Radius.

Ulna.

.Separated lower epiphysis.

Unimpacted fracture.

Impacted fraolure. Simple.

Lower fragment com
minuted.

Oblique fracture through articular end
mlnutlon.

'-Styloid process detached.

[Separated lower epiphysis.

-< Fracture of shaft In lower third.

I Styloid process detached.

\ Colies’

" | fracture,
without com-

Scapbold.

J Simple fraoture.

I Fraoture with dislocation of one fragment.

Radius and J Transverse fraoture.

Clna.j 1 Colics’ fracture with styloid process of ulna torn off.

Radios and Scaphoid. Collea’ fracture with fractured scaphoid.

Ulna and Scaphoid. Fracture of Scaphoid with tearing off of
styloid prooess of ulna.

I need hardly call to your notice the clinical
features which are common to a broken wrist. You
all know the picture which you see so often in the
surgery. A patient, Tather pale and shaking, who holds
one wrist tightly grasped against his chest by the other,
and pushes open the door with his shoulder. He says
that he has just fallen and sprained his hand. It is
very painful, and quite useless. Examination shows
that the wrist is deformed and bent to the radial side,
so as to reveal the lower end of the ulna with un¬
natural clearness. Movements of pronation and supina¬
tion are impossible, or are made by an awkward twisting
of the arm from the shoulder or elbow. Closer exam¬
ination shows that the deformity is due to a bony
swelling in a typical case, the swelling being more
marked on the dorsum than on the palmar surface.

Yet, with all these marked signs and symptoms, it is
remarkable how long a fracture of the lower end of
the radius escaped notice, for it seems to have been
looked upon as dislocation of the wrist, a form of
injury which is very rare. Abraham Colies was not
quite the first to call attention to the true nature of
toe injury, but he was the first to describe it so simply
and accurately as to make it his own, and to rtnder
his name one of the household words in surgery. I
hold in my hand his original paper. It is dated from
St. Stephen’s Green, Dublin, 1814. It is less than four
pages in length, and it appeared in the Edinburgh
Medical and Surgical Journal for the year 1814
Vol. X., p. 182). The paper begins:—“The injury to
which I wish to direct the attention of surgeons has

(*) Delivered at St. Bartholomew's Hoapltal on Wednesday,
November 27th, 1907.

not, as far as I know, been described by any author.
Indeed, the form of the carpal extremity of the radius
would rather incline us to question its being liable to
fracture. The absence of crepitus and other common
symptoms of fracture, together with the swelling which
instantly arises in this as in other injuries of the wrist,
render the difficulty of ascertaining the real nature of
the case very considerable.” Colles then describes the
clinical signs, and adds a few comments on the prog¬
nosis and treatment. It is interesting to notice that a
surgeon of such gigantic experience as Sir Astley
Cooper was not clear as to the mechanism of the
fracture, although he had examined broken wrists post¬
mortem. Colies’ explanation passed current, and
without mucji criticism, until 1842, when Voillemier
stated that fie believed that impaction was essential in
fractures at the lower end of the radius, a conclusion
which was criticised adversely by Prof. R. W. Smith
in 1847, and was adjudicated upon by Prof. E. H.
Bennett in 1879, who found that both writers had been
too absolute in their statements.

A. —Simple Fracture of the Lower End of the

Radius.

I show you a skiagram of a perfectly simple fracture
of the lower end of the radius within a quarter of an
inch of the carpus. It shows clearly the mechanism
of such an injury. The scaphoid and the semi-lunar
bones in the proximal row of the carpus are closely
connected with the articular surface of the radius;
whilst the cuneiform bone is separated from the lower
end of the ulna by the triangular fibro-cartilage. When
a patient falls upon his outstretched hand, the whole
force of the shock comes upon the lower end of the
radius, and it is transmitted rather obliquely because,
as the skiagram shows, the axis of the wrist is itself
slanting. The pressure, therefore, is exerted upon the
outer or styloid-process side of the radius. The skia¬
graph shows further how weak the lower end of the
radius is as compared with the shaft of the bone, for
the expanded end of the radius is cancellous tissue,
with a thin covering of compact bone, whilst the shaft
is compact bone without much cancellous tissue.

The next skiagraph shows a transverse fracture of
the lower end of the radius in a patient whose lower
epiphysis is not yet united. It shows, too, why such
fractures are rare in children, Colles’ fracture being
essentially a fracture of adult life. In a young person
the shock of a fall upon the hand is distributed by
two buffers—first, the elasticity of the epiphysis, and,
secondly, the intermediary cartilage which lies between
the epiphysis and the shaft forming the growing part
of the bone. In young persons, therefore, a severe
injury is saved to the radius, but may be transmitted
further up the arm, causing a backward dislocation at
the elbow, or even a broken collar-bone.

B. — Impacted Fracture of the Lower End of the

Radius.

The next plate shows the condition which we recog¬
nise as typical of a Colles’ fracture. The radius is
broken close to its carpal extremity, and the lower
fragment has been penetrated by the upper fragment
in such a manner that the upper fragment is driven
obliquely into the lower extremity. There is no com¬
minution of the lower fragment; the styloid process
of the ulna and the lower end of the ulna are both
uninjured. A closer examination of the plate shows
that the impaction of the fracture has occurred, so
that the upper fragment enters the lower obliquely
from above downwards, the lower extremity being

D

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Dec. i8, 1907.

CLINICAL LECTURE.

The Medical Press. 657

driven upwards, backwards and outwards. The im¬
paction, moreover, is not complete, because the can¬
cellous tissue of the lower fragment does not contain
both layers of the compact tissue of the upper frag¬
ment, and there is clearly inter-penetration. This is
seen in the side view of the wrist, and is not shown
in the antero-posterior skiagraph. It is well, therefore,
to have two views of every broken wrist, one taken
with the hand flat and one in profile.

C.—Comminuted Fracture of the Lower End of
the Radius.

When the violence leading to a broken wrist has
been considerable, the lower end of the radius may be
comminuted, as is shown in this skiagraph. I called
attention to this form of fracture so long ago as 1887
(Trans. Path. Soc., Vol. XXXVIII., p. 250), and our
museum contains several excellent instances of it. This

is separated from the other half by a line of fracture
extending from the scapho-lunar facette obliquely out¬
wards, and ending at some distance above the base of
the styloid process. A slighter form of fracture which
was probably only recognised as a bad sprain is seen
in this radiograph, where the styloid process of the
ulna is separated without injury to the articular sur¬
face. In neither of these fractures has there been any
injury to the ulna.

E.—Fracture of the Styloid Process of the Ulna.

In these skiagrams the styloid process of the ulna
has been torn away, whilst the radius is intact. It is
plain that the fracture of the styloid process is not

Fig. 1.—Simple Fracture of the Scaphoid, without
Displacement of Either Fragment.

plate shows the lower fragment split vertically into
two pieces, but without much impaction, and with no
injury to the ulna. Such an additional injury renders
the prognosis more serious, because the carpal joint is
involved, and the wrist may easily become stiff unless
it be recognised and measures be taken early to
counteract its effects.

These fractures were practically all the forms of
broken wrist recognised before the advent of skia¬
graphy, but, as our scheme shows, several additional
forms are now clearly recognised.

D.—Oblique Fracture Through the Carpal Arti¬
cular Surface of the Radius.

The next radiograph shows an entirely different form
of fracture. Half the articular surface of the radius

Fig. 2 . —Fracture of the Scaphoid, with Disloca¬
tion of One Fragment.

always at the same spot, for in one radiograph it is
a mere nodule of bone which has been detached, whilst
in these the whole styloid process ha 3 been torn off.
It appears most probable that such fractures of the
styloid process of the ulna have generally been looked
upon as bad sprains of the wrist until radiographs
showed their true nature.

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658 The Medical Press.

CLINICAL LECTURE.

Dec. 18, 1907.

F.— Fracture of the Scaphoid.

The next group of radiographs shows an interesting
series of fractures of the scaphoid, fractures which
have hitherto been very little known, but which are
evidently not uncommon, for here are several different
plates showing similar appearances.

The scaphoid, as you well know, is one of the
larger bones of the carpus partially curved upon itself
and traversed obliquely by a groove. It is easy to
imagine that under pressure from the os magnum
and the articular surface of the radius the scaphoid
would be broken into two fairly equal frag¬
ments, and the figures 1 and 2 which are reproduced
from the radiographs I show you prove that this is
exactly what happens, although there are some who
maintain that the scaphoid is developed from two
centres, and that these apparent fractures are in reality
failures of ossification. In the simplest forms, Figs. 1
and 3, the scaphoid is merely fractured, and no damage

Fig 3.—Colles’ Fracture, with Impaction and
Fracture of the Scaphoid. (The radiograph has
been taken with a splint on the injured arm, and
its outlines are dimly seen.)

has been done to the radius or the ulna ; in one plate,
Fig. 2, the scaphoid is not only fractured, but one of
the fragments has been displaced bodily, so that it lies
on the dorsum of the wrist. This displacement would
have been overlooked if the radiographer had omitted
to take two pictures of the wrist, one flat, the other in
profile, so that here is another instance of the import¬
ance of taking more than one view of every fracture.

Drs. Codman and Chase, of Boston, Mass., have
published a most excellent monograph on the diagnosis
and treatment of fracture of the carpal scaphoid and
dislocation of the semi-lunar bone. It appears in
The Annals of Surgery for 1905, Vol. XI.I., and from

their account I take the following passages:—“ The
patient, usually a male of from twenty-five to thirty-
five years of age, has fallen on his extended wrist
in the same manner as in the injury which usually
causes a Colles’ fracture. He has supposed that he
has sprained his wrist, and for a few days has suffered
severe pain and tenderness, and has been unable to
use his hand for ordinary purposes. During a period
varying from a few days to a few weeks, according to
the hardihood of the individual, he has refrained from
using his wrist. Gradually be has been able to take
up his work again, but after a certain point the sore¬
ness, tenderness, and disability have refused to im¬
prove. Eventually he comes to the hospital complain¬
ing of pain, tenderness and weakness of the wrist.
Examination shows that the fingers have their normal
flexibility, but that the active and passive movements
of the wrist-joint are limited to one-half or less of
their normal arc of excursion. Attempts to continue
passive movement beyond a certain point, especially in
extension, are limited by a most characteristic muscle
spasm very similar to that seen in tuberculous joints.
If the spasm is overcome by force, and the wrist moved
still farther, the pain is intolerable. There is no
crepitus or ecchymosis, but there is seen to be slight
swelling or thickening over the radial half of the wrist-
joint. The outlines of the extensor tendons of the
thumb are made less distinct by the swelling, and
pressure elicits signs of tenderness definitely localised
over the scaphoid bone, and specially in the ana¬
tomical snuffbox.”

Ouc radiographs show that fracture of the scaphoid
occurs in connection with other injuries, and is not
always so simple as in the pictures I have just exhi¬
bited. Here are several varieties of such complex
injuries. The first one is—

G. — Fracture of the Scaphoid, with Dislocation

Backwards of One Fragment (Fig. 2).

The next is—

H. —An Impacted Colles’ Fracture, with Fracture

of the Scaphoid.

In this case there has been some thickening about
the lower end of the ulna. The fracture •<* evidently
of long standing, for the radius is consolidated and
in good position, but the wrist is disorganised, and
has evidently been the seat of severe inflammation.
Until the skiagraph was taken it must have seemed
remarkable that the wrist was so useless when the
Colles’ fracture had united in such a good position.
The two fragments of the scaphoid in this case are
united by a thin band of callus, but there is no good
union.

Here is another radiograph showing still another
variety in which there is—

I. —Fracture of the Scaphoid, with Fracture of

the Styloid Process of the Ulna.

In this case the lower end of the radius seems to
have escaped uninjured.

I have devoted so much time to the exhibition of
the different forms of fracture occurring at the wrist
that the important subjects of prognosis and treatment
must be dealt with very briefly.

The prognosis depends very largely upon the diag¬
nosis. Rational treatment can be adopted when the
nature of the injury is known; otherwise we work in
the dark. The series of radiographs which I have
shown you warn us that fractures at the wrist are
often complex, and that it is impossible to obtain a
satisfactory result when such an injury is treated on
the supposition that it is “only a Colles” or “merely
a sprain,” because the additional injury has been over¬
looked. It is important, therefore, to obtain a good
radiograph in every case, and at the risk of “ damnable
iteration ” I would repeat in more than one position
of the limb. Broadly speaking, the prognosis is good
in simple fractures at the wrist when the styloid pro¬
cess of the radius or ulna is not tom off, or when the
fracture of either or both bones is simple and trans¬
verse. In Colles’ fracture with impaction it is fairly good
even when the lower fragment is comminuted, but in
fracture of the scaphoid it is bad unless the injury is
recognised at the beginning and treated accordingly.
But the arm is needed for much more delicate move¬
ments than the leg, and therefore I would personally

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Dec. 18, 1907.

ORIGINAL PAPERS.

much rather sustain a Pott’s fracture than have a
-broken wrist.

The first essential of treatment is to leave nothing
to chance, but to bring the broken ends of the bone
into the very best possible apposition, and keep them
there until they are united. The impacted end of a
Colles’ fracture should always be separated before a
splint is applied. I make this an absolute rule for
your guidance. There are a few exceptional con¬
ditions where it is better to sacrifice some of the use
of the wrist and leave the ends impacted, but they do
not concern you now, and it is best for you to remem¬
ber that every Colles’ must have the deformity com¬
pletely reduced as soon as possible. A Carr’s splint
must then be applied. It is the best form of splint
for these fractures, because it is easy to make with a
straight splint, to which a piece of a broom handle is
screwed obliquely, and it is comfortable to wear.
The fingers are bound round the end of the splint until
the acute pain and some of the inflammation have
subsided, and this is usually for four days. The
fingers are then left free, though the splint is still
bound to the hand and wrist. Once a day the surgeon
or nurse moves each finger deliberately and in suc¬
cession, so as to ensure the free movement of the long
flexor and extensor tendons in their sheaths as they
pass over the injured wrist, for in these fractures the
tendon sheaths are often damaged by the presence of
inflammatory products. At the end of a month the
splint may be safely replaced by a leather wristlet, or
in a poor person by a small bavarian splint, reaching
from the point above the fracture to the middle of the
hand, and the patient should be instructed to use and
exercise his wrist joint, more especially by movements
involving some rotation at the joint. The joint should
be rubbed from the tenth day onwards if it is possible
to secure skilful massage. The gauntlet may be
dropped at the end of the fourth week from the
accident.

But this treatment is not useful for cases of
fractured scaphoid. The two fragments of this bone
show very little power of union, and it is therefore
necessary to take more active measures.

A fractured scaphoid is generally taken for a sprain
when it occurs as the only injury to a wrist, and it is
often several weeks before the patient has a radiograph
taken. This may account for some of the bad results.
But in the radiograph I showed you the fractured
scaphoid was only a part of other injuries which must
have made the immediate application of a splint a
matter of absolute necessity. The radius in this case
was firmly united, but the two fragments of the
scaphoid are only joined by a slender thread of callus.
An attempt may be made to obtain union when the
scaphoid has been broken, but if at the end of a month
the radiograph shows that it has not occurred satis¬
factorily, the patient should be advised to have one
of the broken pieces removed. Experience has shown
that if the united fracture is allowed to remain, the
wrist becomes the seat of a chronic inflammation
which makes it painful and increasingly useless. The
removal is made through a small incision on the
dorsum of the wrist parallel to and along the inner
side of the tendon of the extensor carpi radialis
longior. When one fragment of the scaphoid is dis¬
located, as in Fig. 2, there should be no hesitation in
removing it at once.

Notk. —A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture for
neat week will be by Dr. Chantemesse , Profeteeur
Agrtgi of the Faculty of Medicine of Paris. Subject:
“ The Serum Treatment of Typhoid Fever (Antityphoid
Opsonisation) ”

The witnesses before the Royal Commission on
Vivisection last week were Dr. Swan and Dr. Cowen,
on behalf of the National Canine Defence League;
Mr. A. G. Scott and Sir F. Banbury, M.P., on behalf
of the Royal Society for the Prevention of Cruelty to
Animals; Mr. L. E. Shore, M.D., Physiological
Laboratory, Cambridge; and the Hon. Stephen Cole¬
ridge, re-called, on behalf of the National Anti-
Vivisection Society.

The Medical Press. 659

ORIGINAL PAPERS.

CASES DEMONSTRATING THE

VALUE OF SPINAL ANALGESIA IN
PROTECTING THE PA1IENT FROM
SURGICAL SHOCK.

By E. CANNY RYALL, F.R.C.S.I.,

Senior Surgeon to the Kensington General Hospital.

The object of this paper is to bring before the notice
of our surgical confr'eres the absence of shock when
operations such as those recorded in the following
cases, amongst others, are performed under the in¬
fluence of lumbar puncture.

When one considers the fatalities resulting from
shock following operative interference, it is of the

S eatest importance to eliminate this factor, and we
ilieve that in spinal analgesia we have the method
for combating it—a method which, we regret, has not
yet received the due consideration in this country
which it deserves.

In these cases no pain was felt during the opera¬
tions. Headaches and vomiting were absent, and the
result as regards shock was ideal in all instances, not¬
withstanding that two of the patients were suffering
from severe heart lesions, and in a third pulmonary
tuberculosis in an active stage already existed.

Case i —Suprapubic Prostatectomy.—Heart
Disease.

J. K., aet. 60, first came under cur care as an out¬
patient at the Kensington General Hospital in 1906,
and gave the following history. About two years ago
he began to be troubled with frequency of micturition
and difficulty in starting the act. He often had pain,
referred to the glans penis, and had noticed blood in
his urine on two occasions. For the past two months
the frequency increased, and he is now compelled to
micturate every hour during the day, and to rise three
or four times each night. Occasionally he has had
sudden stoppage of the flow of urine.

On examination per hypogastrium nothing abnormal
could be detected. Per rectum the prostate .was found
to be enlarged, smooth, of uniform consistence, and
movable. When asked to micturate it was noticed that
the stream was small and ejected with little force.
After the act he was placed on a couch, his glans
penis and meatus thoroughly washed, and a sterile
rubber catheter passed, which drew off 3 oz. of residual
urine which was alkaline, sp. gr. 1025, containing pus
cells and crystals of calcium oxalate, but no blood or
albumen. He was subsequently admitted into hospital
as an in-patient, and on passing a cystoscope we found
the prostate enlarged, and lying in the post-prostatic
pouch was an oval-shaped calculus. He was kept con¬
fined to his bed and placed on a light diet. His
bladder was washed out daily, and urotropine adminis¬
tered in combination with acid sodium phosphate,
This had the effect of rendering his urine acid in re¬
action, and practically free from pus. He had a well-
marked mitral regurgitant murmur, an impulse diffused
and feeble, and a pulse of low tension. Bronchial
rSles could be heard over both lungs. Under these
circumstances we considered that general anaesthesia
should be avoided, and determined to operate under
spinal analgesia.

The day preceding the operation we ordered 4 minims
of liquor strychninae to be injected hypodermically
every six hours.

Operation .—On October nth, 1906, the patient was
anaesthetised as follows : He was seated on the opera¬
ting table with his body bent forwards, the interval
between the third and fourth lumbar spines defined,
and the puncture point marked with pencil. Ethyl
chloride was then sprayed on the site of puncture, and
the needle of our syringe, which was made for us by
Messrs. Allen and Hanbury, plunged into his spinal
canal. Three cc. of a 5 per cent, isotonic novocain-
suprarenin solution, containing novocain 0.15 g., and
suprarenin borate 0.000325 g., was then injected, and
the patient placed on his back. The bladder was then
well washed out with boric lotion, and 12 oz. of supra¬
renin solution injected into the organ as the distend-

66o The Medical Press

ORIGINAL PAPERS.

Dec. 18, 1907-

ing medium. This solution we have now used in
suprapubic prostatectomy for some years, with the
object of controlling haemorrhage and preventing
shock.

Analgesia being complete over the abdomen, we
made an incision above the pubes, opened the bladder,
removed a calculus the size of a pigeon’s egg, and then
enucleated the prostate. The amount of blood lost
was very small. The bladder having been again washed
out, a drainage tube of 1 in. in diameter was inserted
into the bladder, and gauze, covered with cellulose
wadding, applied to the wound. The patient was then
taken back to bed, and sensibility had returned in
abdomen and legs one hour afterwards. During the
operation a running conversation was kept up with the
patient.

After-Treatment .—His bladder was irrigated twice
daily, both through the wound and urethra; urotro-
pine and acid sodium phosphate were given medi¬
cinally. He had no sickness or headache following
rhe operation, and made an uninterrupted recovery,
leaving the hospital bright and cheerful.

It appears to us that suprapubic prostatectomy per¬
formed under spinal analgesia with novocain opens up
a new field in the surgery of this organ. We were par¬
ticularly struck in this case, the patient being an
extremely nervous subject, suffering from advanced
heart disease, as well as in many other prostatectomies
performed under lumbar puncture, with the absence
of shock which is so commonly met with following this
operation under general anaesthesia: and we would
strongly urge operating surgeons who are in the habit
of performing suprapubic prostatectomy under chloro¬
form or ether to give this method a trial, for we feel
certain that if the after-effects following the operation
are as slight in their cases as they have been in ours,
they will seldom make use of general anassthesia.

Case 2.— Strangulated Femoral Hernia.—Phthisis.

A. J. K., set. 33, was admitted into the Kensington
General Hospital, on April 13th, 1907, suffering from
strangulated femoral hernia. On examination, a swell¬
ing about 3 in. long by 2 in. broad could be felt in
the region of the femoral canal, which was tense,
tender, and without impulse on coughing. Pulse 96,
small and wiry.

Frequent vomiting was present. He was very much
emaciated, and both lungs, were the seat of tuberculous
deposit. He was suffering from shock, and his general
condition most unfavourable for general anaesthesia.

A few hours after admission into hospital his dural
sac was injected with 8 cc. of a 1 per cent, solution
of novocain-suprarenin, 8 cc. of cerebro-spinal fluid
having been first withdrawn. Five minutes afterwards
herniotomy was performed. The intestine which occu¬
pied the sac was slate-coloured.

He stood the operation extremely well, and his
general condition improved immensely, but, unfor¬
tunately, his lung trouble caused his death eleven days
later.

Case 3.— Strangulated Inguinal Hernia.

A. P., set. 45, was admitted into the Kensington
General Hospital in a very collapsed condition, suffer¬
ing from a strangulated inguinal hernia.

His trouble commenced 24 hours before admission
by the expulsion of a large mass through the inguinal
canal into the scrotum. He was vomiting for several
hours before he sought relief at the hospital. On
examination he was found to have a large tense swell¬
ing extending from the lower part of the scrotum into
the inguinal canal, which was very tender and with¬
out impulse on coughing, and could not be reduced
by taxis. Herniotomy was performed an hour after
his admission under spinal analgesia; 10 cc. of a
2 per cent, novocain-suprarenin solution was injected
in the mid-line between the second and third lumbar
vertebrae, 10 cc. of cerebro-spinal fluid having been
first withdrawn and discarded. Ten minutes elapsed
between the injection and the commencement of the
operation, during which time a final washing of the
field of operation was carried out. The sac contained
a small portion of intestine, together with a large bulk
of omentum. The latter was tied off in sections, and
excised. The constricting ring was very small and
and after its division the gut and stump of

omentum were replaced into the abdomen, and the
wound closed in the usual way. The patient’s con¬
dition during the operation was surprising. His col¬
lapsed appearance vanished, and he left the operating-
room in a far better state than when he entered. He
was discharged cured.

We have had similar cases of strangulated inguinal
hernia which have had herniotomy performed under
spinal analgesia, and in each instance there was an
entire absence of shock following the operation.

Case 4.—Carcinoma of Rectum.—Heart Disf.ase.

E. C., aet. 55, an extremely nervous patient, was first
seen at my house on April 4th, 1907, when he stated
that he had to go to stool about twenty times in the
24 hours, passing motions which were small in size,
generally semi-fluid, containing mucus and blood. He
was found to be suffering from advanced arterio¬
sclerosis, with double aortic murmurs, and the apex
beat displaced downwards and outwards. He had
marked throbbing in the femoral and carotid arteries.

When about to make a rectal examination, we were
particularly struck with the small size of his anus,
and directly it was attempted to put the finger into
the canal he could not bear it, although there was no
fissure or other sign of disease at the orifice. It was
only after using a local anaesthetic that we were able
to make a momentary examination of the rectum,
which revealed carcinoma, for, owing to the sensitive
condition of the patient, it was impossible to make the
thorough examination necessary for our guidance as to
the advisability of recommending excision of the
growth. . . . .

Five days later a thorough examination of his
rectum was made under the influence of spinal anal¬
gesia with novocain. It was then found that the
growth was fixed to the surrounding tissues, and the
lumen almost obliterated. Excision was therefore out
of the question, and an inguinal colostomy was ad¬
vised, and subsequently performed six days afterwards.
On this occasion he was also given a spinal injection,
consisting of 10 cc. of a 2 per cent, novocain-supra-
rehin solution. Before the injection 12 cc. of cerebro¬
spinal fluid was withdrawn by syringe suction and
thrown away. Analgesia was perfect in three minutes.
He bore the surgical interference well, and was chat¬
ting to us during the operation.

Within three weeks he returned home, with the arti¬
ficial inguinal opening working satisfactorily.

Six days later profuse haemorrhage from the growth
in the bowel took place, and as the rectum required
plugging, a third injection of novocain into the lumbar
sac was given, and the bleeding arrested.

Finally, two days afterwards, a fourth lumbar
puncture was made, and novocain-suprarenin solution
injected. Analgesia having been produced, the
gauze plugging was removed. The patient was so-
nervous and sensitive that he refused to allow any
interference to be carried out without a spinal in¬
jection.

As this patient was suffering from severe aortic dis¬
ease, and his own medical attendants refused to give-
him a general anaesthetic owing to the risk involved,
one had therefore no hesitation in using spinal injec¬
tions, and on each occasion it worked admirably.

Case 5.—Carcinoma of Rectum.—Excision by the
Sacral Route.

J. M., aet. 57, was admitted into the Kensington
General Hospital on September 20th, 1906, suffering
from carcinoma of the rectum.

For several months prior to admission he had
suffered from a constant desire to gc to stool, and
although he passed fluid motions containing blood
and slime, he still felt a sensation as if there were
something in the bowel to come away. On examina¬
tion per rectum a malignant growth could be readily
detected involving the circumference of the bowel, and
extending beyond the reach of the finger. It was freely
movable on the underlying tissues.

On September 21st the operation of colostomy was
performed, and he was discharged from the hospital
within a month. Before leaving, the question of
excising the growth and its danger were fully discussed
with him, but he could not make up his mind to have
the second operation done.

Google

Dec. 18, 1907.

ORIGINAL PAPERS.

The Medical Press. 661

On November 12th, 1906, he was re-admitted for
excision of the rectum, having determined to undergo
the risk of operation with the prospect of getting rid
of the disease. Preparatory treatment for a few days
having been carried out, on November 15th excision
of the rectum by the sacral route was performed under
the influence of spinal injection with 2 per cent,
novocain-suprarenin solution. The operation involved
the removal of the coccyx as well as the lower end of
the sacrum. About 8 in. of the terminal end of the
gut, including the anus, were excised, which necessi¬
tated freely opening up the peritoneal cavity. From
the beginning to the end of the operation the patient
frequently assured us that he could feel no pain, and
throughout its performance no paleness or other change
could be detected in his facial aspect. His pulse was
84 at the commencement of the operation, and 86 at
its termination.

When the operation was completed and he was taken
back to bed, his bright appearance and jocular manner
was a complete surprise to those who saw him. He
left the hospital well. We have seen him a few days
ago, and there is no sign of recurrence of the growth,
a period extending over twelve months having elapsed
since the operation.

THE TREATMENT OF SYPHILIS IN
THE LIGHT OF THE RESULTS OF
RECENT INVESTIGATIONS, (a)

By E. LESSER, M.D.,

Professor of Dermatology, Berlin.

[Specially Reported for this Journal.]
Gentlemen, —Recent times have procured for us
two great steps in advance as regards syphilis—the
communicability of the disease to animals, and the
discovery of the excitors of it by Schaudin, and the
further labours of Hoffmann. By these the subject of
syphilis has been placed upon quite a different basis
as regards diagnosis and treatment, as these now have
a basis of certainty as regards origin and animal ex¬
periment. The question, therefore, has now to be dis¬
cussed : What influences have these advances had
upon our views? I shall only touch upon the chief
points, and shall discuss them chronologically.

First comes the much-discussed question of the
excision of the primary sore. By excision are we in
a position to remove all the virus, and thereby protect
the system against general infection? Undoubtedly
the chances are greater the earlier the excision is
carried out. But, great as the chance was, the uncer¬
tainty of diagnosis was up to now greater still—so
much so that we could not decide as to whether
excision had prevented the general infection, or
whether this would not have come on without it. Now,
by proof of the spirochetae, we are in a position to
make the diagnosis early, and so form a groundwork
for answering the question of the efficacy of excision.
The histological examinations and animal experiments
are but little encouraging as regards any good prospect
from excision. But as Jadassohn properly remarks,
the conditions in the inoculation of apes are different
from what they are in man, and it is also to be con¬
sidered that after removal of many excitors of the
organism, after the analogy of other infective dis¬
eases, the comparatively few remaining excitors may
suffice for further infection. That is true with one
exception so far, that Finger, after excision in one
case that was diagnosed with certainty, saw no
secondary symptoms during two years.

A second question is: What is to be done after the
excision? Formerly general treatment was not begun
if there was no induration of the cicatrix, and no
appearance of general secondary symptoms was indi¬
cated. Now, however, it is recommended that general
specific treatment shall be begun immediately after
excision if spirachefce are found, as we cannot be
sure that all the virus has been removed by the ex¬
cision. Repeated courses, even, have been carried out.
Thalmann has injected a 1 per cent, solution of sub¬
limate under the primary sore with good effect. Before

this, even, Weisspflug had injected a 1 per cent, solu¬
tion of salicylate of mercury into the glands in 32
cases, and in 28 of them saw no secondaries after the
lapse of some years. Thalmann, however, always
associated his local treatment with general, so that his
cases do not serve for answering the question on this
point, and the large number of injections of Weisspflug
are to be looked on as general treatment.

The third question is : When shall the general treat¬
ment be begun? Formerly, most were of opinion that
it should be begun as soon as secondary symptoms
made their appearance, for the reason that, if begun
earlier, the diagnosis might be masked. We did not
know whether the absence of secondary symptoms was
spontaneous or due to the general treatment; whether

S ecific induration had been present or not. Now by
imonstration of the spirochetae we can diagnose a
primary sore with certainty, and masking need no
longer be feared. Then it was assumed that the result
of the general treatment was better when the first
appearance of the general symptoms was waited for.
Now the question comes up whether with earlier
general treatment the virus may not be destroyed in
its place of first localisation, or whether, if this can¬
not be done, the general symptoms, when they do
appear, are not rendered milder by it. Neisser and
Thalmann advocate early treatment. According to my
view the question cannot be decided yet, as the time
is at present too short. The better effect of general
treatment after the appearance of the general
symptoms has been attributed to the organism being
flooded with the virus, and being thereby more
accessible to attack. This view must, however, be
looked upon as incorrect. From the searching investi¬
gations of Hoffmann, however, it may be taken that
the flooding of the system with the virus precedes the
outbreak of the general symptoms by about three
weeks. According to this, mercurial treatment should
be begun at this period

A fourth question concerns the intermitting general
treatment for protracted periods introduced by
Fournier. Most specialists have adopted this mode of
rocedure. As regards its propriety in the period
efore the discovery of the spirochetae, in the Fest¬
schrift for Senator I attempted to put it on a basis,
after Lang’s method, in the following manner: The
form and kind of fever show that when the infection
is general, the virus is latent for a time, then, after
apparent recovery, it again becomes active, because
only a part of the virus has been destroyed. The latter
circumstance is the cause why, in relapses, the number
of disease centres becomes steadily less. The latter
rule is, however, subject to one exception, that the
germs present everywhere in the body break through
direct into the circulation, and so lead to a sudden
flooding of the system with the virus. It must there¬
fore be the aim of all rational treatment to destroy all
the disease germs.

Does mercury, then, act destructfully on the spiro-
chetae? According to Thalmann, the answer is yes.
In favour of this is the fact that in many cases fever
comes on after even the first application of the drug.
The question can only be decided with certainty by
the direct application to the spirochetas. In some cases
Hoffmann saw rapid disappearance of the spirochetae
after injections of sublimate, in other cases the germs
were found afterwards. That mercury destroys the
spirochetae cannot be doubted, but the destruction is
not al ways complete, even when the treatment has been
protracted, as we sometimes see relapses after it.
Hence the desire to find another more certain remedy.
This has not been obtained yet, however, for even
iodine, good as it is in the treatment of syphilis, is
no substitute for mercury. The desire for a substitute
for the latter is justifiable on account of the injurious
effects associated with it. Here also the discovery of
the excitors of the disease has led us farther on. After
the action of atoxyl on various forms of trypanosoma
had been established, Uhlenhuth tried it for the
destruction of the spirochetas in syphilis. The experi¬
ments first performed on apes were encouraging ; then
it was tried in my own clinic on two patients who
were given a number of injections of atoxyl in 0.2 gm.
doses. The result was negative. Lassar met with the
I same want of success. Later on appeared the com-

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(a) Read before the Verrin fUr Innere Medizio.

662 The Medical Press.

ORIGINAL PAPERS.

Dec. 18, 1907.

ir« unications of Salmon, in which atoxyl in large doses
was said to be followed by brilliant results. Upon this
Uhlenhuth gave doses of 0.5 gm., and satisfied himself
of the good effects. Lassar also recorded recoveries
with the high doses. In my own clinic I treated 28
patients with the drug (22 men and 6 women); 3 were
in the primary stage, 19 had secondary, 5 galloping,
and 1 tertiary syphilis. In every case a 10 per cent,
solution of 0.5 to 0.6 gm. of atoxyl was injected into
the muscles. A total amount of 5 to 6 gm. of atoxyl was
given in each case. The result as regarded the dis¬
appearance of symptoms was good, frequently quite
striking. The primary affections receded rapidly, the
secondary more slowly; an iritis healed after three
injections. The effects were striking in ulcerations in
malignant syphilis, in sclerous glossitis, in syphilitic
angina. A myelitis disappeared very rapidly after 6
injections. No specific local treatment was made use
of in any case; for ulcerations, dressings of solutions
of acetate of alum were applied. Sometimes a solu¬
tion of atoxyl was painted on with good effect. In
three cases the results were unfavourable; in one a
relapse took place after 14 days. Along with these
generally favourable results, however, symptoms of
intoxication by atoxyl could not be overlooked. Con¬
siderable accessory effects were not unfrequently ob¬
served, such as violent colic-like pains, with loss of
appetite and sleeplessness, nausea, vomiting, diarrhoea,
and once nephritis with albumin and cylinders in the
urine. These symptoms disappeared when the medi¬
cine was left off, and in every case returned when it
was begun again. In the case of one woman opium
had no effect on the vomiting and diarrhoea; no effect
was produced until morphia was given with bicar¬
bonate of soda. The observations must be continued.
It was known that when other preparations of arsenic
were given, arsenic was discoverable after some days,
and now in one case arsenic could be found six weeks
after it had been given. Generally considerable in¬
crease in weight took place after the use of atoxyl, but
in three cases a loss of weight was shown, so that as
a rule the effect as to nutrition was not unfavourable.
After all, the verdict must be that atoxyl causes a
rapid disappearance of the symptoms of syphilis, and
that therefore it may be very properly made use of in
cases of individual susceptibility to mercury. A con¬
clusive judgment cannot be pronounced at present,
however; that can only be done after years of trial.
We must ever keep one thing before our eyes—that the
risks of a remedy, however effective, must not be
carried too far.

THE NEW MEDICAL SERVICE FOR
THE TERRITORIAL ARMY, (a)

By SIR ALFRED KEOGH, K.C.B.,

Director-General of the Army Medical Service.

The scheme, Sir Alfred said, is one which has
been really devised by the Volunteer medical officers
themselves. So long ago as 1901 a meeting of
Volunteer medical officers at Edinburgh put forward
practically every one of the proposals embodied in the
official scheme, and more recently, at another meeting
of Volunteer medical men, practically the same sugges¬
tions were then made. When he took up the position
of Director-General of the Army Medical Service, his
attention had been first occupied with the organisation
of the Volunteers, because, as was well known to
every student of military medical organisation, the
existing state of affairs was far from satisfactory.
There was now a declared military policy of a
definitely scientific character, under which there would
be an expeditionary force equipped to take the field
abroad at a moment’s notice; and in the absence of
that expeditionary force the whole responsibility of
home defence would be undertaken by the Citizen or
Territorial Army. The absence of the expeditionary
force implied the removal of the regular medical ser¬
vice of the Army, which was not, as a matter of fact,
sufficiently large for the purposes of completely satis¬
fying the needs of the expeditionary force, but was

' (a) Addras. delivered before a representative gathering of medical
men at the Town Hall, Liverpool, on December 10th, 1907.

large enough to form a sufficiently good nucleus. The
whole responsibility for the medidal arrangements of
the Citizen Array, if there were an invasion during the
absence of the Regular Array, would devolve upon
the medical profession. The leaders of military
thought were thoroughly wide awake to the immense
importance of the relation which the medical service
bore to the Army. There was a time when this was
not so, but military science was now being studied,
and it was now clearly realised that the battles of the
future were not going to be won simply at the point
of the bayonet, but by the different sciences composing
the Army. The duty of the medical service might be
summed up in the phrase—the maintenance of the
fighting strength of the Army. Our Army being com¬
paratively a small one, made the prevention of
wastage of fighting force in the field a factor of
enormous value in the winning of battles. There were
some who would say that there would never be any
invasion, or even any threat of invasion. It was in
the same spirit of unprepared ness that we had entered
into all our previous wars; and, although we had
always been victorious in the long run, we had
invariably muddled them at the beginning. Sir
Alfred proceeded to give, with the assistance
of diagrams, a sketch of the operations of an
Army medical organisation in the field, explaining
briefly the duties of the various departments of the
organisation and the system by which they were linked
up. He laid particular emphasis on the value of what
he described as business aptitude, and said that if the
service were inefficient in this respect the wastage of
the fighting force would become exceedingly rapid.
Military experts calculated that the wastage of
strength in our Army in the first year of a war was
80 per cent, of the total strength. A large part of
this was to be attributed to medical shortcomings—
lack of knowledge as to the origin and spread of
disease in camps and insufficient inspection of the
men in hospital, many of whom were not sent back to
fight when they were fit to take their place in the line.
Large numbers of men were returned home from South
Africa in the late war who ought to have been in the
ranks. They had heard a great deal of Army scandals
in connection with that war, but, in his opinion, there
were no scandals, except possibly that the supervision
was inadequate to prevent a great amount of wastage.
Our system of disease prevention and sanitation was
defective in one respect—that the officers who were
charged with the care of the hospitals were also
charged with the* sanitation of the surrounding area.
That was utterly impossible, and for the correction of
this defect they had the beginnings of a sanitary ser¬
vice, in connection with which there was a sanitary
school at Aldershot, which in course of time would
prove to be a great advantage. Another proposal was
that a sanitary committee of business men should
follow the troops in time of war, and assist the medical
staff on the spot, instead of holding a commission of
inquiry after the battle. That kind of committee
would be welcomed by the medical staff. They did
not do much that was wrong, and, taken all round,
their performances in the South African war were a
credit to the profession. In the existing medical
service of the Volunteers, in many battalions there
were four or five medical officers and no hospitals
whatever. They had trained a number of men to pick
up the wounded and to carry them. What they were
going to do with them after picking them up, and
where they were going to carry them, nobody could
say. Civil hospitals would not do for the accommoda¬
tion of the Citizen Army. If a small army of 70,000
men were sent to Liverpool, and had to be kept under
canvas, it would only be a matter of a few days before
there were 2,000 or 3,000 on the sick list. That con¬
dition would grow in intensity until—quite apart from
epidemics—there would be 10 per cent, of the men in
hospital. Obviously the civil hospitals could not
accommodate them, especially as during a time of
invasion there would be great depression and distress,
and the hospitals would hardly have room for them.

There was no sanitary service whatever connected
with the Volunteer Forces, and the conditions of the

OPERATING THEATRES.

The Medical Press. 663

Dec. 18, 1907.

Volunteer Army had been admirably adapted to the
-exclusion of a large number of the leaders of the pro¬
fession in medicine, surgery, and sanitation. Every¬
body who attached himself to the Volunteers was
required to go into camp to make himself efficient—
as if a leading physician would make himself more
efficient as a physician by going into camp. It was a
silly system, which was to be held responsible fcr
many of the shortcomings of the Volunteer medical
service. .

Proceeding to the explanation of the medical
staff scheme connected with the Territorial Army,
Sir Alfred said there were to be eleven specific
areas recognised under the scheme, and every
division would have a medical officer on the staff
of the general, from whom he would receive his orders
and convey them to the staff in his area—thus securing
co-ordination in the medical and military movements.
With a chief medical officer of each division there
should be a sanitary officer. With each battalion
there should be a sanitary organisation. He proposed
that every sanitary officer in the country should be
asked to join that force. Without an efficient sanitary
service it would not require foreigners to bowl our
Territorial Army over, for when they were mobilised—
coming as they did from all quarters and from all
conditions of life—disease would break out much more
rapidly than in an encampment of Regulars, who
would come straight from the barracks, where their
health was under constant supervision. He proposed
also that there should be twenty-three general hospitals
at the great educational centres, so that the aid of the
most eminent experts in the profession could be
obtained ; three field ambulances, consisting of nine
medical officers and a quartermaster and 230 non¬
commissioned officers and men, would also be required
in each division. The organisation of the field
ambulance would imply work in time of peace, but
Liverpool had great facilities in connection with its
special schools, hospitals, and educational institutions.
The conditions of service would be exceedingly simple.
Those who could not go into camp would be asked to
do eight days’ training of some kind. The days would
not necessarily be consecutive, and three hours would
-compose each day. A consolidated corps to embrace
all this was proposed for the purpose of carrying out
the duties which would devolve on the medical pro¬
fession in time of invasion.

CLINICAL RECORDS.

BELFAST HOSPITAL FOR CHILDREN.

-CASES SHOWN AT THE LAST MEETING OF
THE ULSTER MEDICAL SOCIETY, DECEM¬
BER 12TH

By John McCaw, M.D.Dub., F.R.C.S.,
Physician to the Belfast Children's Hospital.

Evelyn M., ast. 10 years. Admitted to Children’s
Hospital on November 22nd, 1907. Child began to
complain of headache and some cough 14 days ago.
On admission nothing amiss could bo found but a
small patch of dulness on the right side behind on a
level with middle of right scapula. Temperature has
been sub-febrile since admission, ne\er rising higher
than ioo° F. She was submitted to Calmette’s
ophthalmo-reaction, and responded markedly. This is
likely tubercular enlargement of a tracheo-bronchial
gland. Under treatment she has improved in general
condition.

Violet W., ®t. 2 years and 2 months, was admitted
to hospital on November 6th last with well-marked
symptoms of tetanus. The jaws are strongly set, tem¬
perature 103 0 . pulse 156, risus sardonicus very well
marked. Antitetanic serum, obtained from the Lister
Institute, London, was injected into the left abdominal
wall, the dose given being 5 c.c. This was repeated on
November 8th, nth, and 16th. A notable feature was
the high rate of pulse, which ranged from 180 to 160
till after the third injection of serum. On the night
of the 7th, restlessness became extreme ; chloral hydrate

was given up to 8 grs., without effect; chloroform was
then administered with good results, and she slept after
it till next morning. The restlessness returned next
night; chloroform was again given in small quantity,
and with the same beneficial effect. The following day
the spasm of the jaws was much relaxed, and she was
able to swallow from a spoon, and tube feeding was
omitted. After this the symptoms gradually subsided,
and she made a perfect recovery. 'Hiere was no wound
on the body, and the only septic focus was a spot or
two like impetigo on the right thigh.

Robert N., ret. 8* years. Has complained of pain
in the forehead for the last year at intervals. Latterly
this pain has become much more obtrusive, and is
now accompanied with well-marked cerebral vomiting.
He has not had any convulsive seizures at any time ;
no optic neuritis. Tested with Calmette’s ophthalmo¬
reaction, he reacted. Much improvement has followed
the exhibition of pot. iodide gr. 5, with liq. hydrarg.
perchlor. £ drachm ter in die. This may be a caseous
tuberculous tumour in the cerebellum. Still under
treatment in hospital. , 4

Tames T., set. 9 years, was admitted to Lhiiaren s
Hospital 6 days ago with well-maTked local asphyxia
in the hands and feet, some small blisters on the feet
and marks of many others that have healed. He has
improved very much under 10 gr. doses of chloride 01
calcium.

OPERATING THEATRES.

VICTORIA HOSPITAL FOR CHILDREN.

Widespread Peritonitis from Sloughing of
Appendix.—Mr. J. Cunning operated on a boy, ®t.
9, who had been admitted for pain in the abdomen
and fecal vomiting. The illness began five days
before with sudden abdominal pain accompanied by
vomiting. His mother called in a doctor next day,
who gave him castor oil. He passed a motion after
the castor oil, but the vomiting and pain continued,
and the vomit became feculent in smell. On the fifth
day he was admitted to the hospital. He looked very
ill with a pain-pinched face and sunken eyes; his
pulse was 140, his temperature lor. The abdomen
was not distended, but was board-like in rigidity all
over. No lump could be detected on account of the
rigidity and extreme tenderness on pressure. There
had not been passage of either blood or mucus. Mr.
Cunning remarked that he had to deal with a case of
widespread peritonitis; the persistent vomiting and its
feculent character indicated that there was intestinal
obstruction; intestinal obstruction is either inflam¬
matory or mechanical, and the extreme rigidity and
tenderness was a clear indication that this was inflam¬
matory. The absence of distension at this stage was
unusual; it put out of account any question of the
obstruction being mechanical. The absence of blood
and mucus being passed from the rectum also put out
of account intussusception as the lesion. The
diagnosis of appendicitis was, therefore, the most
likely one. At the operation the theatre was heated
to a temperature of 80, and the patient was laid on a
table heated by hot water cans, with as little exposure
as possible. The abdomen was opened by an oblique
incision midway between the umbilicus and the
anterior superior spine on the right side. Foul
smelling thin pus was evacuated. On passing a finger
into the abdominal cavity, the appendix was found in
Douglas’s pouch ; it was pulled up into the wound, and
it was discovered that the terminal inch was black
and gangrenous, and just proximal to the gangrenous
portion was a fecal concretion. The appendix and
its mesentery were ligatured and removed. There were
some indications of limitation by adhesions towards
the mid l«ne both in Douglas’s pouch and in the
main part of the abdominal cavity, but the pus was
found to extend upwards in the renal pouch towards

e

664 The Medical Press. TRANSACTIONS OF SOCIETIES.

Dec. 18, 1907.

the liver. A second incision was made in the loin,
and tubes were passed in one towards the liver and
one into Douglas’s pouch. As it was not known
whether the other side of the abdominal cavity was
affected, the right side was covered with dressings and
clean gloves were donned. An incision was then made
on the left iliac fossa, where pus was again found,
both in the pelvis and up towards the spleen. A
second tube was passed down into Douglas’s pouch,
and another was passed in through the left loin towards
the spleen. Dressings were then applied, and the
patient sent back to the ward, where continuous rectal
saline was administered. The whole operation lasted
fifteen minutes. Mr. Cuming said that this was a case
in which suppuration had extended from the appendix
into the pelvis, and then the pus had followed the
usual definite tracks, that is, it had overflowed into
either the renal pouch upwards towards the liver and the
spleen leaving the main central portion of the
abdominal cavity unaffected. These were the cases
which were usually spoken of as general peritonitis
when they recovered, but, of course, they were not
general but only widespread. As soon as the patient
recovered from the anaesthetic he would be propped
up in the sitting position, so that the pus might drain
from the more susceptible upper areas to the less
susceptible pelvic area. The administration of saline
solution by the continuous rectal method was a great
help in the saving of these cases: the larger the
amount of fluid absorbed the more chance there was
of eliminating the toxins, and eight or nine pints in
the twenty-four hours could be easily taken up by
this method. With regard to the gangrene of the
appendix he thought the concretion had produced
either an abrasion or an actual ulcer: this formed a
focus of entry of a virulent brand of either bacillus
coli or streptococci which had caused so much
inflammation and exudation that the circulation of the
terminal inch of the appendix had been cut off. It
should be remembered that the terminal third of the
appendix had no mesentery, and that its circulation
had to be carried on by vessels running along its wall,
so that any violent inflammation at or about the
termination of the mesentery, if it produced much
swelling, would cut off the circulation beyond that
area.

TRANSACTIONS OP SOCIETIES.

ROYAL SOCIETY OF MEDICINE.

Clinical Section.

Meeting held December 13TH, 1907.

The President, Sir Thomas Barlow, in the Chair.

Dr. Edgar Reid (introduced by Prof W. Osier)
showed a case of

OCHRONOSIS.

F., set. 68. A large ulcer on each leg had been
dressed twice daily with carbolic oil, 1 in 20, during
a period of 30 years. Six years ago the ears and
whites of the eyes began to turn black, and two years
ago the urine was first noticed to be dark. In June,
1907, the concavity of each ear was stained a deep
blue-black, and the sclerotics were stained black in
their exposed portions. The extensor tendons of the
fingers were bluish-black in colour over the knuckles,
and the latter showed a slight blue staining. The
skin of the face and exposed parts was of a dusky
hue as compared with the covered parts.

Prof. Osler discussed the case, and pointed out
that carbolic acid poisoning had been noted in the four
last recorded.

Dr. A. E. Garrod had examined the urine, and,

from the observation that 85 per cent, of the sulphates
were in the aromatic form, had concluded that the
patient was a potential carboluric, although no carbo-
luria was actually present. He remarked that all the
previous cases had had either carboluria or alkap-
tanuria— i.e., one or other hydrokinone derivative, and
this pointed to a common origin for all the cases.

Dr. Parkes Weber discussed the early diagnosis of
such cases, and pointed out the confusion that might
arise between cyanosis and haematochronosis.

Prof. William Osler showed a case of

SPLENIC POLYCYTHEMIA WITH CYANOSIS.

Patient was a hard-working woman, in whom, within
the past two or three years, there has been slight
failure of health and strength. She was permanently
cyanosed. She presented in an unusual degree the
three characteristic features of the disease: a per¬
manent cyanosis, a greatly enlarged spleen, and a
polycythemia of 10,000,000 red blood corpuscles.
There was no increase in the leukocytes, and no
marked variation in the size of the red blood corpuscles.
There were nucleated red cells in moderate numbers,
chiefly normoblasts.

The first case of this kind had been published by
Vacquez. Since Prof. Osier’s paper in 1903, some 40
or 50 had been recorded.

Dr. R. G. Hann referred to a case characterised by
great splenic enlargement, polycythaemia, recurrent
attacks of diffuse abdominal pain, but with no
cyanosis.

The President considered that the absence of
cyanosis in Dr. Hann’s case excluded it from the pre¬
sent group. He referred to a case he had recently seen
in which the vasomotor changes were very marked.

Dr. Parkes Weber mentioned that in one of his
cases there had been a great number of normoblasts.
In all the autopsies so far there had been found in¬
farctions with perisplenitis, which might account for
the occurrence of abdominal pain.

Dr. William Pasteur had had a case recently of
splenic enlargement accompanied by periodic ab¬
dominal pain. Post-mortem there was neither infarction
nor perisplenitis.

Mr. T. H. Openshaw showed a case of

TRAUMATIC DISLOCATION OF HIP, IN A BOY OF 1 5 ,
REDUCED BY MANIPULATION AFTER THIRTEEN MONTHS.

Dr. F. Parkes Weber showed a case of
arteritis obliterans of the lower extremity,

WITH INTERMITTENT CLAUDICATION.

M., aet. 32. Complained of cramp-like pains in the
sole of the left foot and calf of left leg, occurring
after walking for a few minutes and obliging him to
rest. When the legs were allowed to hang over the
side of the bed the distal portion of the left foot
became red and congested-looking. No pulsation
could be felt in the dorsal artery of the left foot or in
the posterior tibial. The disease had lasted about
five years, without real gangrene supervening.

Dr. W. F.ssex Wynter showed a case of
METHEMOGLOBINEMIA OF TWELVE YEARS’ STANDING.

F., set. 45. (Under observation since March, 1902.)
Had been in the same state of cyanotic anaemia for
twelve years. There was a general yellowish pallor,
with lilac-coloured mucous membranes, associated with
feebleness, constipation, anorexia, and occasional
vomiting. A pulmonary systolic bruit existed while
the patient was in hospital. Urine normal. Blood
chocolate-coloured, making comparison difficult in the
haemoglobinometer; the colour was not altered by
exposure to CO; red cells, 3,010,000; white cells,
7,000; haemoglobin, 50 per cent. ; index, .74; white
corpuscles normal; bacillus coli not found in blood.

Dr. Poynton had seen this case at St. Mary's Hos¬
pital twelve years ago, and the condition was then, if
anything, worse than to-day.

Dr. C. R. Drysdale asked whether there was evi¬
dence of blood destruction in this case, as sometimes
occurred.

At the President’s suggestion, a committee consisting
of Dr. Drysdale, Dr. Garrod, Dr. Poynton, and Dr.
Wvnter was appointed to investigate the case further.

Dr. W. Essex Wynter showed a case of
amyotonia congenita.

F., aet. 15 months. Admitted to Middlesex Hospital,

Digitized by LaOOQle

Dec. iS, 1907.

TRANSACTIONS OF SOCIETIES.

665

September 21st, 1907, on account of general weakness
and backwardness. The striking feature in the condi¬
tion was the flabbiness of muscles and freedom of
movement in articulations, allowing of flexion and
extension beyond normal limits, so that the toes could
be made to touch the front of the leg and the fingers
the back of the forearm, while the legs could be flexed
up to the chin. The child could sit up and walk, and
was cheerful and intelligent. The muscles did not
contract to strong faradism, and moderate currents
induced no pain.

Dr. Morley Fletcher raised the doubt that the case
might be one of severe rickets affecting chiefly the
muscles.

Dr. Ernest Jones remarked on the deviation from
the title of myotonia, originally given by Oppenheim,
to the condition.

Dr. W. Essex Wynter showed a case illustrating
CCRE OF ASCITES BY PERMANENT DRAINAGE THROUGH
THE FEMORAL RING.

M., aet. 50. Admitted to Middlesex Hospital, July
nth, 1907. For a week there had been swelling of
abdomen and legs, with slight jaundice. The diagnosis
was hepatic cirrhosis. The ascites increased, and on
August 26th tension was relieved by removing 300 02s.
of fluid. This was only of temporary benefit, and on
September 23rd Mr. Sampson Handley made a small
incision below the umbilicus and several pints of fluid
escaped. An incision as for femoral hernia was then
made, and with the aid of one finger in the abdominal
cavity the process of peritoneum was drawn down,
split, and the edges stitched right and left to maintain
the opening. The wounds were then closed. The
ascites did not recur, and by November 20th there was
no perceptible fluid in the abdominal cavity. The
patient had been walking about the ward for a fort¬
night, and neither femoral hernia nor oedema of the
leg had developed.

Mr. Sampson Handley described the operation. He
had had to open the abdomen so as to reach the
femoral ring.

Dr. W. Pasteur showed a case of

ANTERIOR POLIOMYELITIS, WITH PERMANENT PARALYSIS
OF THE DIAPHRAGM AND ABDOMINAL MUSCLES.

M., set. 13J. Illness began in November, 1906, fever
and delirium. Two days later there was loss of
power in lower limbs ; paralysis spread, and mother
noticed that boy could not cough; arms not completely
paralysed. On admission on eightn day, Novem¬
ber 19th, there was flaccid paralysis of the lower
limbs; the diaphragm was paralysed; respiration en¬
tirely thoracic; abdominal muscles paralysed ; ab¬
dominal and epigastric reflexes absent; paresis of all
muscles of upper limbs. Fot ten days the condition
was critical; artificial respiration performed every two
or three hours ; inhalations of oxygen and hypodermic
injections of strychnine given frequently. From March
until the present time the condition had remained as
follows: complete recovery of power in upper limbs ;
considerable recovery of thoracic muscles ; persistent
paralysis of diaphragm, abdominal muscles, and
muscles of lower limbs.

Dr. F. J. Poynton showed

TWO CASES OF THYROID SWELLING IN YOUNG GIRLS.

The first was a typical case of Graves’s disease in a
girl aet. 15. The second case was that of a girl aet. 14
who had been treated for cretinism as an infant.
Whenever thyroid treatment was omitted within six
weeks, the following symptoms appeared : (1) a swell¬
ing in the neck, obviously the thyroid; (2) mental
dulness; (3) slowness of speech ; (4) enlargement of
the tongue. Resumption of the thyroid caused the dis¬
appearance of all these symptoms.

Four weeks ago the patient, who has been steadily
treated ever since these attempts, showed a definite
thyroid swelling. There were no symptoms of Graves’s
disease. At present no increase had been made in the
amount of thyroid given, and the neck still showed the
swelling.

The diagnosis inclined to is partial cretinism, with
compensatory enlargement of an inefficient thyroid to
supply the lack of secretion when the outside supply is
slowly cut off.

Dr. J. Graham Forbes showed a case illustrating

an unusual form of gouty deposit in the left olecranon
bursa in a man set. 34. No evidence of gouty deposit
about great toe joints.

Prof. Osler remarked that such deposits might be
the only sign of gout apart from even the usual tophi.

Dr. Poynton said that microscopically it was clear
that the primary change in these cases was a necrotic
one, and that the deposit was secondary.

Dr. Parkes Weber contrasted the cases in which
the reaction to irritation was mainly a fibrous one with
these in which marked tophaceous deposit occurred.

Dr. Garrod thought that surgical measures in such
cases were valuable provided the joints were not
involved. The olecranon bursa was a favourite site
for tophaceous deposit.

Dr. H. Batty Shaw showed a case of
bulbar paralysis.

F., mt. 47. For twenty years had had a large
bronchocele and slight attacks of periodic huskiness of
the voice. In June, 1907, half the bronchocele was
removed, as the pressure on the trachea was increasing ;
it presented the microscopic structure of carcinoma.

July 8th, voice almost completely lost; stridor;
weakness of left lower facial muscles. July 15th, pain
and stiffness of back of neck. August 21st, atrophy
of right half of tongue noted. August 28th, diplopia.
November 5th, paresis of sixth nerve on right side,
paresis of right half of palate, paresis and atrophy of
the right sterno-mastoid and trapezius ; aphonia ; could
swallow solids with difficulty; paresis of left lower
facial muscles and complete paralysis of left vocal
cord ; vomiting had recently occurred. The diagnosis
lay between primary degeneration of the centres of the
various nerves involved, possibly due to thrombosis,
and a secondary deposit in and about the medulla.
The latter view was supported by the presence of severe
pain and stiffness of the muscles of the back of the
neck.

Dr. H. Batty Shaw also showed a case of
HEPATO-SPLENOMEGALY WITH ASCITES.

F., aet. 3J, was noticed to be short of breath in June
of this year. She was now easily tired and unable to
walk far owing to shortness of breath. The abdomen
was observed to be swollen on November 22nd of this
year, and this has increased steadily.

There were no signs of tuberculosis or of syphilis.
The liver was enlarged and the spleen was felt easily.
Jaundice had not been observed.

ROYAL ACADEMY OF MEDICINE IN IRELAND.

Section of Surgery.

Meeting held Friday, November 29TH, 1907.

Mr. F.. H. Tayi or in the Chair.

Intrameningeal Hemorrhage.

Mr. R. Atkinson Stoney presented a patient whom
he had trephined for intrameningeal haemorrhage. The
following were the notes of the case:—Patient, L. M.,
aet. 44, admitted to Royal City of Dublin Hospital on
Tuesday, September 3rd, 1907. History of failing on
back of head in street while drunk the previous Satur¬
day ; he seemed none the worse at the time. On
Sunday evening began to get drowsy and stupid ; this
condition was increased on Monday. On admission
he was dazed and stupid ; he could not speak pro¬
perly ; started to answeT a question, and then began
to talk nonsense; pupils were equal, contracting to
light; pulse, 65-70 ; temperature, 99 0 ; very restless ;
no mark of injury; complained of pain in right occi¬
pital region ; reflexes normal. On Thursday patient
seemed better; speaking more distinctly; still very
restless. Continued to improve till Tuesday, 10th,
when he began to get drowsy and stupid again. He
was worse on Wednesday. On Thursday morning quite
unconscious ; pulse over too ; colour somewhat blue ;
pupils equal ; very sluggish. In the middle of day
pupils very small, equal, not reacting; pulse over 120
and very weak; moving all his limbs; knee-jerks
absent; Babinski’s sign present on both sides; saw
patient twitch right arm once; did a lumbar puncture,

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666 The Medical Press. TRANSACTIONS OF SOCIETIES.

Dec. 18, 1907.

and drew off a test tube full of clear fluid; slightly
relieved by this for about half an hour, then got worse
again. Trephined over left parietal eminence; dura
mater bulging, dark blue, and not pulsating ; on open¬
ing it found a thin layer of clot and dark fluid blood ;
could not feel any laceration or fracture, thoagh felt
both petrous portion of temporal bone and orbital
plate of frontal. At end of operation pupils were
larger, reacting to light, and brain pulsating ; pulse,
however, was bad, but improved after infusion of
three and a half pints of saline solution ; patient was
better in the evening; swallowed a few mouthfuls of
milk with difficulty. On the next day (Friday) pupils
were reacting; complete paralysis of right arm was
found ; knee-jerks absent; plantar reflexes normal;
pulse varying from 100 to 120. On Saturday, very bad
in early morning; at 1.30 pulse was 140 and very
weak; bad colour, and respirations bad ; dressed the
case; flap was very prominent, not pulsating; on
taking down the flap, found no clot, but brain was
prominent and not pulsating; vessels were congested ;
put a needle about two inches into brain and drew off
test-tube full of clear fluid under considerable tension ;
brain receded somewhat and pulsated feebly; eyes
reacted better; pulse and colour were better. When
dressed next day, flap not so prominent; appeared
slightly conscious; recognised wife and brother.
Gradually improved, and began to use right hand on
Tuesday. On following Sunday a note to say can use
right arm well. At present patient appears in perfect
health ; normal movement of arm ; but some difficulty
in pronouncing some words and complete inability to
read, though able to write and recognise all objects.

The Chairman asked if there was any haemorrhage
going on during the operation, and whether it was on
account of the oozing of blood that the drainage tube
was introduced. He was also anxious to know if
Mr. Stoney’s view of the bulging of the brain after¬
wards was that it was due to distension of the lateral
ventricle, or whether he considered '.here was any
oedematous condition cf the brain tissue itself. Mr.
Stoney had not stated the cause of the marked depres¬
sion of the scalp over the area corresponding to the
part that had been removed.

Mu". Blayney said the case was a puzzling one, in
view of the history that had been given. The typical
history of intrameningeal haemorrhage was that the
patient became unconscious, and did not become con¬
scious again ; but in the case before them the patient
did not lose consciousness when he met with the fall.
One would imagine that violence sufficient to produce
haemorrhage inside the skull would have caused uncon¬
sciousness. Then there was a prolonged period in
which there were no signs of increased intracranial
tension. He thought the bulging of the brain after
the operation was due to some inflammatory
phenomenon.

Mr. Stoney, in reply, said he had brought the case
forward in the hope of eliciting some explanation of
the sequence of events, as he had to confess he found
it difficult to do so himself. The history had been
difficult to obtain, as the man was drunk at the time
of the accident, as well as everyone who was with him.
So far, however, as he could make out, there was no
loss of consciousness at the time of injury. When the
signs of increased pressure began to appear, he thought
it was the commencement of (Edema of the brain, and
he was under the impression that operation offered
little hope of improvement, but he felt that the
localising signs justified an attempt to find out their
cause. On opening the dura mater there appeared to
be no fresh haemorrhage, and on exploration he could
find no laceration and no fracture. He was doubtful
as to whether the haemorrhage occurred at the time of
the injury, the symptoms of increasing compression
being due to oedema of the brain, or that the haemor¬
rhage had occurred later on and was producing the
symptoms of pressure by itself. He thought the pro¬
trusion of the brain was mainly due to the collection of
fluid in the lateral ventricle. A useful point in the case
was the fact that it showed that the descriptions in
the books of typical cases of intrameningeal haemor¬
rhages could not be entirely relied upon. It showed
also that cases of head injury should nev’r be looked
upon as hopeless.

Mr. W. I. de C. Wheeler exhibited a case of ascites
from hepatic cirrhosis cured by the Talma-Morisoa
operation performed three years ago. The patient haul
been frequently tapped before the operation, and
drained through an exploratory laparotomy wound,
but without any beneficial result. For about three
weeks after the epiplopexy fluid collected, and a small
amount has persisted, neither getting more nor less for
the past three years. The patient, who weighed about
7i stones before operation, now averaged 11 stones.
The amount of fluid withdrawn by paracentesis before
the radical operation was performed approximated two
gallons per fortnight for three months. Mr. Wheeler
considered this case an ideal one for operation for the
following reasons:—(i) Previous tappings and laparo¬
tomy failed to give relief; (2) progressive emaciation
and the appearance of slight jaundice was a warning
against further delay; (3) the exploratory laparotomy
revealed an attempt by Nature to anticipate the opera¬
tion by the formation of adhesions; (4) the liver was
enlarged, not atrophied, and therefore sufficient liver
cells remained to carry on life; (5) there was an
absence of an cardiac or renal complication. The great
number of successful cases recently published were
referred to, and the absence of the true “ hob-nailed ”
liver and of an alcoholic history in so many cases com¬
mented upon. Mr. Wheeler considered that the efficacy
of the operation was no longer in doubt.

Mr. Haughton said his experience of the operation
was limited to two cases, which he described.

Mr. R. C. B. Maunsell quoted a case in which the
operation had proved unsuccessful, in which a
markedly cirrhotic kidney was found at the post¬
mortem.

Mr. Benson asked if there was any cirrhotic con¬
dition in any other part of the patient’s body, as he
had seen a case of a lady who had cirrhosis of the lung
eight or ten years previous to the condition of the liver
coming on. He thought it might add to the patient's
comfort if he were tapped to get rid of the fluid that
still remained.

Mr. Stoney and the Chairman also recalled cases of
the operation.

Mr. Wheeler, in reply, said the patient had nothing
in the way of cirrhosis in any other organs, but the
last time his urine was examined it showed signs as if
he was getting cirrhosis of the kidneys. He was not
inclined to do anything more in the case as long as the
man remained in his present condition. The fluid still
remaining was the same in amount as it was at the
time of tne operation.

Mr. Seton Pringle exhibited a case of mucous
colitis in which he had performed appendicostomy
some months ago. The patient, a strong labouring
man, with no sign of neurosis about him, sought treat¬
ment some two years ago for an uneasy burning sen¬
sation in the lower bowel and rectum, some pruritus
ani, and the passage of a quantity of mucus in the
stools. He was found to have haemorrhoids, and these
were removed by operation, but he returned some two
months later worse than ever, and now the whole
motion was often composed of cylinders of mucus.
A course of treatment, consisting in daily irrigation of
the large bowel with astringents and antiseptics, was
then commenced, and persisted in for months, the
patient at the same time being dieted and stomach
sedatives, etc., given by mouth. As the treatment
resulted in no improvement, Mr. Pringle performed
appendicostomy last June in order to enable the whole
large intestine to be systematically washed out. After
giving a short history of this operation and describing
its performance, Mr. Pringle pointed out that many
cases of cure of mucous colitis by its aid had been
reported, and so far no failures. Since last June the
patient has washed out his own colon daily with
various antiseptics, and latterly has been using argyrol
1 in 1,000 in the morning and normal saline solution
at night, but Mr. Pringle regretted to have to report
that the condition was in no way ameliorated, and be
regards the treatment in this case as a complete failure.
In conclusion, he called attention to the fact that the
bowel had been examined carefully with the electric
sigmoidoscope, and no gross lesion found, so that this
is apparently a true case of mucous colitis, and not

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Dec. 18, 1907.

CORRESPONDENCE.

The Medical Press. 667

one of those cases of ulceration, kinking or growth
■which often so closely simulates this disease.

Mr. Maunsell said he considered the operation a
most useful one. He suggested that if the medical
treatment did not cure the patient, an ileo-sigmoid-
ostomy might be successful, in which case the excluded
piece of gut could be resected subsequently.

Mr. Benson thought ipecacuanha might be tried.

The Secretary thought that, notwithstanding
recorded cases, the operation was not a very successful
one in cases of mucous colitis.

Dr. Stevenson asked if any difficulty was experi¬
enced in keeping the aperture from closing, and
whether the catheter was kept in the whole time.

Dr. Pugin Meldon said that a weak solution of
peroxide of hydrogen would clear away any foreign
matter in the intestines; mixed with borax and bicar¬
bonate of soda it might do some good.

Mr. Haughton instanced a case of operation for
ventral hernia which caused the disappearance of
colitis that had been treated for a long time medically
without success, and he raised the question as to
whether Mr. Pringle had satisfied himself that there
was no reflex cause for the disease in this case.

Mr. Pringle, in reply, said he would seriously con¬
sider the question of further operation if the suggested
medical treatment proved of no avail.

Mr. Maunsell presented the case of an elderly man
on whom he had operated for a carcinoma of the floor
of the mouth. By the time the patient presented him¬
self for treatment the growth had involved the tongue,
and was extensively adherent to the jaw. The opera¬
tion consisted of removal of half the tongue and a
portion of the jaw, extending from the neighbourhood
of the middle line to the last molar tooth. At a sub¬
sequent date the lymphatic glands on the same side
of the neck were exposed, from the angle of the jaw
to the clavicle, and removed. At the latter operation
very considerable trouble arose in connection with the
taking of the anaesthetic, probably due to the removal
of the levators of the larynx at tho previous operation.

The Chairman said there was no doubt that the
probability of permanent benefit from operation for
cancer of the tongue was not at all great, particularly
in such a case as that before them. He expected that
Mr. Maunsell’s idea was to make the man’s life more
endurable, supposing that glandular recurrence came
on after the removal of the disease in the mouth. In
operating on parts far back in the mouth he recom¬
mended the performance of a preliminary laryngotomy.'
He thought it enabled them to work easier than where
the patient had to breathe through the mouth. In a
recent case, in which he had performed a preliminary
laryngotomy, he found there was no anxiety about the
haemorrhage. Although Professor Kocher’s recent
method was only a modification of an old method, he
considered it a great advance.

ULSTER MEDICAL SOCIETY.

Clinical Meeting held in the Medical Institute,
Belfast, on Dec. 12TH.

The President, Dr. John McCaw, in the Chair.

Colonel J. R. Dodd, F.R.C.S., and Captain E. P.
Connolly were elected Fellows of the Society, and
Drs. S. R. Hunter, Foster Coates, and R. Jamison
were elected Members.

Dr. Allen showed a case of coloboma of the iris
and choroid.

Mr. Robert Campbell showed a case of malforma¬
tion of one great toe.

Dr. A. B. Mitchell showed a boy of 8 suffering
from an obscure nerve lesion of several months dura¬
tion. There was a most peculiar gait and staggering
movements, but no loss of power. There had been
optic neuritis, and there was now atrophy. On the
whole the general opinion was that the case was one
of cerebellar tumour.

Dr. Cecil Shaw showed a child of 9 suffering from
a peculiar thickening or chemosis of the conjunctiva
in one eye This was situated high up under the
upper lid, and had persisted unchanged for some three
months in spite of various local applications. Dr. |

Cecil Shaw also showed a girl of 15 with extensive-
ulceration and cicatrization of the pharynx and soft
palate of four years’ duration. No history of syphilis
in the family could be found, nor any other signs of
syphilis in the girl.

Dr. McKisack showed a case of exophthalmic
goitre in a young woman. As her symptoms grew
steadily worse during two months of medical treatment
in hospital, surgical interference was decided upon,
and half the gland was removed by Mr. Robert Camp¬
bell, since when there had been a distinct improve¬
ment.

Dr. Rankin showed a series of cases undergoing X-
ray treatment for lupus and epithelioma.

Dr. John McCaw showed 4 cases, which will be
found in another column under heading “Clinical
Records. ”

Dr. Dempsey showed a tumour weighing 27 lbs.,
which he had removed from a woman lately.

Professor Symmers and Dr. A. E. Mitchell
exhibited specimens of primary sarcoma of the
pancreas, and secondary deposits in the left ovary,
liver, and right lung.

Mr. Hanna showed the brain of a child who had
been submitted to a radical mastoid operation, and
afterwards developed purulent cavernous sinus throm¬
bosis. No abscess was found in the brain.

OPHTHALMOLOGICAL SOCIETY OF THE
UNITED KINGDOM.

Meeting held Thursday, Dec. 12TH, 1907.

The President, Mr. R. Marcus Gunn, in the Chair.

The following is an abstract of Mr. Nettleship’s
paper on

SOME CASES POSSIBLY ALLIED TO TAY-SACH’S INFANTILE
RETINITIS.

It was suggested that the amaurotic family idiocy of
Waren Tay and Sachs, although usually fatal in in¬
fancy, and limited to children of pure Jewish origin,
might sometimes be milder, allowing the child to live
several years, or even to grow up, and that many
families of “ Gentiles ” contained more or less Jewish
blood. The author thought that cases such as those
described by Dr F. E. Batten, Mr. Mayou, and others,
in which amblyopia, with slight changes in the
macular region, came on a few years after birth, and
was sometimes associated with progressive cerebral
degeneration, might be mild examples of Tay’s disease.
Also that the same might be tr re of certain cases of
amblyopia counted as congenital, in which there was
central defect in the field, and sometimes nervous or
mental failure, but no tendency to early death. In the
best marked of these cases there was colour-blindness,
often total and complete, and day-blindness, but in
the less severe ones there might be no colour defect
and no dislike of strong light. All these forms of
non-fatal amblyopia were, like Tay’s disease, liable to-
run in families.

CORRESPONDENCE

FROM OUR SPECIAL CORRESPONDENTS
ABROAD.

FRANCE.

Tarls. Dec. i5tb, 19 * 7 .

Uraemia.

The clinical forms of uraemia are very varied and
differ according to individual cases, yet there is a
certain number of symptoms which are common to all
varieties.

The quantity of urine, for instance, is always
diminished at the period of uraemic accidents, but it
varies in degree according to the cause of the uraemia.
In uraemia following acute or subacute nephritis
(parenchymatous nephritis) oliguria is very pronounced
even to anuria. On the other hand where the subject
suffers from interstitial nephritis the quantity of urine
may be almost normal, considering that during the

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by Google

668 The Medical Press.

CORRESPONDENCE.

Dec. 18, 1907.

course of the malady and before uraemic symptoms
had set in, the patient urinated two or three quarts
daily.

Parallel to oliguria, urea diminishes considerably
and frequently albumin increases, but not constantly.

Generally speaking, the temperature falls pro¬
gressively below the normal, especially where the
malady is approaching a fatal termination.

Arterial hypertension accompanies constantly uraemia
and the pulse becomes slower; this bradycardia is
nearly always observed in the chronic forms.

In certain cases the sight is affected with slight
amblyopia or even complete amaurosis. The principal
characters of this last accident lie in the fact that it
is independent of any ocular lesion, appears suddenly
and is always transitory, disappearing after the attach.

Of all the nervous symptoms, headache is the most
important and the most frequent, resembling frequently
migraine. The headaches, says M. Chauffard, are
intense, continual, or intermittent, accompanied by
vertigo and inaptitude for all intellectual work.

Among the cutaneous troubles observed in the course
of uraemia may be mentioned pruritis, eczema,
urticaria, erythema, and in some case a kind of frost
produced by urea covers the skin under the form of
small white crystalline flakes ; it is always a grave sign,
and is observed only in the last stages of uraemia.

The above symptoms are general to all forms of
uraemia, but when the acute symptoms set in they
affect chiefly the nervous system, the respiratory
apparatus, or the digestive tract.

The nervous troubles consist in convulsions,
delirium, and coma, which is the final stage.

Convulsions can complicate all varieties of nephritis,
but they are especially frequent in nephritis follow¬
ing scarlatina, and principally in children and in
parturient women (eclampsia).

Delirium is observed generally, according to
Dieulafoy, in persons predisposed to mental disturb¬
ance, either from alcoholism or from some hereditary
taint.

Coma is the natural termination of all other nervous
forms of uraemia. In some cases it sets in gradually,
preceded for several days with a sensation of heavi¬
ness in the head, the patient becoming apathetic and
somnolent.

In other circumstances it strikes the patient
suddenly; he falls and remains unconscious. This
apoplectic attack has been studied by Raymond; it
generally affects persons of a certain age suffering
from chronic nephritis which had remained latent and
only brought into evidence by the attack. The
patient succumbs almost immediately; it is an im¬
portant cause of sudden death. Brouardel used to say
that sudden deaths from kidney affection were much
more frequent than from any other cause.

The respiratory symptoms of uraemia are dyspnoea
sine materia or that associated with, and more or less
dependent on, bronchitis and pulmonary congestion.

The former may consist in a simple sensation of
oppression, or it may be acute resembling attacks of
asthma when the patient is seized with anguish and
a sensation of impending death. The respiration of
Cheyne-Stokes is observed in the last period of chronic
nephritis, and constitutes a symptom of great gravity.

As a general rule, the existence of uraemia should be
suspected in every patient of over 40 years of age who
suffers from dyspnoea.

Lasbgue describes three types of bronchitis due to
albuminuria.

In the first, the patient complains of intense
dyspnoea, coming on in paroxysms, and especially at
night; it is due to an attack of pulmonary oedema.

The second type is characterised by dyspnoea, coming
on suddenly; cough is frequent, and expectoration is
mucou9; crepitating r&les are perceived by ausculta¬
tion.

In the third form bronchitis is general, cough fre¬
quent, and expectoration abundant

Besides these forms there remains acute oedema of
the lungs. Suddenly, and generally at night, the
patient is seized with acute dyspnoea, the face is
cyanosed, cold sweats cover the body, and expectora¬

tion, spumous and sanguinolent, is exceedingly abun¬
dant. Fine r&les, which invade rapidly all the chest,
like the incoming tide, according to the expression of
Renaut, are heard by auscultation. The pulse becomes
thready, the heart becomes weakened, and the patient
succumbs rapidly unless he is bled promptly.

The digestive symptoms of urasmia consist of furred
tongue, vomiting, and sometimes diarrhoea. Vomiting
is one of the most constant signs ; the patient rejects
at first food, and afterwards has bile and mucus. The
amount of liquid rejected in the 24 hours is sometimes
very considerable. Chronic uremia is observed chiefly
in persons oyer 50 years of age, already suffering from
chronic or instertitial nephritis. The premonitory
symptoms are those already mentioned—headache, in¬
tellectual apathy, insomnia, troubles in the respiraton
rhythm, attacks of nocturnal dyspnoea. According to
Fournier, inappetence, vomiting, diarrhoea, succeeding
to a prolonged period of constipation, are the constant
symptoms of chronic uraemia.

Acute uraemia is met with chiefly in the course of
acute nephritis, and particularly in children. It is also
observed in individuals who have suffered from latent
chronic nephritis, which was suddenly manifested by
uraemic accidents.

Acute uraemia frequently has for its only symptom
sudden coma (apoplexy). Individuals, says M. Cas-
•taigne, who in the midst of their occupations—fre¬
quently even while at table or immediately after—fill
suddenly and die in a few minutes. Such cases are
frequently observed in asylums for the aged.

The treatment general to all forms of uraemia is that
of nephritis. The patient, who should be recommended
to avoid all cold or brusque changes in tempera¬
ture, is put on milk, given drastic purgatives, diuretics,
intestinal antiseptics (benzo-naphtol), and enemas of
cold water. Such is the treatment of the attenuated
form of uraemia.

In the graver and complicated forms the treatment
should be more energetic. Blood-letting for coma,
eclampsia, and acute oedema of the lungs, inhalations
? f oxygen gas, small doses of morphia, subcutaneously
if the dynspncea is not relieved, or inhalations of
nitrite of amyl. Pills of ipecacuanha (1 grain), and
°P 2 JJ m (i-toth grain) may be given until nausea sets in.

The vomiting and diarrhoea of uraemic persons
should, in general, be respected, as they remove the
toxines which the kidney cannot eliminate. Where it
is judged necessary to arrest one and the other, it is
generally sufficient to place the patient on the hydric
diet (a quart and a half of boiled water daily) for two
or three days.

GERMANY.

Berlin. Dec ijth 1907.

The Prussian Minister for Medical Affairs has
recently issued an ordinance directing midwives to use
creosol soap as a disinfectant in place of lysol, the
one in use before this.

The creosol soap is directed to be made in the fol¬
lowing manner: 60 parts of linseed oil are to be heated
in a water bath in a roomy, loosely closed vessel; then
is to be added under agitation the following solution—
viz., 12 parts of potassium hydroxyde in 30 parts of
water and 12 of rectified spirit. The mixture thus
formed is to be heated to complete saponification, and
when this has taken place 100 parts of creosol of a
boiling point of 199 0 to 204 0 C. are to be added. The
resulting liquid must be clear, and of a yellowish
brown colour. It is to be marked “For external use
only.” It must be used ii\a 1 per cent, solution only,
and must be prepared for use in the following
manner: A litre of lukewarm water to be poured into
a clean dish or bottle, and 10 grammes of the creosol
soap are then to be added under agitation. It must
never be prepared for use in a tinned or painted vessel
The Sleep of School Children.

The School Physician, Dr. J. Bernhard, has recently
issued a report on this subject after an examination
of 6,551 children. He reports that for all ages from
7 to 15 years of age the time the children get for sleep
is far behind their physiological requirements. This
shortage of 9 leep he attributes to the work the children
are required to do at home, such as carrying out

zed by GoOgle

Dec. 18, 1907.

CORRESPONDENCE.

The Medical Press. 669

parcels, street trading, etc. Only one-third of the
-children have a bed each; the rest sleep two or three,
or even four, in a bed.

At the Hufeland Society Hr. Ewald showed the
Reactions of the Bence-Jones’ Albuminous Bodies,
-which are derivatives of albuminosis. In very slightly
warmed urine a cloudiness takes place at a temperature
of 37 0 to 40° C. This becomes stronger on further
heating. By still further heating, however, the urine
becomes clear again. The process was the reverse,
-therefore, of that which took place with albumen.

The patient from whom the urine was obtained was
a man, ast. 56, who came from Russia, and presented
the following symptoms : He had suffered for years
from mitral insufficiency. He had complained lately
of pains over the region of the left breast, great weak¬
ness with distension of the abdomen. There were no
•cedematous swellings, and no other noticeable disturb¬
ances. The abdomen was distended in a peculiar
manner, just like an india-rubber cushion. A tumour
the size of a small apple could be felt between the
umbilicus and the left ribs. Tapping of the sternum,
tibia or bones of the arm caused no pain. There was
•complete absence of free and combined hydrochloric
acid in the stomach contents. Digestion imperfect. In
the urine, which was of a sp. gr. of 1,010, were the
above-mentioned albuminous bodies precipitated by
xicinic acid, and to an extent of 1 to 3 per cent. The
fundus oculi was free. There were no typical changes
whatever in the blood ; with the exception of a small
Increase of the lymphocytes the blood was quite normal.

The diagnosis was based on the urine alone. The
appearance of Bence-Jones’ albuminous bodies had been
associated with various diseases, all of them connected
with the bony system.' According to Ellinger, they
were cases of chondro- or lymphosarcoma, which
appeared in a multiple form within the bones, but
which were not visible outwardly. According to the
speaker, two forms must be distinguished, the one pre¬
senting the form of chronic osteomalacia, in which
■easily palpable bony changes were present; the other
ran its course with symptoms of gradually increasing
weakness. The case shown belonged to this category.
The condition of the urine was in favour of this. Cases
of true Bence-Jones* albumosuria were very rare. The
lymphosarcomata developed either in the bone marrow
or in the abdomen. There was no demonstrable ascites,
but some fluid was certainly present in the abdomen.
During the last few days the patient had complained
of pain in his left arm, and had vomited several times.

The treatment of such cases was indicated pretty
plainly: injections of atoxyl, and Rontgen-ray treat¬
ment over the spleen every second day. The results
were apparently favourable. The number of lympho¬
cytes had diminished, but this might be accidental.

Hr. Benda communicated a short note on
Periarteritis Nodosa and Periarteritis Syphili¬
tica.

Attention was first drawn to these subjects in 1866
by Kussmaul and Maier. The clinical features of the
affections were obscure. The symptoms were those of
a labourer who had previously been healthy, and who
bad gradually faded away with marasmus. At the
autopsy numerous small vesicles were found on small
vessels and widely distributed over the internal organs.
On closer examination small aneurysms were found, in
which the external layers of the vessels participated.
Up to 1904 17 such cases had been collected. Three
publications on the subject had appeared during the
past three years. The pathological conditions were the
same in all cases—viz., a widespread aneurysmosis of
the smaller arteries passing on to the larger ones. There
was a tendency to thrombosis, and to a change in the
other organs. The cerebral arteries had escaped attack
except in one instance; all the other arteries were
liable to become implicated. In two cases observed
by the speaker a diagnosis of chronic nephritis had
been made. In one case there was hypertrophy of the
left ventricle, emphysema and symptoms of stasis ; in
the other cirrhosis of the liver. In this case death was
brought about by haemorrhage into the abdominal
cavitv. The diagnosis had never been determined with
certainty during life, and only once had a microscopical
examination confirmed the suspicion.

AUSTRIA.

Vienna, Dec. 18th, 1907.

Angioma Arteriale Racemosum.

Clairmont reported the history of a case on which
he operated for a racemose angioma on the head. He
commenced the operation by incising the circumference
of the tumour, and then dissected the vascular swelling
from before backwards. Fourteen days after the
operation the patient took an epileptic fit; the fits have
repeated themselves since that time. They seem to be
due to the distension of the intra-cranial vessels from
the collateral circulation.

Radio-Therapy of the Ischias.

Freund exhibited a case of ischial neuralgia of a
persistent character that resisted all sedative drugs, but
yielded to irradiation. The sacrum and foramina were
exposed only twice to the rays, when comfort was
obtained, and after the sixth application the pain dis¬
appeared completely. He recorded the history of other
five similar cases, with equally beneficial results. He
thinks these happy results are obtained by the Rontgen
rays dilating the vessels and relieving the contractile
fibres around the nerve.

Relation Between Lymph and Glycosuria.

Biedl gave the Association a lengthy demonstration
of the close relationship between glycosuria and lymph
circulation by cutting of the chylous and lymph cur¬
rents by ligature on the ductus thoracica, which pro¬
duced glycosuria. From this he concludes that there is
a principle in the lymph that has the power of trans¬
forming the saccharine principle into a glucoside,
which is eliminated in the form of glycosuria. This
substance in the lymph is the product of some internal
organ, and has the power of regulating the transforma¬
tion in the organism.

Cranio-Plastic Operations.

Lotheissen next showed the members a child over
two years old with a defect in the cranial bones,
measuring 7 by 5 centimetres. The history of this
defect led to the conclusion that it was the result of
a traumatic cephalic tydrocele. He first commenced
by a periosteal flap from bone according to the Muller -
Konig method, which did not succeed. He next
adopted the Hacker-Duraate method, which is to
induce a subaponeurotic flap to take the place of the
dura mater, but with no better result. In hopeless
despair he resorted to transplanting cartilage from
bone, but with no more success.

Fleishmann thought this was a case where the
dentine was absent as in rhachitis. In this disease the
calcareous changes take place early and linger long.

Tania Cucumerina.

Koenigstein showed a child whom he was treating
for taenia. For two months past the child had been
passing segments which were diagnosed as cucumenna.
He had passed into the stomach by means of a tube
i gramme of extract filicis maris in a syrup of pepper¬
mint, but the half of it was soon after vomited. A
metheglin or hydromel was next prepared and
administered, bringing away three of the worms entire,
which confirmed the diagnosis.

According to statistics about 50 per cent, of these
cases arise from children playing with cats, but in
this case no direct contact with either cat or dog could
be traced. Is it possible that the infection was earned
by external parasites such as fleas, which have been
proved to carry one of the taenia’s transitory forms?

Pemphigus Contagiosus.

Koenigstein presented another case, a child, six
months old, with large circular and poligonal mark¬
ings on the body with different colours. From its age
he thought the bullae could not be pemphigus
neonatorum, but rather Eschench’s pemphigus
infantum, or more generally speaking pemphigus
contagiousum from the well-known infectious nature
of the disease. Nurses and mothers convey the infec¬
tion easily. In the Leipzig Children’s Hospital in 18
months out of 400 children 98 were infected with the
disease. Koch records 30 children in one neighbour¬
hood where the infection was undoubted. The
bacterium found is a staphylococcus pyogenes which
when cultivated and inoculated produces the disease.

Digi

Dec. 18, 1907.

CORRESPONDENCE.

670 The Medical Press.

Clinically, as well as anatomically, this disease differs
from the pemphigus chronicus of the adult. It differs
from impetigo contagiosa from its efflorescence, rapid
formation of pus, and from its not attacking the face,
soles of feet, and palms of hands.

HUNGARY.

BuduMit, Dec. is, 1907.

At the recent meeting of the Budapest Interhospital
Association, Dr. Ro?3a presented a patient with
Stricture of the (Esophagus.

The patient began to have difficulty in swallowing,
with regurgitation of food, about one year ago, neces¬
sitating eventually a gastrostomy. This operation was
done in the St. Rochus Hospital, with apparently a
good result. An oesophageal bougie could not be
passed beyond the level of the junction of the manu¬
brium with the gladiolus. He had the patient swallow
a large amount of bismuth, and then made a radio¬
graph, which showed the obstruction, and to the left
of it a tumour. The obstruction was a saccular one.
After the passage of steel sounds, the man was able
to swallow milk, but at present was feeding himself
through the gastrostomy wound. This case showed the
value of X-ray and bismuth for diagnosing these con¬
ditions.

Chemistry of Chronic Nephritis.

Dr. Kovkcs concludes, from the chemical examina¬
tion of the blood, kidneys, and various other organs,
particularly with reference to the chlorides, as follows :
In health the amount of chloride of sodium in the
kidneys generally exceeds that in the blood and the
other organs. In a large number of cases of nephritis
the difference is still more marked, but exceptions are
common, especially in the early stages. The amount
of salt in the blood and tissues in nephritis is usually
above normal; yet there are many cases where the
opposite holds, despite the presence of «dema, albu¬
minuric retinitis, and uraemia. The percentage of
chlorides found in the pericardial, pleural and peri¬
toneal fluids of nephritis is not constant. Since higher
figures were obtained with the transudates of other
conditions, it is improper to conclude that transuda¬
tion in nephritis is a result of retention of salt. There
can be no question, however, that there is a decided
retention in the kidney of chlorides, sodium potas¬
sium, calcium and magnesium. In the early stages of
nephritis the blood and tissues contain less water and
more solid residue, but in the later stages this is no
longer constant.

The Origin of Acute Miliary Tuberculosis.

Dr. Kuthy carefully investigated all the autopsy
records of four years in order to decide how a local
tuberculous process generally becomes disseminated.
In 95 per cent, of the cases tubercles of the vessels
or of the thoracic duct were found which had per¬
mitted the bacilli to gain the blood-stream. It is
well known that Rippert strongly opposes this theory,
since he has frequently hunted in vain for tubercles
large enough in the walls of the vessels in his cases
to account for the large number of metastatic deposits
in the body. Furthermore, he states that the focus is
not always ulcerated, and that the different size of the
tubercles, especially in the lung, argues for a different
age. It seems more probable to him that an active
proliferation occurs into the capillaries, and that the
blood is constantly contaminated from this source.
The author states, however, that the capillary focus is
generally inadequate, and that it is often present even
where there are no miliary tubercles is due to the fact
that the same number of bacilli is not transported to
all parts of the body, and that different tissues do not
permit an equal development.

Pyramidon in Tuberculosis.

In the internal section of the St. John Hospital in
Budapest the fever of consumptives is managed as
follows: As soon as the patients reach the hospital,
they are put to bed. If the fever does not disappear
spontaneously after five to six days, he receives 20
centigrammes of pyramidon in half a glass of water,
which he is instructed to swallow slowly during half
an hour after his midday meal. If effective the dose

may be diminished after several days, while sometimes
it may be necessary io give more. With inverse type
of fever, the drug must be administered during the
early morning hours. Bad after-effects are rare, and
never amount to more than urticaria, profuse per¬
spiration, of darkened urine. A marked improvement
will be noticed in the condition of the patients as soon
as the fever has disappeared; they will increase in
weight rapidly, and the process in the lungs will tend
to recede.

FROM OUR SPECIAL J
CORRESPONDENTS AT HOME.

BELFAST.

Public Health. —The Public Health Committee of
the Corporation have submitted to Mr. Birrell the fol¬
lowing points which they wish included in the Bill he
is expected to introduce next Session :—(1) To establish
municipal dispensaries for the treatment of tubercu¬
losis ; (2) medical examination of school children, as
in England ; (3) to obtain control of all milk supplies,
whether coming within their district or not, including
the inspection of dairies, and cattle in them; I4I to
establish and operate plant for the sterilisation and
pasteurisation of milk, including purchases and sales;
(5) to insure their sanitary officers against sickness and
death from infectious disease; (6) to compensate

persons stopping employment on account of infectious
disease ; (7) to provide for the appointment of a deputy
medical superintendent officer of health in the absence
or illness of the medical officer; (8) to require that all
district medical officers of health should be qualified
by the possession of a diploma in sanitary science:
(9) the Committee are of opinion that the milk pro¬
visions, including the ice-cream clause of the Public
Health Amendment Act Bill, which were struck out
when the Bill was before Parliament last Session,
should be reintroduced; also that power should be
iven them to maintain persons removed from their
omes to temporary places while their homes were
being disinfected. As will be seen, these recommenda¬
tions open up many broad and controversial questions,
and, if adopted by Mr. Birrell, would give new and
far-reaching powers to the Public Health authorities,
which might easily be abused. Their adoption in til?
is, however, far from likely.

LETTERS TO THE EDITOR.

“THE BROWN DOG” INCIDENT.

To the Editor of The Medical Press and Circular
Sir, —There is no analogy between the slaughter of
a bullock in an abattoir and the death of the “Brown
Dog,” for ffce simple reason that no law exists, that
I am aware of, as to the time or manner in which a
bullock should be killed. Had we such a law, and the
slaughterer treated it with contempt, no doubt he
would be prosecuted, and a well-merited punishment
result. There is such a law for the victims of vivisec¬
tion ; allow me to repeat it:—“The animal must
killed immediately the object of the experiment is
obtained.” Out of the vivisectors’ own mouths we
know this law was flouted, for the object was obtained
after the second operation, and no juggling with
anaesthetics can make the third operation other than
a transgression of this law, and therefore illegal. Had
the Home Office done its duty, and not been a mere
tool in the hands of the vivisectors, their prosecution
ought to have followed.

I am, Sir, yours truly,

Dec. 15th, 1907. Frances E. White.

To the Editor of The Medical Press and Circular
Sir,—Y our correspondent, Frances E. White. > s
perfectly correct. On the evidence of Messrs. Starling
and Bayliss, the brown dog was vivisected three
times. For some two months it was kept without
exercise, and in a more or less mangled condition, m
a cage. In contravention of humanitarian provision*
in the Act, Professor Starling, instead of its being

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Dec. 18, 1907.

CORRESPONDENCE.

The Medical Press. 671

*v~

killed “in a perfectly legal and proper manner,
handed over this dog to Mr. Bayliss, who in his turn
failed to see that the dog was killed as required by
the Act; and, as far as the evidence at the trial
shows, the sworn testimony left the manner of the
dog’s death a mystery, the evidence being contradictory
and unsatisfactory. You, Sir, however, now tell us
that when you wrote that the dog “was destroyed in
a perfectly legal and regular manner,” you simply
spoke of the death of the dog. Let us have none of
that juggling which you dislike so much. Will you,
as you know, tell me (what could not be discovered
at the trial) when the dog was actually killed, by
what means, and by whom?

I am expressing no opinion as to the advisability of
the erection of the statue, or the taste displayed by
the inscription thereon. The latter may or may not
be “libellous.” But if “the greater the truth, the
greater the libel ” holds good, and this is a libel, it
is about as big a libel as one can think of. But you,
Sir, posing as a champion of legality at times, ask
“would the anti-vivisectionists have preferred another
dog to have been used instead?” Why, most
certainly, yes! And for two reasons—first, because,
though we desire to repeal the Act licensing vivisec¬
tion, we desire, in spite of the example of certain
“ highest authorities ” (as Sir William Church would
say) that an Act should be obeyed and its provisions
respected ; secondly, a fresh dog would in any case
be preferable to the lengthened spinning out of the
doing to death of this brown dog. As to serums, I
am only a layman, but for years I have studied the
ipse dixits of responsible practitioners and experi¬
menters, and I know something of their own accounts
of results achieved in cases of diphtheria, with and
without its use. I think you will easily find some
dozen high authorities who have produced excellent
cures without the results of animal experimentation
in diphtheritic cases? I have no time to supply you
with information in detail, and which you can easily
discover yourself. One would like to know your
opinion of medical students who behave as some did
at Acton, and used stink-pots for ladies’ annoyance?
Hoping you will give us your exclusive knowledge of
the brown dog’s death simply and clearly with no
juggling, so very distasteful to us all, and I propose
to trouble you no further.

Yours, etc.,

George W. F. Robbins.

The Battersea General Hospital

(The Anti-Vivisection Hospital), I.ondon, S.W.

Dec. 12th, 1907.

[We have published Mr. Robbins’ letter in full,
except for one sentence consisting simply of abuse
which we thought better to delete. Mr. Robbins admits
he is a mere layman : we therefore feel absolved from
arguing technical medical points with him. The value
of anti-toxin in diphtheria, of course, is admitted by
every physician experienced in fevers. If Mr. Robbins
will do us the compliment of reading The Medical
Press and Circular for the last few weeks, and also
for this, he will ascertain our opinion about the
student dist irbances. With regard to the dog’s death,
we repeat that it was destroyed in a “perfectly legal
and proper manner.” If anti-vivisectionists wish to
labour the point of the demonstration being given on
a dog which was under an anaesthetic used for a pre¬
vious operation, there was no doubt, on the face of it,
a technical breach of the Home Office regulations per¬
taining to that particular certificate. Nothing but
disingenuousness could distort it into anything worse.
Being fond of dogs ourselves, we would like as few
to be used for experimental purposes as need be. When
an animal is under an anaesthetic, it can make no
difference if two operations lasting, say, half-an-hour
each, are performed, or one lasting an hour. If Mr.
Robbins prefers two dogs to be used when one would
do, to our mind that shows that he cares more for
“getting at” his opponents than for animals’ lives.
The fact of the matter is, neither operation killed the
dog in question, but it was subsequently destroyed in
the adjoining room after the demonstration was over.
To say that it was “ done to death ” is equivalent to
a charge of improper killing.— Ed. M. P. and C.]

THE PROFESSION AND THE PUBLIC.

To the Editor of The Medical Press and Circular.

Sir,—I t is remarkable that no fewer than five letters
in your correspondence pages of this week have direct
or indirect bearing upon the question of the present
position of the profession in relation to the public.
First there are the anti-vivisection contributions on the
“Brown Dog” disturbances. There cannot be any
doubt that the students’ demonstrations merely express,
whether foolishly or not, the indignation which every
member of the profession must feel with regard to the
torrent of calumny to which medical men are being
systematically treated by anti-vivisection fanatics and
their blind followers. These fanatics, although some¬
times disclaiming the intention, are virtually engaged
in a well-organised campaign carried on by active
agents throughout the length and breadth of the land,
in which the main argument of speakers and writers
virtually holds up the whole profession to execration
as the supporters of “ vivisectors,” “anti-human
wretches,” who devote their lives to the infliction of
unspeakable torture upon poor dumb brutes, well
knowing that the results must be of more than doubtful
value. They often charge the bulk of doctors with
callousness and cruelty due to the training which they
imagine students go through. The anti-vaccinationists
are carrying on another campaign hardly less widely
and actively. These fanatics charge the whole pro¬
fession—those who duties do not include vaccination
as well as those who are called upon to perfonn the
operation—with carrying on for paltry gain a gigantic
conspiracy through which a loathsome poison is dis¬
seminated among the people, including their own
children, whom they sacrifice to cloak their hypocrisy.
The other letters which you print to-day on “The Mid¬
wives Act,” “Proprietary Medicines,” “Medical Law,” -
and “Quack Methods,” simply illustrate from other
various standpoints the position of degradation and
political impotence in which the profession stands.
Vast masses of the public have become imbued with
ideas which make them look upon the profession with
suspicion and dislike, if not with hatred.

Is it necessary that, to use the vulgar phrase, the
profession should take all this lying down? I do not
know, but this I do know, that if the present state of
things be allowed to continue it must become more and
more difficult, as time goes on, to bring into the pro¬
fession men of honour and of self-respect. I do not
think I can be exceptional, and in my own case I have
persuaded my son, a boy of uncommon talent with a
bent towards science and to a career as a medical
practitioner, to abandon his intention in favour of
some avocation less likely to lead to humiliation and
unhappiness. If the position of the profession cannot
be improved it win soon become impossible for anyone
to succeed in it from the worldly point of view unless
he lower himself to the intellectual level of his patients,
make up his mind to pander to popular prejudices,
and deliberately adopt the principles and practices of
dishonourable charlatanism. I enclose my card, and
subscribe myself,

Yours, etc..

Another Obscure Practitioner.

December 12th, 1907.

HUMANITARIAN ABATTOIRS.

To the Editor of The Medical Press and Circular.

Sir,—T he City Corporation are to be congratulated
upon having at last taken action in the matter of
slaughterhouse reform, and we note with satisfaction
the inauguration of their commodious abattoir at
Islington, in which up-to-date and humane methods
of killing will be employed.

The Humanitarian League has been working for this
reform for years, and is at the present time urging
upon the London County Council the need of estab¬
lishing abattoirs in the place of the many private
slaughterhouses which exist within the metropolitan
district. The advantages of public over private
slaughterhouses, both for hygienic reasons and humane,
have been repeatedly demonstrated by recognised
authorities, official and otherwise. Many years aga
Sir Richard Thorne Thorne, Medical Officer of the-
Local Government Board, recommended the abolition

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672 The Medical Press.

REVIEWS OF BOOKS.

Dec. 18. 1907-

of private slaughterhouses and the substitution of well-
ordered abattoirs in which it would be possible to
on force an efficient scrutiny as to the fitness of the
meat for human consumption. The same conclusion
was arrived at in the Report of the Royal Commission
on Tuberculosis in 1898; also in that of the Public
Health Committee of the L.C.C. in 1899, an ^ at a
conference of sanitary authorities held at the County
Hall on July 7th, 1904, on the subject of the Adminis¬
tration of the Public Health (London) Act.

In view of this, and of the fact that municipal
slaughterhouses have been established in a number of
provincial towns in many parts of the United Kingdom,
as well as on the Continent, there is the more reason
why the L.C.C. should no longer postpone the carrying
•out of its own Public Health Committee’s recommenda¬
tion, to the effect that, “ as a first step towards ensuring
the proper inspection of meat, private slaughterhouses
should cease to exist in London.”

I am, Sir, yours truly,

Joseph Collinson.

Humanitarian League, 53, Chancery Lane, W.C.,
November 13th, 1907.

THE THERAPEUTICAL SOCIETY.

To the Editor of The Medical Press and Circular.

Sir,—Y our correspondent, Dr. Burnet, refers to some
rule of the Therapeutical Society hindering open dis¬
cussion. There is no rule, however, which relates to
the publication of any of its proceedings. The re¬
strictions which were imposed by the then Council
have been removed by their departure into the calm
refuge of the Royal Society of Medicine. I imagine
the delay in resuming meetings is due to want of a
secretary. Do you happen to know of one?

I am, Sir, yours truly,

A Fellow.

December 12th, 1907.

THE NATURE OF THE SOUL.

To the Editor of The Medical Press and Circular.

Sir, —In reference to your article (December nth)
mentioning my appearance in Black and White, I
surely need hardly say that it was not there either directly
or indirectly through any of the few business qualities
I possess. The exciting cause may be traced to a paper
on “The Psychology of Crime,” which I read recently
before an elite medical audience, at which some dis¬
tinguished laymen were also present.

I shall feel obliged if you will Teriew the paper next
month, when it appears in the Journal of Mental
Science, and devote a little space to the criminal ques¬
tion in your valuable and influential columns.

I am, Sir, yours truly,

22, Langham Street, W., Albert Wilson.

December 16th, 1907.

OBITUARY.

THOMAS GLASBROOK DAVIES, L.R.C.P ,
L.R.C.S.Ed., L.F.P.S.Glasg.

We regret to record the unexpected death of Dr. T.
Glasbrook Davies, of Manselton. Dr. Davies was only
taken ill last Thursday, but somewhat serious symptoms
showed themselves on Saturday night, ard it was seen
that he had pneumonia. Notwithstanding his illness,
Dr. Davies insisted upon attending to a young man
who was injured last Sunday morning, and this pos¬
sibly aggravated his case, as the weather was very bad.
He succumbed at his residence in Courtenay Street,
Dr. Davies was only 39 years of age, and was exceed-
ingly popular, and great sympathy is felt with his
bereaved widow and relatives. It was only about two
years ago that he married a daughter of Mr. David
"Glasbrook, Morriston.

LITERARY NOTES.

Mr. Cornwall Round has published a third edition
of his little tract, “Self-Synthesis a Means to Per¬
petual Life” (London: Simpkin, Marshall and Co.,
1907, pp. 32, price is.), in which we have found much
to interest us. The author discusses the influence of

the sub-conscious on the conscious mind, or, as he
prefers, the subjective on the objective mind, and
shows to what an extent the life and conduct may be
altered by self-suggestion. He carries his views to an
extreme point in maintaining that death is merely the
result of suggestion received from others, and that
therefore it may be avoided by a stronger self-sug¬
gestion. The author gives examples of some of the
ways by which self-suggestion may be practised.

The Caxton Publishing Company announce a work
in the press, an “Atlas of Obstetrics,” to which the
stereoscopic method has been applied throughout. The
work is edited by Dr. Barbour Simpson and Mr.
Edward Burnet, M.B., Ch.B., of Edinburgh. The
work will be on the same lines as “The Edinburgh
Stereoscopic Atlas of Anatomy. ” Its aim is to provide
a permanent record of things “as they are seen ” ; to
supply a complete set of types of normal and abnormal
pelves; and to illustrate the mechanism of labour in
a manner unapproached by any other method of
demonstration. Professor Sir J. Halliday Croom con¬
tributes a preface to the work.

#**

We have received a “ Household Emergency and
Reference Chart” from Major R. J. Blackham,
R.A.M.C. This chart is designed to convey, in a
graphic manner, practical directions for action in a
variety of emergencies likely to occur in everyday life,
and it gives us pleasure to say that the author has
certainly fulfilled his object. The information is
conveyed in language which cannot fail to be under¬
stood by any person of average intelligence., and this
fact, of course, contributes greatly to the undoubted
value of Major Blackham’s scheme. While the chart
has a wide field of applicability, we recommend it in
particular to parents, school teachers, and to all, in
fact, who have the care of children. It would be well
if every household and school were provided with a
copy.

REVIEWS OF BOOKS.

ON PNEUMONIA (<z).

This small work is really the substance of clinical
lectures and demonstrations delivered by the author at
the West London Hospital to post-graduates. So much
has been written on this subject that it is difficult to
find anything new to say regarding it. Referring to
the connection of pneumonia with influenza. Dr.
Hood suggests that the attack may be of the nature
of a lung paresis, and, judging from the physical
symptoms, the state is one of rapid oedema or passive
engorgement. He quotes actual cases bearing out his
contention. The distinction between ordinary and in¬
fluenzal pneumonia is that in the latter form asthenia
and copious perspiration are more common, the range
of temperature is not uniformly so high, and is far
more irregular. The difficulties of diagnosis are very
fully dealt with, and illustrative cases introduced.

As to treatment, there is no specific. Dr. Hood
wisely insists on the necessity of abundance of pure,
fresh air as an essential part of the treatment. Coal-
tar compounds are condemned. He has a good deal to
say regarding the treatment of fever, and mentions
that pure, fresh air will often quickly influence the
pyrexia in many cases. Tepid sponging is the best
remedy against restlessness and insomnia. If drugs
are needed chloralamide is one of the best. Sulphonal
and veronal are often disappointing in their results in
such cases. Dr. Hood has found digitalis to be of
little service, but strychnine “is certainly one of the
most useful drugs we possess,” while oxygen is often a
valuable adjunct to treatment. Those who have to treat
pneumonia—and what general practitioner has not?—
will find in Dr. Hood’s teaching much that is practical
and common-sense. It is thoroughly sound, and
appeals at once to the reader. Many suggestions as to
diagnosis will also be gleaned from this small volume,
which we have perused with much interest and no little
satisfaction.

(a) "Some of the Clinical Aspect* of Pneumonia." By Donald
W. C. Hood, C.V.O., M.D, Cantab, F.R.C.P. Lond.; Senior
Physician to the West London Hospital. London: John Bale,
Sons, and Danielsson, Ltd.

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Dec. i 8, 1907.

WEEKLY SUMMARY.

The Medical Press. 673

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT GYNAECOLOGICAL AND OBSTETRICAL LITERATURE.

Remarks on the Theory ot Chorioepithelioma.—

Eden ( Journ . Obst. and Gyn., December, 1907).—After
reviewing most of the literature on this subject, and
giving notes of a case, the writer sums up the whole
question as follows: Chorioepithelioma is a form of
malignant growth which occurs in both sexes. It is
very much more frequent in women than in men, and
pregnancy is its most potent predisposing cause. In
women it usually arises from fragments of chorionic
tissue, normal or abnormal, which have been retained
from a previous pregnancy. It may, however, occur
in. women independently of previous pregnancy, and
in such cases its origin cannot at present be explained.
In men it is generally, perhaps invariably, of terato¬
matous origin. F.

The Menstrual Fnnction: Its Influence upon Chronic
Inflammatory Conditions ot the Appendix. —Reder
(Amer. Journ. Obst., Noveniber, 1907).—Why should
the menstrual function provoke an attack of appendi¬
citis? The menstrual function can only provoke an
acute attack in an appendix that is chronically dis¬
eased. The menstrual function must be considered as
an habitual functional hyperaemia, and as such must
be looked upon as the causative factor. After a pains¬
taking consideration of cases, I can state that only in
the severest forms of adnexal disease can the inflam¬
matory condition communicate itself to the appendix,
and cause the primary acute attack. It is in the chronic
form of appendicitis, be it a catarrhal or an inter-
stitially diseased appendix, where a pelvic hyperaemia
can arouse the dormancy of a smouldering appendix
and provoke the clinical manifestations for acute
attack. Why a smouldering appendix should show
activity one, two, or three days before menstruation,
and remain quiescent at other times, is a difficult
matter to reason out satisfactorily. I have come to
the conclusion that such an appendix can show activity
independently of the menstrual function provided the
proper conditions exist favourable to an attack. Why
have not these patients suffered any acute attacks at a
time when the menstrual function was not in evidence?
Equilibration of the metabolic forces is essential to
the maintenance of health. These women are in good
health, and only at the time of their periods do they
suffer from this abdominal pain. We must infer from
this that there is a sufficient force of the element of
health in the body to keep in check the microtic action
of a diseased appendix. I assume that upon this prin¬
ciple it may be explained why acute attacks have not
occurred in these women during their intermenstrual
periods. On the other hand, at the time of menstrua¬
tion, every woman suffers more or less from a systemic
depression. Through anatomical channels and often
through pathologic tissue changes ; the appendix must
share in the congested condition of the pelvic viscera,
and such an influx of blood to a surrounding appendix
is an incentive for bacterial activity. It could be
expected that through the lowered vital resistance the
obsonic power of the blood would be reduced, thereby
favouring the pathogenic microbes harboured in the
stagnant secretions in the lumen of a diseased
appendix, or that through the lymph channels have
found lodgment in the walls of the organ. F.

Phlebitis Following Abdominal Operations. —Ffaff
(Amer. Journ. of Obst., November, 1907).—After dis¬
cussing the etiology of post-operative phlebitis, and
stating it occurs in about 2 per cent, of cases, the
writer, in conclusion, says it seems to him we are
justified in accepting as facts:—(1) Many of these
cases are simply extensive blood clots, without any true
inflammation ; (2) an abnormal plasticitv of the blood
must be present in order that thrombosis may be the
result of surgical traumatism ; (3) the clot generally
receives a mild form of infection introduced into the
wound at the time of the operation, and in turn an
invasion of the vein wall results ; (4) as stagnation is

such an important element in the etiology, getting our
patients up earlier will undoubtedly reduce the liability
to thrombosis; (5) as an abnormally high degree of
plasticity of the blood is essential in developing the
disorder, the blood ought to be tested by some recog¬
nised standard in every case, and if found in a danger¬
ous state, operation should be postponed until medica¬
tion shall have brought it back to a normal condition.

F.

Treatment of the Pnerperinm. —In an interesting,
papier on this subject Kroemer (Deutsche Med.
Wochenschrift, 1907, Nr. 1-4) begins with the pro¬
phylactic measures which ought to be taken to pre¬
vent disturbance during the puerperium. When there
is a pathological vaginal secretion during pregnancy,.
he recommends shaving and thorough disinfection of
the vulva with at the same time vaginal douching,
twice daily with sublimate solution 1 in 2,000. In
such cases also, internal examination must be avoided
if possible. He does not agree with Zweifel’s pro¬
position that blood clots should be removed from the
vagina post partum. When the lochial secretion is
profuse and smells badly, the vulva must be
particularly well disinfected, and the vagina douched
with peroxide of hydrogen or potassium permanganate.
He warns against internal disinfection when labour
is progressing spontaneously. Before operative
delivery the field of operation must be cleaned with
lysol 1 per cent, solution, if the vaginal con ents are
decomposed and smelling. If the uterus is probably
the seat of the cause of the fever, it must be douched
out after the operation with alcohol. In order to
prevent relaxation of the abdominal walls and its
consequences, the author advises that the patient
shall wear an abdominal belt from the sixth month-
of her pregnancy. The skin must be taken care of
by baths, etc. Varicose veins must be treated with
bandages, baths, and massage. He also recommends
Prochownik’s diet. The women should practise during
pregnancy to use the bed pan in bed. If there has
been any crushing of the bladder, for example after
difficult forceps or pubiotomy, a catheter must be kept
in the bladder during the first eight days, and the
bladder douched daily. Immediately after labour the
abdomen is to be bound from the trochanters to the
costal margin. Towards the end of the puerperium
any retroflexion or descent must be corrected with a
pessary. He warmly recommends Bier’s treatment for
mastitis. He impresses the importance of combining,
in cases of puerperal sepsis, the removal of any
infection from the uterus with a careful inspection of
the perineum, the vulva, the vagina, and the cervix.
When retention of portion of the placenta is suspected
the uterus should be examined digitally, and, if
necessary, curetted with a large blunt curette. If in
cases of thrombo-phlebitis operative measures are
decided on, he advises laparotomy and ligature of all
the four veins. He binds himself to nothing as
regards total extirpation of the septic uterus. For
the general treatment of puerperal fever he recom¬
mends nuclein, and at the same time subcutaneous
infusion of normal saline solution to increase the
leucocytosis, and quinine or ergot to excite the uterine
contractions. He also recommends the serum treat¬
ment. G.

The Signification of Slow Pulse with Rise of
Temperature during the Puerperium. — Merletti
(Ginecologia , 1906, Nr. 4) states that in some cases in
which the temperature rises very often to a consider¬
able height while the pulse rate remains practically
normal the prognosis may be regarded as favourable,
and he then proceeds to arrange the causes which he
has experienced of this condition. It is especially
associated with intestinal disturbances, on the one side
diarrhoea and on the other constipation with absorp-

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674 The Medical Press.

MEDICAL NEWS IN BRIEF.

Dec. 18, 1907.

tion of toxic substances, also with lochiometra for
example in cases of pathological anteflexion of the
uterus, and also in cases of pure nervous disturbances.
The author gives several examples for each of these
kinds of fever, and especially interesting is the history
of a puerpera in whom the great anxiety to nurse her
child and the daily fiasco of trying to accomplish
this was associated with a high temperature up to 40
degrees. The most important and the most frequent
is the intestinal fever; it begins not infrequently with
a rigor and can reach a great height, while the pulse
rate remains normal or rises very slightly. The
author believes that when the pulse is slow in spite
of a high temperature, and when there is no proof of
disease in the generative tract, the presence of a
serious puerperal condition need not be considered,
and that such local treatment as uterine douching, etc.,
is useless and should not be employed. G.

The Cysts of the Corpus Luteum. —In an extract from
an article on this subject, Grusdew (Zenlralbl. fiir
Gynak., 1907, Nr. 50) is reported as having stated that
ovarian abscesses, malignant neoplasms, and cysts
develop in the corpus luteum, and that the cysts are
the most frequent. The cysts which have been de¬
scribed so far were usually about the size of an apple.
The author operated on and examined a cyst of the
corpus luteum as big as a man’s head. The corrugated
appearance of the inner surface of the tumour was
badly developed, and the lutein layer was absent. This
is to be explained according to the author by the
great size of the cyst and the excessive thinning of its
walls. In addition to this the author has observed
two cases of hsematoma of the corpus luteum. In both
cases multiple cystic degeneration of the corpus luteum
and excessive production of lutein cells were to be
observed in the ovaries. There was no appearance of
malignant deciduoma in the genital tract. These cases
prove in the author’s opinion that a haematoma cf the
corpus luteum may reach a large size, even as large
as a child’s head. The contained blood comes from
the capillaries of the lutein cell layer. The epithelium
which lines the interior of cysts of the corpus luteum
is in some cases the morphologically altered endothe¬
lium of the capillaries of the lutein layer. G.

Necrosis and Suppuration in Myomata. —O. v.
Franque (Zeitsch. fiir Geb. und Gyn., Bd. LX., Hft. 2)
reports three cases of necrosis in uterine myomata. In
the first case of these, the necrotic tumour had per¬
forated into the uterine cavity, and was partly expelled
into the vagina, while in the second patient the uterine
contraction produced by the necrotic tumour had
caused a perforation of the external wall of the uterus
into the abdominal cavity, and in the third into the
layers of the broad ligament. The age of the patients
varied between 31 and 40 years. They all recovered
after operation. In another case suppuration occurred
in a large interstitial uterine myoma. The patient,
ast. 51, III.-para., had had the menopause. The most
remarkable point was that the suppuration occurred one
year after the menopause through the blood stream
without any apparent cause. The following are among
the author’s conclusions:—The sub-febrile tempera¬
tures so frequently observed in cases of total necrosis
of interstitial myomata are to be regarded as a result
of absorption of pyogenic substances from the necrotic
masses. In all cases of soft myomata, hooking up of
the tumour must be avoided during operation, in order
that the rupture of the capsule with its possible disas¬
trous results may be avoided. G.

On December 9th there was announced the result of
the poll of the 747 governors of Hampstead General
Hospital regarding the proposed amalgamation of the
North-West London Hospital with that institution, as
suggested by the King’s Hospital Fund. The in¬
patients’ department of the North-West London Hos¬
pital has been closed, but the out-patients’ department,
it is proposed, should be continued as a branch of the
Hampstead Hospital’s work, the latter institution to
have staff consultants, like other general hospitals.
Much feeling has been aroused amongst Hampstead
medical men on the latter proposal. The poll res ilted
in 195 governors being in favour of the amalgamation,
and 187 against.

Medical News in Brief

Royal College of Aurgeons, England.

At a meeting of the Council held on Thursday last,
Mr. Henry Morris, President, in the chair, it wa-i deter¬
mined to advertise the vacant office of Conservator of
the museum, and to invite candidates to send in their
applications before February 1st next. A report was
received from the Museum Committee recommending
certain alterations in the standing rules relating to the
office. A report was received from the Board of
Examiners in Dental Surgery regarding a resolution
adopted by the British Dental Association at its annual
meeting with reference to the period of instruction in
mechanical dentistry. Upon the recommendation of
the Board of Examiners, the Council determined to
adhere to their regulation prescribing not less than
two years’ instruction. The Board further reported
that they had considered the application from the
University of Leeds for the recognition of the dental
department of that University, and the Board being
satisfied that the requirements of the College had been
complied with in regard to the appointment of the
staff, the scope of the courses of instruction, and the
opportunities for hospital practice, it was decided to
add the University to the list of dental schools recog¬
nised for the education of candidates for the Licence
in Dental Surgery of the College. Mr. Clinton T.
Dent, Surgeon to St. George’s Hospital, was re-elected
a member of the Court of Examiners. The report on
the annual meeting of Fellows and Members, and the
resolutions carried thereat, was postponed to a future
meeting of the Council.

The President reported the proceedings of the
General Medical Council at their recent Session, and a
vote of thanks was given to him for his services as the
representative of the College. He further reported
that he had been asked and had consented to serve on
a Committee of that Council which has been ap¬
pointed to ascertain what legal provisions exist in the
Colonies and Dependencies of the Empire and in
foreign countries for the prevention of medical prac¬
tice by other than legally qualified persons, and to
consider what steps should be taken to procure
effective legislation for the same purpose in the United
Kingdom of Great Britain and Ireland.

With reference to a letter from the Deans of the
medical faculties of the Universities of Leeds, Liver¬
pool, and Sheffield, suggesting the desirability of
holding the primary examinations for the Fellowship
at other times of the year than May and November,
the Chairman of the Committee, to whom the letter
had been referred, stated that the Committee proposed
to postpone their report, with the object of ascertaining
the views of the several medical schools upon the pro¬
posed change before submitting any recommendation
to the Council upon the subject.

Murderous attack on a Medical Man.

Henrietta Fitzgerald, 30, described as a machinist,
living in Burton Crescent, was charged on remand,
before Mr. Mead, at Marlborough Street Police Court,
on Saturday, with having maliciously wounded Dr.
Ernest Cranmer Hughes by striking him on the head
with a hammer.

The woman, who was well dressed, was accommo¬
dated with a seat in the dock. She, it appeared, fancied
she had a grievance against the doctor, and, meeting
him in Dean Street, Soho, on November 22nd, struck
him on the head with a hammer, injuring him so
severely that he had to be taken to Guv’s Hospital.
When she was arrested she exclaimed, “I wish I had
killed him. I meant to have a revolver, but didn’t
have enough money.”

Dr. Hughes now for the first time attended court,
and gave evidence. He said he was assistant surgeon
at the Lock Hospital, Dean Street, Soho. He first saw
the prisoner the last Friday in August, when she was
suffering from a certain disease. During September he
received two letters from her, which he answered. He
went away for his holidays, and when he returned in
October he again saw her in Dean Street She asked
him for a certificate with reference to an operation she

Dec, i8, 1907.

PASS LISPS.

Thp. Mepical Press. 675

fancied had been performed on her, but which had
not, and he refused to give her one. Subsequently he
received a letter from the Registr ir of the General '
Medical Council. He handed the letter to the secretary |
of the Lock Hospital. Afterwards he was asked to
attend a meeting of the board of the hospital, and
after the matter complained of had been investigated,
nothing was done. From the letters he received from
her he thought she might be insane. On Novem- '
ber 22nd, just after he left the hospital, the prisoner ;
came up to him and said, “You are Mr. Hughes, are
you not? ” He replied “Yes.” Whereupon she struck
him on the arm with a brown paper parcel, which con¬
tained the hammer produced. She became very excited,
a crowd collected, and he was going to give her in
charge. While looking round to get a policeman she
struck him on the left side of the head, just above the
ear, with the hammer.

Mr. Mead committed the prisoner for trial at the
Central Criminal Court.

The Army and Navy Male Nnraea' Association.

The object of this co-operation is to afford to the
public the opportunity of engaging thoroughly well-
trained male nurses and sick attendants of assured good j
character. The personnel of the society is composed
solely of retired non-commissioned officers and men of
the nursing section of the Royal Army Medical Corps,
and of members of the sick berth staff of the Royal
Navy. No man’s name is entered on the register as a
nurse until he has obtained his certificate of three
years’ training in the military hospitals, or, in the case ■
of the Navy, until he has completed his first term of ;
service, and unless he can furnish the fullest evidence [
of good character. The selection of men for admission
on the register is made by the executive committee after
the fullest examination of each candidate’s records and
testimonials. The co-operation will be able to supply,
in addition to male nurses, asylum attendants,
masseurs, dispensers, valets or travelling attendants,
laboratory and hospital porters, P.M. porters,
operating theatre attendants, and assistants in X-ray
and electrical departments of hospitals. It is esti- I
mated that the sum of ^2,000 will put the society upon
a sound basis, and enable it to commence work at once.
All communications to be addressed to the Hon. Secre¬
tary, Miss Ethel McCaul, R.R.C., at the offices, 47B,
Welbeck Street, Cavendish Square, London, W.

Cbangr* at A*. Ueorge’s H'spHal.

A special meeting of the governors of St. George’s
Hospital was held on December 9th for the purpose of
considering some important changes in the manage- !
ment of the institution. Hitherto the offices of j
secretary and superintendent have been combined, and 1
for some time this arrangement has been found to be
inconvenient. The whole matter has been thrashed
out by the committee, and a scheme was submitted to
the court of governors. It was decided to appoint a
medical superintendent who should reside in the
hospital, and a secretary who should be allowed to
live at his private house. Under the old rules the j
office of secretary was open only to bachelors and
members of the Church of England, but the governors
have now taken a broader view, and the official may
be a married man and is not required to undergo a |
religious test. The meeting was presided over by Mr.

A. William West, the treasurer, and amongst the forty
governors who attended were Lord Arthur Hill,
Captain C. B. Balfour, Sir William Bennett, the Hon.
Dudley Fortescue, the Hon. Sydney Carr Glyn, Dr.

T. Ridge Jones, and the Rev. A. G. Locke.

The Irlah Un've-sltv Question.

At a full meeting of the staff of Trinity College,
Dublin, summoned by the Provost on Saturday, the
following was passed unanimously: —

“That, fully realising the importance of a settle¬
ment of the University question, this meeting of the
staff of Trinity College and members of the Academic
Council think it undesirable to express any opinion on
proposals which have not yet been formulated as a >
Government Bill, but they think it right to re-affirm J
the declaration contained in the statement issued by !
the Executive Committee of the Dublin University I

Defence Committee in March, 1907—viz., should the
Government determine to introduce a measure which,
while leaving to Trinity College and the University
of Dublin their present independent and unsectarian
character, would at the same time be acceptable to our
Roman Catholic fellow-countrymen, it would be a
matter of supreme satisfaction to all who are interested
in higher education in Ireland, and who desire a
final settlement of the whole question. We, for our
part, have confined ourselves to working out our
solution. We have not thought it our duty either to
advocate or oppose any scheme for the satisfaction of
the reasonable claims of Roman Catholics which does
not interfere with our own development along un¬
denominational lines.”

Royal Academy of Medicine In Ireland-

At a meeting of the Obstetrical Section of the Royal
Academy of Medicine, held on Friday last, the
following resolution was unanimously adopted: —
“That the Obstetrical Section of the Royal Academy
of Medicine regard the recommendations of the
General Medical Council regarding obstetrics teaching
as in many cases a very great advance on the present
conditions. The section, however, considers that the
suggested alterations of the period of attendances on a
Maternity Hospital from six months to three months
would not be advisable or practicable. The section
considers that instead of reducing the attendances, the
licensing bodies should adopt such regulations as will
insure the regular attendances of the students at the
clinical teaching of the hospitals. With regard to the
adoption of a practical examination in midwifery and
gynaecology, the sections consider that such a step
is most desirable, and urge its members to aid it by
all means in their power.”

PASS LISTS.

Royal College of Surgeons of England.

At an ordinary meeting of the Council of the
College held on the 12th inst., the following members
of the College, having passed the required examina¬
tions and conformed to the 'Bye-laws, were admitted
Fellows of the College: —

Hugh Ainsworth, captain, I.M.S., M.B., Ch.B.Vict. ;
William Appleyard, M.B., B.S.Lond. ; E. W. Bain,
M.B., B.S.; W. E. Brierley, M.B., Ch.B.Vict. ;
Hubert Chitty, M.B., B.S.; Colin Clarke, M.B.,
L.R.C.P.Lond. ; A. J. Couzens, L.R.C.P.Lond. ;
Millais Culpin, M.B., B.S.; W. E. Fisher, L.R.C.P.
Lond. ; J. G. French, M.B., B.S. ; H. T. Gray, M.A.,

B. C., Cantab. ; Henry Hardwick-Smith, M.B.Cantab.,

L. R.C.P.Lond.; S. C. Hayman, L.R.C.P.Lond. ;
Reginald Jamison, M.A., M.B., B.Cffi.Oxon.; Thomas
McPherson, M.D.McGill; R. D. Maxwell, M.D. ;
Edwin Maynard, L.R.C.P., D.P.H.Lond.; W. S. V.
Stock, M.B., B.S.; Philip Talbot, M.B., Ch.B.Vict.

The following candidates, not being members of the
College, were also admitted Fellows:—L. R. Braith-
waite, M.B., Ch.B.Vict. ; K. McKenzie Duncan,

M. B., Ch.B.Glasg. ; Edward Gillespie, M.B.,
Ch.B.Glasg. ; J. L. Falconer, M.B., Ch.B.Vict. ;
David Ligat, M.B., C.M.Glasg., D.P.H.Vict. ; H. F.
Shorney, M.D., B.S.Melb.

The following is a list of new licentiates in dental
surgery:—Stanley Bellman, R. D. Bennett, L. W.
Biscombe, John Button, J. W. Doherty, W. A.
Dredge, William Drew, R. Dent, H. G. Dumayne,
J. G. Femie, E. E. Fletcher, A. W. Gant, Percy Gee,
R. J. Gibbings, J. K. Hargreaves, Ernest Harrison,
A. F. Hochapfel, Graham Hunt, C. E. James, T. N.
Jeffries, H. E. Jones, A. T. Knight, Isaac Levy,
Oswald McGowan, J. F. Maguire, L. T. B. Matthews,
Federico Montuschi, F. R. H. Myers, C. R. M. Peaty,

C. G. Plumley, P. J. Proud, Lewis Richter, E. G.
Robertson, C. R. Rudolf, F. H. Salter, R. A. Scott,
H. V. Sharp, Sydney Shovelton, A. W. Smith, I. S.
Spain, W. M. Swan, A. C. Tippett, A. I. Ward,
R. G. White, and R. T. Wood.

Diplomas of membership of the College were issued
to John Lewis, Univ. Coll. Hosp., and to J. L. Todd,
McGill Univ., Canada.

Digitized by GoOgle

676 The Medical Pkess. NOTICES TO CORRESPONDENTS

Dec, i 8, 1907.

NOTICES TO
CORRESPONDENTS, ffc.

CoMiaroHMifTB requiring a reply in this oolnmn an par¬
ticularly requested to make nse of a Dutinctive Signature or
Initial, and to avoid the praotioe of alining themselves
" Header,’’ ** Subscriber,” ” Old Subscriber,” eto. Much oon-
fuaion will be spared by attention to this role.

SUBSCRIPTIONS.

Subscriptions may oommenoe at any date, but the two volumes
each year begin on January 1st and July 1st respectively. Terms
per annum, 21s.; post free at home or abroad. Foreign sub¬
scriptions must be paid in advanoe For India, Messrs. Thacker,
Spink and Oo., of Calcutta, an our officially-appointed agents.
Indian subscriptions an Bs. 15.12.

ADVBRTIEBMENTS.

Fob Onb Insrbtiox! —Whole Page, £5; Half Page, £2 10s.;

Quarter Page, £1 6s.; One-eighth, 12s. fid.

The following reductions an made for a series:—Whole Page, 13
insertions, at £3 10s.; 26 at £3 3s.; 52 insertions at £3, and
pro rata for smaller spaoes.

Small announcements of Praotioes, Assistances, Taoancies, Books,
Ac.—Seven lines or under (70 words), 4s. fid. per Insertion;
fid. per line beyond.

Obioinal Articles ob Letters intended for publication
should be written on one side of the paper only and must be
authenticated with the name and address of the writer, not
necessarily for publication but as evidenoe of Identity.

Contributors are kindly requested to send their communica¬
tions, if resident in England or the Colonies, to the Editor at
the London office; if resident in Ireland to the Dublin office, in
order to save time in reforwarding from offloe to offioe. When
sending subscriptions the same rule applies as to offloe; these
should be addressed to the Publisher.

Saccharine. —There is some evidenoe that diabetes is a
miorobio disease in some oases, though at present the theory
does not fit all the facts of the case. The idea that it is so
obtains a certain amount of confirmation from the fact that it
is endemio in certain parts of Bengal, and not in the surround¬
ing districts and provinoee.

Mb. R. Wriqht. —We have no knowledge of a sanatorium that
aocepts patients at the very moderate fee mentioned. ''here are,
of course, oharitable Institutions in whioh patients are received
without oharge, on the recommendation of subscribers, but we
take it this is not what you are seeking. There it a '' Handy
Reference List ” published at fid. by Pullman and Sons, Limited,
Thayer Street, London, giving a complete list of sanatoria with
their charges, whioh we would advise you to consult.

Edinburgh Student. —We know of no work on anatomy that
answers your requirements so fully as Professor Buchanan’s
recent " Manual of Anatomy ” (University Series of Text-Books),
as it is systematic and practical, and includes embryology.
The illustrations are in oolours, and will be found very helpful.

PERSONAL PARAGRAPHING.

The Evening Standard of December 7th, contained tie follow¬
ing paragraph:—"One of the King’s Phvsicians Extraordinary,
a Knight of Grace of St. John of Jerusalem, 8ir Joseph Fayrer,
reached the venerable age of eighty-three, and in the mild
climate of Falmouth, where he is passing his declining years, he
still devotes much of his time to literature and the fine arts.
Apart from his lifelong praotice as a surgeon, and his long
servioe in India, including the Mutiny, the professorship of the
Medical College of Calcutta, and the presidency of the Medioal
Board of the India Office, he lias written many books, both pro¬
fessional and otherwise. Among the better known of the latter
class are ' With the Prince in India,’ ‘ The Life of Sir R.
Martin, C.B.,’ and ' Reoollcotions of My Life,’ ’’

May the memory of the good deeds of all of us survive as
vividly I . ,, . „

D. g—We are much obliged for your kind compliments. The
incidents, regrettable enough in themselves, are being worked for
all they are worth to throw odium on the profession, and we feel
it our duty to expose suoh sorry tactics.

L. M.—There is no valid objection to the course you pro¬
pose, and you are justified in taking it without reference to
anyone, as you have been so badly treatod. It would be better,
however, to take a philosophical view of the matter, and call
on your fellow practitioner to make a personal explanation of
your motives in doing so. Then no blame could possibly be
imputed to you. . ..

N. R. G.—1. Yes. We agree entirely. 2. Yes, but with the
reservation you mention. 3. No. It does not follow, and your
ingenious theory does not hold water.

PROMOTION.— The Indian Medical Service offers excellent oppor¬
tunities In the direction referred to. The next examination for 16
Commissions in the Service will beheld in London on Tuesday the 28tb.
January, 1908, and the four following days. Particulars regarding
pay. promotion, Ac., in the Service, and the necessary forms of
application, can be obtained from the Military Secretary, India
Offloe. London. You will find fuller particulars on referring to our
advertlsment columns.

p.m.: Medioal Out-patient (Dr. Whipham); Dermatological (Dr.
G. N. Meaohen); Ophthalmologioal (Mr. R. P. Brooks).

Thursday, Dick mb zb 19th.

Child-Study Society (Parke* Museum, Margaret Street, W.).
—8 p.m.: Leoture: Miss A. Ravenhill: Some Results a i an.
Investigation into Hours of Sleep amongst Elementary School
Children in England.

Medical Graduates’ College and Polyclinic (22, Chenies
Street, W.O.).—4 p.m.: Mr. Hutchinson: Clinique. (8urgical).

North-East London Post-Graduate Oolleoe (Prince of
Wales’s General Hospital, Tottenham, N.).—2.30 p.m. Gynaeco¬
logical Operations (Dr. Giles).—Cliniques •—Medioal Out-patient
(Dr. Whiting); Surgical Out-patient (Mr. Canon); X-Ray (Dr.
Pirie). 3 p.m.: Medical In-patient (Dr. G. P. Chappel). 4.30
Throat Operations (Mr. Carson).

Hospital fob Sick Children (Great Ormond 8treet, W.O.).—
4 p.m.: Lecture:—Dr. Hutchinson: Some Diseases of the Newly
Born.

Gbntbal Midwifes' Boabd (Caxton House, Westminster) u
2.45 pm.

Friday, December 20th.

North-East London Post-Graduate College (Prince of
Wales’s General Hospital, Tottenham, NJ.—10 a.m.: Clinique: —
Surgical Out-patient (Mr. H. Evans). 2.30 p.m.: Surgical Opera¬
tions (Mr. Edmunds). Cliniques:—Medioal Out-patient (Dr.
Auld); Eye (Mr. Brooks). 3 p.m.: Medioal In-patient (Dr. M.
Leslie).

Jlppointtneme.

Beattie, Thomas, M.D.Durh., M.R.O-P.Lond., Honorary Physl-
oian to the Royal Victoria Infirmary, Newoastle-upon-Tyne.

Bolam, Robert A., M.D., B.S.Durh., M.R.O.P.Lond., Honorary
Physioian to the Skin Department, Royal Victoria Infirmary,
Newoastle-upon-Tyne.

Cassidt, M. A., M.B., B.C.Oentab., M.R.C.P.Lond M.R.C.S.Eng ,
Resident Assistant Physioian at St. Thomas’s Hospital.
London.

Codd, J. Alfred, M.D., B.Sc.Lond., Physician to the Wolver¬
hampton and Staffordshire General Hospital.

Go wring, B. W. N., M.R.C.S., Honorary Surgeon to the Dorset
County Hospital.

Smith, J. B., M.B., M.S.Edin., Certifying Surgeon under the
Factory and Workshop Act for the Hertford District of the-
oonnty of Hertford.

Timms, Alec Boswell, L.R.C.P. and S.Edin, L-F.P.8.Glasg.,
Visiting Medioal Offloer to the Cardiff Workhouse.

Vise, J. N. B., L.R.O.P.Lond., M.R.C.8., Certifying Surgeon
under the Factory and Workshop Act for the Axminster
District of the oounty of Devon.

Baontnes.

Kent County Asylum, Maidstone.—Fourth Assistant Medical
Offloer. Salary, £175 per annum, with furnished quarters,
attendance, coals, gas, garden produce, milk, and washing.
Applications to the Medical Superintendent.

The Hospital for 81ck Children, Great Ormond Street, London.
W.O.—Casualty Medical Officer. 8alary, £200 per annum

with lunch. Applications to the Secretary. (See Advert.)

Corporation of Majohestor.—Assistant to the Medioal Offloer of
Health. Salary, £200 per annum. Applications to rite
Chairman of the 8anitary Committee, PudUo Health Office,
Town Hall, Manchester.

Suffolk District Asylum, Melton.—8econd Assistant Medical
Offloer. Salary, £160 per annum, with board, furnished
apartments, attendance, snd laundry. Applications to the
Medioal Superintendent.

Bristol General Hospital.—Senior Honse Surgeon. Salary, £120
per annum, with board, residence, eta Applications to the

Liverpool Sospital for Consumption.—Resident Medioal Officer
for the Sanatorium at Kingswood, Delnmere Forest. Salary.
£400 per annum, with a house (unfurnished). Applications
to Alfred 8hawfleld, 77a, Lord Street, Liverpool.

Cardiff Union.—Assistant Medioal Offloer. Salary, £130 pa-
annum, with rations, apartments, attendance, and washing.
Applications to Arthur J. Harris, Clerk, Union Offices,
Queen's Chambers, Cardiff.

Births.

Riley.— On Deo. 12th, at 3, Culverden Gardens, Tunbridge Wells,
the wife of Francis Riley, M.D., B.8., F.R.C.S., of a son.

jB arrays.

Bebrt— Logan.— On Deo. 14th, at the Wesleyan Church,Hammer¬
smith. Sidney M. Berry, HA., younger son of the late Dr. Chart*
Berry, of Wolverhampton, to Helen, eldest daughter of J. M.
Logan, of Bedford Park, Chiswick, W.

4Keeting« of the Societies, Hectares, &c.

Wednesday, December 19th.

Rotal Microscopical Society (20, Hanover 8quare, W.).—8
p.m.: Mr. E. Large: Exhibition of Selenite Specimens showing
interesting features due to Twinning. Papers:—Mr. J. Murray :
Some Afrioan Rotifers.—Mr. E. M. Nelson: 0) Gregory and
Wright’s Microscope; (2) A Correction for a Spectroscope.

Medical Graduates’ College and Polyclinic (22, Chenies
Street, W.O.).—4 p.m.: Mr. J. Cantlio: Clinique (Surgical). .

North-East London Post-Graduatf. College (Prince of
Wales's General Hospital, Tottenham, N.).—Cliniqncs:—2.30

Bcaths.

Cart.—O n Deo. 10th, at 71, Thomev Hedge Road, Gunnersbnry,
Middlesex, Tristram Cary, M.D., third son of the Rev.
Anthony Cary, Rector of Glendermott, Londonderry.

Falls—O n Deo. 11th, at Curraghmore, Bournemouth, Alma,

Mary, widow of William Stewart Falla, M.D. _

Spong.—O n Dec. 13tb, at Lynated, Beckenham, llliara Spec*
M.R CS., L.R.C.P., eldest son of the iste William Nash Spong.
of Faversham. Kent, aged 52. _ v

Williams— On Deo. 13th, at Holt Street House. Wrexham,
Joseph Llewelyn Williams. M.B., aged 63.

The Medical Press and Circular.

" SALUS POPUU SUPREMA LEX."

v °l* CXXXV. WEDNESDAY, DEC. 25, 1907. No. 26.

Notes and Comments.

The distinctions awarded by the
Roll of State for medical and scientific
Merit eminence are few and niggardly,

* and we should like to see them
greatly enhanced. But, while wait¬
ing for that desideratum, we may content ourselves
with a new Order of Merit, not the one recently-
conferred on Miss Florence Nightingale, but that
created by the Vaccination Inquirer for districts and
unions having between 40 and 50 per cent, of the
children born in them returned as unvaccinated.
This strange honour was instituted in 1903, and
thirty-three names were inscribed on the roll; in
1004, the last year presumably for which com¬
plete returns have been issued, the number is
thirty-six. Three London Unions, Mile End Old
Town, Poplar, and Bethnal Green figure in it,
together with two registration counties, Northamp¬
ton and Bedford, and fifteen provincial unions. The
highest “ honour " belongs to Hinckley, which has a
percentage of unvaccinated births amounting to
48.4; while the wooden spoon belongs to I.eignton
Buzzard, with 40.2. The Vaccination Inquirer,
which seems to make very little inquiry about
vaccination, and to express a great deal of dog¬
matism about it, naturally rejoices at the increasing
list of the claimants to its distinctions, but bewails
the loss of three old recipients which have fallen
awav from the faith, whether as the result of a
small-pox outbreak or not we do not know. We
do not gather if any token of the “honour” is
bestowed upon the successful ones, or whether the
barren distinction of enrolment is all the consola¬
tion achieved. If it did not savour of idolatry one
should be induced to suggest that a golden calf
might be awarded to the union having the highest
“ percentage not cowpoxed ”; such an emblem
might stimulate noble emulation and serve as a
totem for the anti-vaccination tribe. But perhaps a
model of a lunatic asylum might be more
appreciated.

Our contemporary, John Bull, for
„ Dir* »* December 14th, contains the follow-

Treatment ,n £ not ' ce '“ Senile (Bath).—We

are not medical experts, and cannot
take upon ourselves the responsi¬
bility of advising the ‘ Rice ’ or anv other treat¬
ment for rupture.” The first thought that occurs
is, O si sic omnia. When the veriest rags. of
papers do not hesitate to give medical advice and to
publish lying statements about doctors’ errors, it
is something of a relief that one paper at least
should proclaim its disqualification to give expert
advice on technical subjects. But we confess, if
we may humbly assume the title of expert, that we
are as ignorant of the “ rice ” treatment of rupture
as our contemporary. Indeed, beyond connecting
the word with a theory of beri-beri and a simile
for cholera stools, “ rice ” suggests but little 10 us

in medicine, and how it should be used in the treat¬
ment of hernia is a “ poser.” The rupture quack is.
always somewhat of a mystery; how he manages
to persuade his victims to do anything except wear
a truss and yet imagine benefit is difficult to con¬
ceive. Still more so is that the seniles of Bath
should regard John Bull as an authority on the
disease, except on the well-recognised principle that
there are many people who think all editors are
Admirable Crichtons and Dr. Murrays rolled into
one.

The limerick craze has been a god-
Limericks send to the papers which have

and opened their columns to that intel-

Insanity. lectual form of entertainment, for
the numbers of would-be prize¬
winners who have bought their issues, not for their
literary charm but for the limerick coupon, must
have had a prodigious effect on their circulation.
It is sad to record that a poor fellow, the tramp-
master of the Cheltenham Workhouse, should
have been literally so “crazed” by these competi¬
tions as to take his ow-n life. At the inquest it was
proved that he had hanged himself after unsuccess¬
fully attempting to cut his throat with a razor, and
medical evidence showed that he was much excited
over limerick competitions, and was greatly dis¬
appointed that he had not gained a prize. The
Coroner was shown between fifty or sixty counter¬
foils of sixpenny postal-orders, and it was said that
he had spent a large amount of money in going in
for competitions. Moreover, manv “ last lines ”
were produced in Court. The victim had sent a
letter, from which it was evident he was much
annoyed at his non-success, to each of the papers
in which he had competed. An extract from this
ran : “ I have read the lines to which prizes have
been awarded in your limerick contests for some
w-eeks past, and if there is no favouritism or fraud
in the contests, then it is time the adjudicators
consulted a medical man and had their heads-
examined ; most of the winning lines have no merit
whatever.” Although the jury returned a verdict
of “ suicide whilst temporarily insane,” we arc
tempted to doubt the insanity of a man who had
diagnosed the situation with such acumen, and
given such excellent advice to those concerned.

In the South-West London Police
Notification Court - Dr - S - A - Mugford, of Bal-

Errors. ham. was recently summoned by
the Wandsworth Borough Council
for failing to notify to Dr.
Caldwell Smith, Medical Officer of Health
for Wandsworth, a case of infectious disease. The
defendant pointed out that he tried to do every¬
thing possible to acquaint the medical officer. He
had telephoned to the Public Health Department
of the Borough Council, and received a message

Digitized by CjOO^Ic

to say that Dr. Caldwell Smith was absent, and
that there was no one to receive Che official notifi¬
cation. He thereupon communicated with the
Metropolitan Asylums Board and had the patient
removed. When asked why he did not send the
notification by post, he said he wanted the patient
removed immediately, and if he had posted the
intimation, a day’s delay in the removal would have
laken place. The caretaker at the Borough
Council offices, a curious official to use for the
purpose, said that he had not received the intima¬
tion, but Dr. Mugford was quite positive about the
message having ibeen received. The magistrate
said that it was more an act of inadvertence than
anything else that Dr. Mugford had not actually
sent the formal certificate, and if it was the case that
■notifications could not be received at the Town Hall
at any period of the day, there must be a screw loose
in the department somewhere, and the sooner it
was remedied the better. He imposed a penalty of
one shilling only, and sharply declined to allow the
prosecution their costs. We presume that, a
technical error having been committed, it was
impossible not to convict, though that is by no
means certain, but the smallness of the penalty and
the refusal of costs sufficiently indicate the magis¬
trate’s opinion.

We do not hesitate to characterise
And their use t ^ 1e Police Court for the

Results purpose of getting a penalty out of
a medical practitioner who has
notified a case in every way except
fcy using a certain form as not only a blunder, but
a distortion of the legal process. And when to that
is added the fact that the administration of a health
department of a large London borough is so con¬
ducted that urgent notifications cannot be received
and acted upon during the daytime, it strikes us
ihat justice demands that the position of defendant
and prosecutor should be reversed. The notifica¬
tion of infectious diseases is not an end, but a

means to an end, and if the power to use the legal
means provided by the Act is tyranicallv and arbi¬
trarily used, not only is public health administration
brought into proper contempt, but it fails in its
most important function, that of maintain-
fng proper relations with the real health guardians
of the people, namely, the medical practitioners.
We lately had occasion to comment on the protest
made by the Manchester Medical Guild against the
action of the health department of that city in
invading the privacy of patients’ houses and bed¬
rooms in defiance of their own and their doctors’
wishes. We deplore the tendency that shows itself
in various quarters for some health departments,
now that they have come into being by medical
advice and support, to assume towards both the
people and the medical profession these bureau¬
cratic methods which are as ill-advised as they are
un-English. Unless health authorities work with
the community in a sympathetic and considerate
manner, their power will properly be curtailed,
and the advance of practical hygiene delayed for
years. The Notification of Births Act puts a new
and most powerful weapon in their hands, and if
it be employed in any but the gentlest and most
beneficent fashion, it will utterly defeat its own
end.

There is a happy land for doctors,
A Happy but unfortunately it is situated at
Hunting- some distance. A correspondent of
Gronnd. the Glasgow Evening Times, how¬
ever, draws attention to it, and his
description makes the mouth of the British medical
stru ggler water. The land of delights is New Zea¬
land, whose natural charms are sufficiently well
known not to need description here. But over and

above its charming climate, its beautiful scenery’,
and its virile population, New Zealand, says this
gentleman, quoting another writer, could accom¬
modate five hundred more doctors, and supply them
with a clear income of £400 to £500 a year. In
the large towns incomes running up to ,£2,000 a
year are not .put of the way, but the ordinary-
country practitioner is wanted, not in single spies,
but In half a battalion, and the Dominion lies at his
feet. Says one writer : “ This may be a help to
many who are wondering when they will find a
practice. Let them make straight for New Zea¬
land and get out into the country and have a good
time, instead of a wearisome wait on 1 dead men’s
shoes ’ in our home cities.” The prospect is so
alluring as to tempt us to fling down the pen and
seek the shipping agent; but we must warn our
readers who are longing to be off that vaccination
is not popular in New Zealand, and that “doctors
w’ho depend on this operation are looked on some¬
what suspiciously.” Alas! all amber contains its
fly.

LEADING ARTICLES.

MIDWIVES IN DEFAULT.

The Central Midwives’ Board has, thus early in
its career, ibeen called upon freely to exercise its
penal powers. A number of licensed midwives have
been struck off the register, and it is a matter of
interest, as well as of importance, to the medical
profession, to realise Che conditions under which the
particular offences in question were committed.
There is, of course, something to be said on the
score of the formation of a new register in which
many worthless persons must necessarily be in¬
cluded, and from which it is obvious they will, in
the nature of things, be rapidly excised. Some of
the offenders show that they treat the fact of being
licensed under the Act with absolute levity and con¬
tempt, inasmuch as they have not even satisfied the
preliminary condition which demands equipment of
each midwife with various drugs and appliances.
Without such provision the most elementary-
skilled midwifery could not be conducted, for
example, in the administration of antiseptic
douches, the taking of temperatures, and catheteri¬
sation. That is a serious matter enough, chiefly
because it shows the absolute indifference of a
certain number of women to the responsibilities
undertaken by them on registration. A similar
recklessness led to several names being, struck off
for failing to call in a medical man in cases of
retained placenta, ruptured perineum, and puerperal
fever. This is precisely one of the things that it
was predicted would take place were a hybrid class
of registered women practising in one branch of
medical work under the aegis of registration. This
attitude was exemplified in an exaggerated degree
in the case, to which we made allusion last week,
of a midwife who prescribed quinine and iron to
one of her clients. Indeed, one can readily imagine
how hard it would be for a half-educated woman to
grasp the fact that, although she might administer
any one of the whole family of purgatives, solid or
liquid, in any form or any combination, with the
authorisation of the State that granted her a
licence, nevertheless she might not prescribe any

a by Google

Dec. 25, 1907.

LEADING ARTICLES.

The Medical Press. 679

other drug in any other way. In this difficulty
■of drawing the line lies the great, and to many
medical minds, the insuperable objettion to the
whole Act. The woman who is authorised to attend
the simple confinement will find little difficulty in
convincing herself that she is competent to deal
with the difficult cases. It is hardly possible, on
any other assumption, to explain the numerous
cases in which licensed midwives have neglected
to summon medical aid. The greatest and most
appalling defect revealed in the whole of these
charges, however, is the fact that women attending
puerperal fever cases either failed to report the case,
or neglected to use disinfectants and call in a medi¬
cal man, or went on attending other cases, and
thus spread this terrible infection. The fact of the
matter is that it takes a long and careful medical
.training to recognise a morbid condition of the
kind, and it is absolutely useless to expect the aver¬
age ill-educated midwife to recognise the fact that
her patient has been invaded by a deadly infection.
Some of the women subjected to the disrupture of
the Board had not even furnished themselves with
the thermometer essential to the formation of an
•early diagnosis of the malady. On logical grounds,
the man in the 9treet will one day probably be forced
.to the conclusion, long since arrived at by the
general practitioners of the United Kingdom,
namely, that the conduct of labours should be left
In the Hands of qualified medical men and women,
and that there is absolutely no need to set aside a
special class of registered women for that particular
work, any more than it is necessary to certify
nurses to attend, say, pneumonia, broken bones, or
skin diseases. Most medical men will probably
agree that before receiving any recognition as a
competent midwife a woman should have a pro¬
longed and careful nursing education. Further de¬
velopments under the Midwives Act deserve to be
•watched closely, as they may in no distant future
demand great attention at the hands of the legis¬
lature when called upon to frame a fresh Medical
Act.

THE FEEDING OF SCHOOL CHILDREN.

The progress of Society towards the attainment
of its ideals is seldom rapid, and perhaps it is well
in some cases that advances should be made chiefly
in response to well-ascertained shortcomings.
Otherwise, so much is man a creature of impulse,
the community might find itself kept in a more or
less continual commotion by the pursuit of im¬
possible ideals. In the case of public education
.there is still a great deal to be learnt in our treat¬
ment of school-children, apart from the altogether
vexed questions of what we ought to teach them
.and the best way of imparting knowledge. For all
that, the State has within the past few years made
some noteworthy advances as regards the children
who are educated at the expense of the public.
Roused by the cry of national degeneracy, a great
•deal of attention has been recently paid to the physi¬
cal conditions and requirements of the people. One
of the indirect benefits of that awakened interest
has been to focus a large amount of enquiry upon
1 'he schools. A general demand for the proper
sanitary control of the educational environment has
been followed by various salutary measures, and has
culminated in the Act which for the first time in¬
stitutes the systematic medical examination of
scholars. The absolute necessity of such a pro¬

vision is well illustrated by the increase for many
years past of diphtheria, which is essentially a school
disease. Then, again, who can doubt that the
scarlatina problem, which is the despair of sana-
tarians, is largely influenced by the conditions of
school-life? There is little need to labour the point,
however, for it stands to reason that the bringing
together of children in large numbers at an age
when they are peculiarly open to attack by in¬
fectious disease is to multiply the already complex
problem presented to the medical officer of health
in the attempt to control the great zymotic mala¬
dies. Almost at the end of the series of new faiths
came the sudden recognition of the fact that it is
useless to teach starving children, and that the
backbone of the nation might be strengthened to
an incalculable degree by providing food for the
State children whose parents were unable to fulfil
that necessary’ duty. The outcome of this new
gospel was the Provision of Meals Act, whereby
local authorities were empowered to feed school-
children at the public charge. This statutory per¬
mission was speedily taken advantage of in various
large centres of population, among which may be
mentioned Brighton, Birmingham, Bristol, and
Manchester. Curiously enough, the greatest city,
not only in the kingdom but also in the world,
declined to use their powers under the Act. The
consequences of this short-sighted policy are
not far to seek. Every ill-fed child of the
poorer classes of the community must inevit¬
ably become, sooner or later, a charge upon
the State. So that Londoners, who to-day
are saved a small direct tax to feed these foodless
scholars, will in the long-run have to pay many
times that amount to hospitals, workhouses,
prisons, and Poor-law infirmaries. We are not con¬
cerned with the politics of the London or any other
County Council. At the same time, as a medical
journal, we cannot help feeling the deepest interest
and anxiety when any well-conceived plan for
advancing the collective stability of the public health
is permitted to go astray by the apathy or short¬
sightedness of local administrations. It needs little
argument to show that the refusal to make good so
grave a defect in our social system as the existence
of many thousands of children in a state of chronic
semi-starvation must be to undermine the future of
our race. No class of the community is in a better
position than the medical profession to judge of the
ravages worked by shortage of food amongst the
poor, for they are brought into close contact with
the facts themselves in all their phases. On the
score of public health, and of the radical necessity of
fostering the vitality of the rising generation, not
to mention considerations of political economy and
of ordinary humanity, we trust that wiser and better
views will utimately prevail on this point in the
London County Council, and that other local
authorities in all parts of the kingdom will follow
them in adopting this salutary Act. It is a weak
alternative to draw upon the resources of private
charity to replace what should, in our opinion,
clearly be the recognition by public citizenship of
an elementary duty. The springs of private bene¬
volence are already seriously drained in attempting
to satisfy the needs of the medical charities, which
will suffer proportionately if donations be diverted
to the feeding of the school-children by channels
that must at their best be somewhat intermittent
and altogether uncertain.

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D

68o The Medical Press.

CURRENT TOPICS.

Dec. 35, 1907.

CURRENT TOPICS.

A Workhouse Scandal.

An inquiry into the death, on December 4th, of a
recent inmate of Wandsworth Infirmary, is being
made by the Westminster Coroner under unusual
circumstances. As the inquiry, which involves an
explanation, is still incomplete, we refrain from com¬
ment upon the case. There is one point, however,
to which the attention of all Poor Law medical
officers should be directed, namely, the discharge
of responsible nursing, dispensing, and other more
or less directly medical services in the midst of a
mass of other duties. One witness, who is alleged to
have made some lapse, produced the following list
of duties :—

(1) Assist with coaling and removal of ashes and
poultice tins. (2) To obey all orders of the medical
officers and stewards. (3) To bathe all male patients
on admission, unless countermanded by the medi¬
cal officer. (4) To search the clothes of the male
patients when admitted, and place them in a num¬
bered bag and rack in the clothing-store ; make list
of all articles, and put clothes away thoroughly
dry. (5) Immediately hand to the steward all
money, documents, or other valuables found on
patients. (6) Bake carefully and thoroughly all
foul clothes, underclothing to be taken to the
laundry, and the whole afterwards placed in the
clothing-stores. (7) To be responsible for the good
order of the patients’ clothing-store. (8) To assist
in carrying patients or articles of furniture to and
from the wards. (9) To take to the master all the
clothes of deceased male patients, entering a list of
the articles in a book. (10) To bake all foul bed¬
ding, clothes, etc., from the wards with great care,
and disinfect any room when desired. (11) To assist
every day with the patients’ dinner, and convey milk
to such parts of the infirmary as directed. (12) To
collect the bottles for the dispensary, and deliver
them to the nurses when the medicines are made up.
(13) To wash the bottles for the dispenser. (14) To
keep In good order the bottle-room, dispensary,
store, drug-room, and the two bath-rooms of the
male receiving ward. (15) To sweep daily and wash
down on Saturdays, or more often if required, the
disinfecting chamber, the yard adjoining the
mortuary, and the steps leading to the subway. Also
to take weekly turn in rotation with the other
porters in the washing of the new bath-room, lava¬
tory, etc. (16) To attend to the hall when required.

For this multifarious service the Guardians paid
the munificent sum of ;£i per week.

Inaccurate Prescriptions.

The vital importance of the purity of accuracy of
the ingredients of the physic compounded by
chemists is self-obvious. In places where the
matter has been put to the test startling results
have been in various cases forthcoming. Only last
week a London chemist was fined £5, or in default
one month’s imprisonment. The defendant did not
appear, but he runs a good chance of the more
serious punishment should he offend again in a
similar way. At last the modern tendency of magis¬
trates appears to incline towards greater severity.

It would be hard to imagine a meaner or more in¬
jurious offence than that of substituting one pre¬
paration for another ordered by a medical man, no
matter whether the motive be parsimony, conveni- |

ence, or a desire to save time. As the gentleman
who appeared for the City solicitor remarked, the
matter was most serious because medical men
depended upon accuracy in the making up of pre¬
scriptions, and Dr. Teed, the public analyst, had
told them in his report that many drugs had been
considered worthless, whereas in reality they had
never been tried. Since April last 23 City prescrip¬
tions have been analysed, and no fewer than twelve
of them were found to have been inaccurately
dispensed. The state of trade morality thus dis¬
closed reflects most undesirably on the main body of
a class of men whom the public have learnt to
regard with entire confidence.

An Alternative Drink for Alcohol.

A correspondence has been recently evoked in the
columns of a London newspaper by a writer who
advocated an alternative drink containing tincture
of capsicum to allay the craving for alcohol. This
caught the eye of a scientific gentleman, who
promptly pointed out that tinctures, being made
with spirit, to prescribe fhem in such cases was
simply adding fuel to fire. This statement brought
a number of medical men into the fray. One side
maintained that tinctures could be made without
alcohol. Strictly speaking, we fail to see how a
non-alcoholic extract could consistently be called
a “ tincture,’’ although most medical men are aware
that it is possible to substitute for nearly all
pharmacopoeial tinctures a cheaper non-alcoholic
preparation which is usually fairly equivalent from
a therapeutic point of view. In the case of capsi¬
cum the extract, as a matter of fact, is much
stronger than the tincture. The other class of
medical critics emphasise the abs'urdity of objecting
to the presence of such a fractionally minute dose
of alcohol as that contained in a few drops of tinc¬
ture of capsicum. Were the objection to alcohol
pushed to the absurd degree of excluding all
alcoholic preparations of drugs, the practice of
physic would be handicapped thereby in a quite
unnecessary manner. Incidentally, the interest
shown in the discussion under notice illustrates the
deeply-rooted belief of the vulgar in the possibility
of specific drug cures, and, so to speak, antidotes
for alcoholism. It would be difficult to produce an
illustration of a more widely diffused popular error
than the one upon which the fortunes of the drink

“ cure ” is founded. -

Incriminated Kippers.

A recent case in the High Courts opens up a
novel and somewhat interesting point in the annals
of ptomaine poisoning. It concerned an action for
breach of warranty on the sale of an article of
human food, namely, kippers. The defendants, in
reply, denied the warranty, and alleged that all kip¬
pers supplied by them were sound and wholesome.
The plaintiff one afternoon went to the defendant's
restaurant and there partook of tea, bread .and
butter, and kippers. He noticed, he said
in evidence, that part of the fish had a
musty smell and did not eat any more.
On the following morning he was seized with a
violent attack of ptomaine poisoning, from which
he ultimately recovered. His medical attendant
stated that he had seen a similar case in his own
household from eating an unsound kipper. Such
cases, however, must be, we imagine, extremely
rare. There is the cogent fact adduced on behalf
of the defence by Dr. Alfred Stokes, Public Analyst

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PERSONAL. _ The Medical Press. 68 l

Dec. 25, 1907.

for Paddington, who testified that poisoning from
kipper was unlikely, namely, that the in¬
ternal organs of the herring were removed in the
course of preparation, which further involved salt¬
ing, smoking, and drying—to say nothing of the
purification by cooking. The jury had little diffi¬
culty in finding a verdict in favour of defendants.

A Public Medical Service.

The medical men of Birmingham have inaugu¬
rated an important scheme for the service of persons
who are unable to pay ordinary fees. Any practi¬
tioner of twelve months’ standing is qualified to
join, provided he does not attend any sick clubs.
Branch institutions are to be formed as necessary,
and the medical officers are to be chosen from
members. Each applicant has to be passed by one
of the staff, who is responsible for fitness. A fee
of at least twopence per week is to be paid by each
person joining the organisation as a patient, and
members are to be remunerated toy a division of
profits at stated intervals. Each patient is entitled
to choose his or her medical attendant. The
medical benefits do not cover confinements, con¬
sultations, disease arising from misconduct, serious
injuries, dentistry, surgical operations, anesthetics,
and the supply of bottles or appliances. At the
same time, it is proposed to make certain definite
charges for nij^ht visits and extra services of
various kinds. This appears to be a well-thought-
out plan for facing the competition of hospitals,
clubs, and other agencies that divert the poor from
their proper medical attendants, namely, the general
practitioner. The future of this energetic organisa¬
tion deserves to be carefully watched by the medical
profession generally. It is not the first time that
the medical men of Birmingham have shown them¬
selves capable of firm action in the attempt to
defend their own interests.

The Manchester Epileptic Colony.

Manchester can boast of the finest epileptic
colony in the world, and is making great efforts to
seriously combat the disease. The medical report
of the colony shows that during the past year, with
the average number of colonists standing at 171,
the total number of fits recorded was 29,4^4. These
were unequally divided among the colonists; some
had none, others had very many. One woman is
reported to have had 2,814 * n twenty consecutive
days, with a maximum for twenty-four hours of
239. Another woman is said to have had 609 heavy
major attacks in eight consecutive days. Both
these patients are now going about; one of them
has been free from fits since May. Another girl
had 1,743 in February, 725 in June, and 565 in
August. Such cases must obviously make great
demands on the part of the staff. The epileptic
colony movement is one that deserves the hearty-
support of philanthropic persons.

The “Brown Dogr” Disturbances.

In our last issue we referred to some of the news¬
paper comments on the recent “brown dog”
disturbances, remarking on the curious antipathy
to the medical profession which they revealed. We
are glad to see that some of the more respectable
weeklies have shown more fairness, and have
drawn attention to a point in connection with the
disturbances which had escaped general notice.
This is the refusal of the police authorities to allow
the medical students the privilege accorded to all
other sections of the public, of holding meetings in
Trafalgar Square, and of walking in procession
through the streets. So far as we can learn, there
was no special disorder attached at first to the meet¬
ings of students, and we fail altogether to understand 1

why they should have been specially selected for
bludgeoning by the police. The disorder, indeed,
seems to have been enormously increased, if not
created, by the injudicious Interference of the police
authorities. The object for which the students
met may have been a foolish one or a wise one, but
it was no worse than the hundred-and-one other
objects to which meetings in Trafalgar Square—
undisturbed by the police—are devoted. It is
hardly the function of the authorities to act as
censors of the purposes of meetings in public places,
and, as we suggested last week, Russian methods
are out of place in London.

Copper in Spinach.

Two fines of ^5 and £4, with costs, have recently
been imposed in London police courts for selling
preserved spinach in tins. Analysis showed in one
case 4.70 grains of copper sulphate, and in the
other 3.29 grains per pound. Medical evidence
showed that the proportion of the copper salt men¬
tioned would be injurious to health. Half a pound
of such spinach would in some cases cause symp¬
toms of irritant poisoning. The defendant stated
that tinned spinach was used in every restaurant in
London, and he claimed that the prosecution should
be turned to the wholesale manufacturer from
whom the tins came. Some years since a similar
exposure took place in the case of preserved peas.

PERSONAL.

Dr. Deane Sweeting has been reappointed an
Examiner in State Medicine at Cambridge University.

Dr. C. Guerin and Professor A. Calmette have been
awarded the Louis Boggio prize for their researches on
tuberculosis.

The King of Spain has conferred upon Dr. A. J.
Rice Oxley, Physician-in-Ordinary to Princess Henry
of Battenberg, the Order of Isabella the Catholic.

Under the will of Mrs. Fanny Peach, the Notting¬
ham General Hospital has benefited to the amount of
,£r,ooo, and the Brompton Cancer Hospital to that
of £500.

Among new members of the Council of the Metro¬
politan Hospital Sunday Fund are Sir James Reid,
K.C.B., Sir Thomas Smith, K.C.V.O., and Mr.
Thomas Wakley.

In our last issue we stated that Dr. Arthur J. Hall
had been appointed Lecturer on Practical Medicine,
University of Sheffield. In so doing' we-referred to
Dr. Hall as Physician to the Sheffield Royal Infirmary.
This should have been the Sheffield Royal Hospital.

The Liverpool medical students’ annual dinner,
which took place on December 14th, with Professor
Rushton Parker as chairman, and Dr. John Owen as
Vice-Chairman, was made the opportunity for pre¬
senting Professor Parker with his portrait in oils.

Among the new members of the General Council of
King Edward’s Hospital Fund for London are Lord
Rosebery, the Speaker of the House of Commons, the
President of the Local Government Board, Professor
Osier, and Dr. Edwin Freshfield.

Bv the will of the late Mr. Thomas Berry, the
Clinical Hospital for Women and Children, Man¬
chester ; the Altrincham Provident Dispensary and
Hospital, the Salford Royal Hospital, and the Ancoats
Hospital and Dispensary receive j£i,ooo each.

The honorary surgical staff and committee of the
Margate Cottage Hospital have presented Mr. William
Knight Treves, F.R.C.S., with an illuminated address,
in appreciation of his thirty years’ service.

Diai

Googl

e

682 The Medical Press.

CLINICAL LECTURE.

Dec. 25, 1907.

A Clinical Lecture

ON

THE SERUM TREATMENT OF TYPHOID FEVER

(ANTITYPHOID OPSONISATION).

By DR. CHANTEMESSE,

Professeur Agrege of the Faculty of Medicine of Paris.

[specially reported for this journal.]

During the last six years (April, 1901, to July, 1907) j
5,621 cases of typhoid were admitted to the Paris hos¬
pitals with a mortality equivalent to 17 per cent. Since
then a thousand typhoid patients have been treated in
my fever wards with a mortality of only 4.3 per cent.
My treatment comprises cold baths (24 0 to 30^ C.), plus
the injection of antityphoid serum.

In 1906, Professor Brunon, of Rouen, and Dr. Josais,
of Paris, brought to the notice of the Academy of
Medicine an improvement in the typhoid mortality
under the serum treatment, this having fallen from
between 10 and 12 per cent, to from 3 to 4 per cent.
During the same period the mortality at the Val-de-
Grace Hospital remained at 10.6 per cent.

Under the influence of the antityphoid serim the !
course of the disease is invariably modified in much j
the same manner. The evolution of the disease is
sharply divided into two periods, the first being the
stage of reaction following the injection, the second
the process of defervescence. The first stage lasts from
a few hours to several days, during which the tem¬
perature falls but slightly or not at all—indeed, it
may even be a shade higher; then suddenly it goes
down, the baths are required less frequently, and a
steady decline sets in. The constitutional symptoms
accord with the state of the temperature, and the
patient does not feel any benefit until the onset of the
second stage. When this sets in the patient may have
hyper-pyrexia, necessitating several baths daily, but he
feels better, the appetite returns, and he secretes plenty
of urine. At this juncture there supervenes a very
curious—indeed, characteristic—sign in typhoid fever,
modified by the serum treatment—viz., a striking
change in the vaso-motor system.

Every physician is familiar with the typical facies
of the typhoid patient, in whom, in spite of the high
central temperature, the tip of the nose, the hands and
the feet are cold, and the nails are cyanotic. In
patients treated with the serum, at the expiration of
the stage of reaction the facies markedly improved.
Colour returns to the cheeks, the stupor is modified,
the hands lose their pallor and are warm, and the
nails have a rosy hue. This improvement In the peri¬
pheral circulation persists throughout, and accounts
for the wonderful improvement in the appearance of
patients thus treated.

The improvement is the more marked the earlier the
serum has been injected after the onset of the disease—
that is to say, at a period before the organic resistance
has been broken down, and can therefore react ener¬
getically to the treatment. I have not lost a single
patient during the last six years in my fever service
in whom the injection has been made withi.i the first
seven days of the disease.

When the serum treatment is resorted to late—and by
late is meant more the gravity of the damage already
done than the mere number of days—the results are
less rapidly favourable. The serum cannot bring about
the disappearance of the nervous lesions, nor prevent
the necrotic intestinal lesions when already present.

The blood pressure goes up within a few hours of
the injection, and may reach between 12 and 15 cm.
of mercury; this is sufficiently well marked to enable
us to dispense with cardiac tonics. The pulse rate
usually declines with the temperature. It may rise
somewhat in presence of an unusu-v.lv intense reaction,
but this is of no particular gravity. I have seen plenty
of patients with a pulse rate of 150, which is regarded
as of fatal significance, yet they recovered.

The urinary secretion greatly increases in amount. 1

Whereas the polyuria usually only supervenes wilt
convalescence, in injected patients it is observed in the
course of a few days, and sometimes amounts to 8 or
10 pints. If there be albuminuria before the injection,
it soon subsides after it, and it is very rare for patients
who were not albuminuric when injected to become so
afterwards.

The influence of the serum on the temperature curve
i3 appreciable for ten or twelve days, after which
either convalescence sets in or the temperature con¬
tinues to fall until recovery, the attack being compara¬
tively short, or else, in the graver cases, the defer¬
vescence is stationary for some days, remaining above
normal, as if the remedy no longer produced any effect,
then convalescence sets in in the absence of a relapse.
In any case the relapse usually only lasts a few days,
especially when the original attack has been severe.

Convalescence is usually rapid, especially in patients
treated early. Nevertheless, those in whom the disease
has been promptly arrested by the serum, must take
great care for some weeks to come, for I have occa¬
sionally seen a patient relapse two or three months
later. This persistence of the microbe is, indeed, a
well-recognised occurrence, and is manifested by
osteitis and periosteitis. In this connection I must
mention the remarkable effects of a small injection of
serum in loco dolenti. We are aware that, as a rule,
osteitis is of protracted duration, and usually ends in
suppuration requiring surgical intervention. As soon
as there is swelling and nocturnal pain, we need only
inject one drop of the serum into the centre of the
lesion, whereupon, within a few hours, the pain sub¬
sides, the swelling disappears, and recovery takes place
in two or three days. The same treatment is applicable
in the event of orchitis or typhoidal mammitis.

The low mortality in my thousand patients is evi¬
dence per se that complications must have been infre¬
quent. Intestinal haemorrhage only accounts for 4 out
of the 47 deaths, while perforation accounts for 19,
so that the treatment appears to protect less against
this complication than others. This is explained by
the fact that the intestinal lesions are the first to occur,
and are already present when the injection is carried
out, hence the importance of injecting early. I have
never met with intestinal perforation in patients in¬
jected within seven days of the onset.

I have made a number of observations in order to
ascertain whether the conjunctivas of typhoid patients
displayed a marked sensitiveness to the bacillus which
might be useful in arriving at a diagnosis. Such is
actually the case, and it may be well for me to describe
the mode of employment of the test. The test solution
is prepared as follows-: A layer of gelose in a flat
bottle is inoculated with the virulent bacillus and
placed in the warm chamber for 18 or 20 hours, by
which time the surface has become covered with a cul¬
ture, which is removed after adding 4 or 5 cc. of steri¬
lised water, and the bacillary mass is poured into a
large tube. This is heated over a water bath
at 6o° C. to destroy the vitality of the bacilli;
it is centrifugated, and the bacilli are dried
in vacuo. The microbial mass is rubbed down
in an agate mortar, with a little chloride of
sodium. When thoroughly rubbed down we add
4 cc. of sterilised water, and continue the process,
gradually adding water to the extent of 100 grammes
for, say, 3 grammes of the microbial mass. The tube
is then set aside to repose for two days, heating it
to 6o° daily for half an hour. The supernatant liquid
is then decanted. It is almost transparent, and,

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Dec. 25, 1907.

CLINICAL LECTURE.

The Medical Peess. 683

should any flakes be present, it is again centrifugated.
It should be but slightly opalescent when it is slowly
poured into ten times its bulk of alcohol. The alcohol
becomes cloudy, and is allowed to deposit for three
hours, when it is decanted, and the coagulum that has
formed at the bottom is rapidly dried in vacuo. We
thus obtain a yellow mass, which is rubbed do vn to a
fine powder in an agate mortar. When to be used,
the powder, which contains a small proportion of
toxin adherent to a substance that reacts to the test for
albuminoids, is triturated, and it dissolves slowly, in
the proportion of 10 milligrammes to 1 cc. of water—
that is to say, enough for twenty observations. Thus
prepared, the powder keeps very well in a closed
bottle. The resulting fluid should be opalescent and
free from flakes.

One drop of the solution is dropped into the lower
conjunctival cul-de-sac, the patient’s head being
thrown back to prevent it escaping. Within two or
three hours there is a sensation of heat, and the red¬
ness extends to a caruncula; there is some weeping
and fibrinous exudation. The effect attains its maxi¬
mum in from six to ten hours after instillation. The
intensity of the reaction depends on two factors: first,
on the sensitiveness of the patient, which varies within
wide limits ; and, secondly, on the quantity instilled.
The quantity given has been shown by experience to be
sufficient to determine a reaction in typhoid patients,
and not in others. But the typhoid toxin is irritating
fcr se, and what we must rely upon is not the existence
of a reaction, but its intensity and its persistence.

The point to which I attach particular importance,
since I have never found it wanting in true typhoid,
is the persistence of the redness. This persistence is
easily detected by comparison with the untreated eye.
It may persist for one, two, or even five or six days,
after which it clears up. After upwards of 200 obser¬
vations, I have never seen the slightest untoward effect.
Fifty persons suffering from non-typhoidal diseases
gave no reaction, with one exception—that of a tuber¬
culous woman who had had typhoid two years before,
and in this case it had disappeared on the following
day. Sixty-seven patients with well-marked typhoid
gave a positive reaction.

The most interesting feature of this research is the
following: Several times at the onset, or in the course,
of an attack of typhoid fever, the ophthalmo-diagnosis
gave a positive result,, while the sero-diagnosis was
negative, and only became positive several days later.
As a matter of precaution the ophthalmo-diagnosis
should only be tried in eyes which appear normal and
healthy, or naked eye examination and the reaction
should be quite apparent after 24 hours. It is possible
that this delicate reaction may ultimately lead us to
include among typhoid affections slight febrile attacks
in which the sero-reaction proves negative.

The serum I employ is obtained from horses in
which intravenous injections of virulent microbes
have been practised for a long period, or the soluble
typhoid toxin injected beneath the skin.

The soluble toxin is prepared by cultivating in flat
bottles, in a bouillon of ox spleen, very virulent
typhoid bacilli. The bacillus develops on the surface,
and the toxins are elaborated beneath. In seven days
this is collected in small bottles, and heated to 55 0 C.,
and centrifugated. The injections in the horse must
not be repeated at too short intervals, for each one
determines a sharp rise of temperature, and the horse
becomes immunised but slowly. Those give the best
results that have been injected periodically for several
years. The properties of the serum vary somewhat
according to the lapse of time that has taken place
since the last injection of toxin. It attains its maxi¬
mum preventive power in about 20 days.

Only small doses are required, and I have been
able, by using the serum of animals injected for several
years, to use only a few drops for each injection, a
dose sufficient to determine the modifications in the
course of the disease already referred to.

The influence of an injection lasts about 10 days.
I rarely make a second unless the disease displays a
tendency to become protracted, and in such case the
second injection should be less in amount than ihe
first, for it sometimes gives rise to local tumefaction,
a result that never follows the first injection.

Injected into healthy rabbits and guinea-pigs, the
serum gives rise to no constitutional symptoms.
Animals previously injected resist inoculation with a
quantity of typhoid toxin that proves fatal to animals
not so protected. If the toxin and the serum be in¬
jected separately but simultaneously, the action of the
former is almost as intense as when no serum is used,
but the leucocytic defence is vastly more rapid and
energetic than in animals where no serum is used;
moreover, the bloo'd returns to normal much more
promptly. If the injection of serum be made too
late— i.e., in presence of urgent symptoms of intoxica¬
tion—the favourable reaction is, so to speak, inhibited,
and is not produced. The effects of the serum last for
some time, and animals that have been injected there¬
with six or seven days previously still manifest marked
resistance to subsequent injections of the toxin.

In order to properly grasp the action of the immu¬
nising injection, we must examine the spleen and bone
marrow of the animals under observation. The differ¬
ence in animals thus treated and the control animals
is so marked as to be visible even to the naked eye.

The effect in the healthy man and the typhoid patient
is exactly the same as in animals. Phagocytosis is
stimulated in a marked degree—in fact, the state in¬
duced in the organism of the typhoid patient by the
injection of the anti-typhoid serum is one of opsoni-
sation. This is shown by estimating the opsonic index
in patients subjected to serotherapy. The opsonic
index by Wright’s method is the relationship between
the power (to take up typhoid bacilli), which leuco¬
cytes possess in normal human serum, and the power
which these same cells acquire under the stimulus of
typhoid blood either before or after the injection of
serum.

The opsonic index is somewhat variable, according
as we are dealing with a slight or severe form of the
disease. In mild cases the opsonic curve shows that
the opsonic index is high even before the injection of
serum— i.e., 2.1 (unity being the normal). The day
following the injection the opsonic index rises, reach¬
ing its highest point on the fourth day ; then it falls
a little as the injected serum is eliminated and defer¬
vescence set 9 in, while the patient’s serum contains a
progressively higher quantity of opsonines. When
convalescence is well marked the opsonic index remaiis
high for a month or so after recovery. When con¬
valescence is protracted, the opsonic index is lower.

In severe cases the opsonic index is low before the
injection, after which there is a sudden and marked
rise during the three or four following days. This
period, no doubt, corresponds to wholesale destruction
of bacilli throwing toxic products into the blood of
the patient already intoxicated by the typhoid fever,
and the patient reacts by a rise of temperature which
is the phenomenon of the reaction; hence the desira¬
bility, in severe cases, of restricting the destruction of
bacilli by only employing very small doses of the
serum.

Between the fourth and twelfth day after the in¬
jection the curve of the index falls, although remaining
above what it was before the injection. Then in severe
cases the index oscillates round a fixed point until
recovery ensues.

We must avoid giving the patient too severe a shock
or we run the risk of inhibiting the production of
opsonines. When the case takes a turn for the worse,
as, for instance, in the event of intestinal perforation,
the opsonic index steadily falls until the fatal result
supervenes.

Already in 1902 I pointed out that “the graver the
illness the smaller must be the dose of serum.” This
struck many as a strange utterance, but it is now ex¬
plained and justified by observation of the oposonic
curves.

It may be asked why, being in possession of such a
powerful means, I still employ cold baths. My answer
is that the baths are necessary to assist the patient in
resisting the pyrexial reaction that follows the injec¬
tions. Anti-typhoid serum is not an absolutely com¬
plete treatment, but it is one of great power which we
have to learn how to use. At Cairo, in 1902, I sug¬
gested that “by the addition of anti-typhoid serum to
hydrotherapy the typhoid mortality might be reduced
to 4 or s per cent.” Five years have passed since thal

684 The Medical Press.

ORIGINAL PAPERS.

Dec, as, 1907.

time, and a much larger number of cases of typhoid
fever have been treated at the hospital, and I have
Qothing to modify in that suggestion.

Note. —A Clinical Lecture by a well-known teacher
appears in each number of this journal. The lecture for
next week will be by Harry Campbell, M.D., FM CJ
Lond., Physician to the West Hud Hospital for Nervous
Diseases. 8ubject: “ The Diet of the Aged."

ORIGINAL PAPERS.

INTERSTITIAL KERATITIS FROM A
MODERN STANDPOINT, (a)

By SYDNEY STEPHENSON, M.B., C.M.,

Editor of " The Ophthalmoscope."

It would be difficult or impossible to over-estimate
the diagnostic importance which attaches to some of
the ocular stigmata of inherited syphilis. By their
discovery the nature of many and many an obscure
case has been cleared up. I can recall a couple of cases
of necrosis recognised as syphilitic in one instance by
the finding of disseminated choroido-retinitis, and in
the other by the advent of interstitial keratitis. The
most striking case with which I am acquainted, how¬
ever. was related by Edmond Fournier in his mono¬
graph on late heredito-syphilis (“ Recherche et Diag¬
nostic de l'her6do-syphilis tardive,” 1907, p. 325). A
man, set. 34, was believed to be suffering from sarcoma
of the pelvis, declared by three competent hospital sur¬
geons to be beyond the reach of operation. The patient’s
elder brother, aet. 36, was examined by my friend
Dr. Antonelli, with the ophthalmoscope, and found to
be affected with positive stigmata of congenital
syphilis. The result of this discovery was happy in
the extreme. For after two months’ treatment by
mercurial injections and potassium iodide, the pelvic
growth disappeared without leaving a trace and the
patient was restored to perfect health. His remark
was amply justified when he exclaimed : “ J'ai itt
sauvt par les yeux de man frtre.''

Of all the ocular manifestations of inherited syphilis,
none is better known or easier to recognise than diffuse
interstitial or parenchymatous keratitis.

The disease is not exactly a common one. For
example, Greeff, (Die Keratitis interstitialis in ihren
Beziehungen zu AUgemeinerkrankungen , 1897) collected
figures respecting 36,385 eye patients, and found that
interstitial keratitis had been diagnosed in 297— i.e.,
in 0.77 per cent, of the total number. Again, among
5,142 eye patients seen by me at the North-Eastern
Hospital for Children, London, 49, or 0.95 per cent, were
affected. The proportion would naturally be some¬
what higher at a children’s hospital than elsewhere.

The disease has been familiar to surgeons for many
years. Wiilliam Mackenzie (“ A Practical Treatise on
the Diseases of the Eye,” 1830, p. 419.”) who takes in
ophthalmic science the position occupied by Sir Thomas
Watson in general medicine, was acquainted with the
malady, which was called by him “scrofulous corneitis.”
Mackenzie noted its coincidence with deafness, a pecu¬
liar hoarseness of voice, swollen lymphatic glands,
nodes on the tibiae, and effusion into the bursa beneath
the tendon of the extensores cruris, symptoms some
of which we now recognise to be manifestations of
inherited syphilis.

It was, however, reserved for Jonathan Hutchinson
(“ A Clinical Memoir on CertainDiseases of the Eye and
Ear, consequent on Inherited Syphilis,” 1863) to show
that interstitial keratitis was “ almost always a direct
result of inherited syphilis.” and to give a description
of its clinical characters and morbid associations that
is as truthful to-day as when he wrote it forty-four
years ago. In particular, Hutchinson drew attention
for the first time to the diagnostic value of certain

malformations of the teeth often met with in cases
of interstital keratitis.

A few years later James Dixon (“ A Guide to the
Practical Study of Diseases of the Eye,” third edition,
1866, p. 95) went farther, and proposed to substitute
for Hutchinson’s name, “ chronic interstitial keratitis,”
that of “ syphilitic keratitis,” since there existed, he
said, “ no special form of keratitis connected with
uired syphilis.”

till more recently, Hutchinson (“ Syphilis,” London,
1889, p. 75) has claimed that " interstitial keratitis
in its typical form is always a consequence of syphilis,
and is in itself sufficient for the diagnosis.”

To some extent, however, the pendulum of profes¬
sional opinion has now swung back to the views ex¬
pressed so many years ago by William Mackenzie.
The view current to-day, especially upon the Continent,
is, that while parenchymatous keratitis is usually a
manifestation of inherited syphilis, yet a proportion
of the cases are due to other factors, among the more
important of which are tuberculosis, acquired syphilis,
influenza, malaria, and trypanosomiasis. In a word,
it will scarcely be denied that interstitial keratitis is
the local manifestation of some general disorder, be it
syphilis or otherwise.

It will clear the ground if a few figures be quoted as
to the relative frequency of inherited syphilis as a
cause of interstitial keratitis. Davidson found 20 per
cent., Alexander 35.3 per cent., Fournier 41.5 per cent..
Hirschberg 61 per cent.. Saemisch 62 per cent., Horner
64 per cent., Mauthner 80 per cent., Bosse, 81 per cent..
and Silex 83 per cent, of the cases to be due to a
specific cause in the shape of inherited syphilis. Pfister
(Klin. Monatsbl. f. Augenheilkunde , XXVIII., 1890
p. 114) found certain evidence of hereditary lues in
40.8 percent, of his 130,cases and presumptive evidence
in 23.8 per cent.—total. 64.6 per cent. Nettleship
(“ Diseases of the Eye,” fifth edition, 1890, p. 120) found
personal (54 per cent.) or family (14 per cent.) evidence
of inherited syphilis in 68 per cent, of an unspecified
number of cases, and in most of the remaining 32 per
cent, there were strong reasons for suspecting its
existence. My own figures, dealing with 101 cases,
gave inherited syphilis in 70 or 69.3 per cent.

Other statistics might readily be quoted, but enough
have been given to show that, broadly speaking ade¬
quate evidence of inherited syphilis may be obtained
in about two-thirds of all cases of parenchymatous
keratitis.

With regard to the frequency of tuberculous inter¬
stitial keratitis, some interesting figures have recently
been published by H. Rabiger (ref. in Archives of
Ophthalmology. November, 1907, p. 875). In 349 cases
of keratitis observed at the University Polyclinic at
Berlin, tuberculosis was found with certainty in 11
per cent., and with probability in 9.7 per cent.—total.
20.7 per cent. In my own series of 101 cases tuber¬
culosis was identified as the cause of the keratitis in
10—that is, in 9.90 per cent. The more extended
employment of Calmette’s serum test will doubtless
help us to recognise such cases with more certainty.

It would appear that interstitial keratitis is by no
means rare as a late, tertiary consequence of acquired
syphilis. The connection was first mentioned by Velpeau
in 1840 (“ Maladie des Yeux,”) and was described
in 1861 by Follin (Pathologic Fxterne, T.I.. p. 708,
1861)—that is to say, two years before the publication
of Hutchinson’s famous memoir.in which he commented
on “ the entire absence of interstitial keratitis from
the rdle of tertiary symptoms of acquired syphilis ”
(loco, citato., p. 221). In a later work (“ Syphilis,” 1889,
p. 237), however, Hutchinson modified this view, and
recognised the possibility of an acquired interstitial
keratitis.

According to figures collected by Pfister from Pro¬
fessor Haab's klinik (loco citato), of 130 cases of kera¬
titis 3.8 per cent. (2.3 per cent, certain and 1.5 per cent,
somewhat doubtful) were due to the acquired disorder,
while Ancke (Centralb . f. prak. Augenheilkunde. 1885.
p. 360) found the proportion in 100 cases to be as
high as 10 per cent. Among my series of 101 cases of

zed by GoO^lc

(«) A contribution to the discussion on Inherited Syphilis, nt the
Society (or the Study of Disease In Children, on December 18th, 1907.

Dec. 25, 1907.

ORIGINAL PAPERS.

The Medical Press. 685

parenchymatous keratitis, 4, or 3.96 per cent, were
unquestionably due to acquired syphilis.

It is important to note that such cases have been
met with, even in children. For example, Mauthner
(Zeissl’s Lehrbuch der byphilis p. 279) saw a case of
interstitial keratitis in a suckling that had contracted
syphilis from its nurse. Moreover, Trousseau (Annales
d'oculistique, September, 1895, p. 206) has mentioned
the case of a boy, a:t. 8, who was infected by his
nurse with syphilis. The result was a very severe
attack of bilateral keratitis. Lastly, I reported a
case of the kind (The Ophthalmoscope , Vol. I., 1903,
p. 169) in a girl, set. 12, who had suffered from a chancre
•on one upper eyelid two or three months after birth.

It may be noted as an interesting point that quite
a number of cases of interstitial keratitis have been ,
known to follow an indurated chancre on the eyelid
or conjunctiva.

The name “ interstitial keratitis ” is good in so far
as it directs attention to a prominent feature of the
malady—namely, to opacities “ like microscopic
masses of fog,” situated at various levels in the sub¬
stance of the cornea. It suggests, nevertheless, a
mistaken view as to the pathology of the condition
<Fuchs, v. Hippie, Pfluger, de Lapersonne, C. D.
Marshal, Parsons, &c.). The available evidence indi¬
cates that the ailment is primarily an inflammation of
the tissues of the ciliary body, which forms (as every¬
body knows) the middle part of the uveal tract, of
-which the other parts are the iris and the choroid.
From the ciliary body inflammation spreads forwards
to the iris as well as to the deeper layers of the cornea,
and backwards to the anterior parts of the choroid.
Keratitis and the commonly associated choroiditis and
iritis, therefore, are, strictly speaking, conditions
secondary to an inflammation of the ciliary body.
The underlying process may conveniently and accur¬
ately be described by the expression “ anterior uveitis.”

If this view be not grasped, it becomes difficult to
understand some clinical features of the disease. For
example, in my experience, it is not very uncommon
for the ailment to begin with what appears to be an
accumulation of pus in the anterior chamber of the
inflamed eye (a). This hypopyon, of course, repre¬
sents an exudation from the inflamed ciliary body,
which has passed through the pupil and has thereby
gained the anterior chamber. Another early sign is
the existence of deposits on Descemet’s membrane,
the “ aquo-capsulitis ” of the older, and the “keratitis
punctata ” of the more modern, writers, and this,
again, is to be regarded as the expression of an exuda¬
tion from the ciliary body. The occasional bleeding
into the anterior chamber (hyperaemia), which may
usher in an attack of parenchymatous keratitis, is
almost certainly due to the rupture of some small
<listended vessel in the ciliary body. None of these
appearances can be explained on the theory that the
disease is primarily one of the cornea.

Further, the iritis which often precedes or accom¬
panies the keratitis can be best accounted for by an
extension forwards from an inflamed ciliary body.

A similar remark applies equally to the choroiditis
which is frequently found when the cornea has cleared
enough to allow of an examination of the fundus
with the ophthalmoscope. In cases where choroiditis
is known to precede by months or years the develop¬
ment of keratitis, the backward extension to the choroid
has antedated the forward extension to the cornea, or
has possibly occurred independently of the ciliary
inflammation. Cases of this type are sometimes of an
unusually severe type. The following is an example :

John O-, a:t. 8. first seen on January 5th, 1893.

A typically syphilitic subject, with “ bossy ” forehead,
rhagades, and dwarfed and notched upper central
incisors, and a tendency to ptosis. Sight equalled
about one-fifth of the normal, as the result of widely-
spread, bilateral choroido-retinitis. In September,
1893, the right eye developed interstitial keratitis,
and seven months later (April 25th, 1894) the left eye
followed suit. On May 30th each knee-joint became

(<*) Hypopyon wag present In many of my 101 oases of Interstitial
Keratitis.

distended with fluid. The comeae presented a peculiar
appearance, since an irregular area towards the centre,

5 mm. at its widest part, resembled damp wash-leather,
and was everywhere surrounded by a zone of plum-
coloured vascular tissue—a confluent “ salmon patch,”
in short. Viewed from the side, the cornea projected
forward cone-wise, the blunt apex of the cone being
formed by opaque cornea and its sides by the vascular
patch. By this time the lad had become somewhat
deaf, without discharge from the ears. On June 19th,
a portion of the grey opaque central area had ex¬
foliated. Deafness was increasing. Both ankles had
become swollen. In August, 1894, the lad developed
delusions, which became very pronounced towards the
end of that month. He used vile language, insisted
upon getting out of bed for the express purpose of
breaking the windows of the ward or, for that matter,
anything else he could grope his way to, for by this
time he was, to all intents and purposes, blind. John

O-,was then transferred from the Ophthalmic School

to another institution, where “ he developed most acute
mania, and had delusions that people were coming to
kill him and that there were bloodhounds in the cup¬
board.” In 1902—that is, nine years after I first saw
him—the patient was an inmate of Darenth Asylum,
quite blind, and suffering from imbecility with occas¬
sional attacks of excitement. One of his eyes had been
removed owing to an injury.

The case just described presented several peculiari¬
ties, and amongst them ulceration of one cornea. This
complication, in my experience, is not common. For
instance, among my 97 cases (a) of interstitial keratitis
it occurred in 4—that is to say, in 4.12 per cent. That
it might occur was known to Hutchinson, who alluded
to one or two cases on page 29, of his oft-quoted memoir.
W. Spencer Watson ( Ophthalmic Hospital Reports ,
Vol. IV., p. 296), writing a few years after Hutchinson,
reported an instance of unilateral ulceration observed
in a series of twenty-live cases of interstitial keratitis,
R. Ancke ( Centralb . /. prak. Augenheilkunde , 1885,
p. 296) had one example of ulceration among 100 cases
of interstitial keratitis. E. T. Collins ( Ophthalmic
Hospital Reports, Vol. XI., 1887), described four cases
in comeae which showed extreme vascularity, and in
which a small central island of non-vascular tissue was
alone left. This islet became yellow and then ulcerated.
In one of Collins’ cases there was perforation, but cica¬
trisation took place in the other three. His patients
showed unmistakable signs of inherited syphilis,
either in the teeth or the physiognomy.

In a majority of cases of parenchymatous keratitis,
one cornea is first attacked and the other cornea, accord¬
ing to Hutchinson ( loco citato, p. 29), “ after from one
to two months.” But it should be borne in mind that
the interval may be and often is much longer than this.
The extreme instance reported by Consiglio ( Beitrage
z. Augenheilkunde, May. 1905), where the interval
amounted to twenty-six years, must be almost unique,
although in his case the evidence of inherited syphilis
was not altogether conclusive. My own series includes
one case where the interval amounted to about seven

years, The facts follow :—Edmund D-, set. 13,

seen on December 22nd, 1899. with early interstitial
keratitis affecting the right eye, which had been diver¬
gent since infancy. After making a nearly complete
recovery, the right eye relapsed in September, 1905.
On November 30th, 1906, the following note was made :
“ The left eye has been affected for the last fortnight—
i.e., there has been an interval of seven years between
the attacks in the two eyes. The patient is deaf and
his teeth are typical of inherited syphilis. Hutchin¬
son’s triad is therefore present.”

All observers agree that parenchymatous keratitis
is essentially a disease of childhood. On this point
there is no difference of opinion. It is, nevertheless,
relatively rare in very young children, and equally so
after mature age has been reached. Hutchinson, for
example, had never witnessed its occurrence earlier
than two years or later than twenty-six years. It
is most frequent between the ages of five and eighteen

(a) FoarcasM due totoqulred ij-phtli* omittod.

Digitized by G00gle

686 The Medical Press

ORIGINAL PAPERS.

years (Hutchinson), or of six and fifteen years (Nettle-
ship).

The age-incidence of my 97 cases, arranged in quin¬
quennial periods, comes out as follows :—

Period.

Number.

Percentage.

1 to 5 years

6

6.19

S to 10 ,, ..

■ ■ 38

39.18

10 to is ,, ..

.. 26 ..

26.80

15 to 20 ....

.. 14 ••

14.43

20 to 25 ,. ..

8

8.25

25 to 30 ....

2

2.06

Over 30 „ ..

3

3-09

An inspection of the foregoing figures will at once
show that of my 97 cases, four-fifths, or 80.41 percent.,
occurred between the ages of 5 and 15 years. My series
includes one case in a woman, aet. 36, whose syphilitic
inheritance was attested by notched upper central
incisors, rhagades at angles of the mouth, and by a
node on the frontal bone, one inch above the inner end
of the left eyebrow. R. Marcus Gunn (The Polyclinic,
December, 1902) reported a case in a patient, aet. 36 ;
Pfister, (loco citato ) in a man aet. 37! ; and Greeff
(loco citato, p. 13) in a man of 38 years.

The rule that syphilitic parenchymatous keratitis
is relatively commoner in females than in males, is
supported by an analysis of my own cases, 97 in
number. Of the total, 37 (38.14 per cent.) were in
males, and 60 (61.86 per cent.) in females. It is, per¬
haps worth noting, that the same curious disproportion
between males and females applies also to juvenile
tabes dorsalis. Thus, Cantonnet (Archives d’ophthal-
mologie, November, 1907), as the result of an analysis
of 88 cases, found that females were affected in 63.6
per cent, and males in 37.3 per cent.

It should be noted that the figures given by Baker
and Story (Ophthalmic Review, November, 1885), and
by Ancke (Centralbl. f. prak. A ugenheilkunde, 1885,
p. 360) respectively form an exception to the general
experience as to the age-incidence of keratitis, as stated
above.

The discovery of the specific cause of syphilis in
the shape of the treponema pallidum, together with the
possibility of inoculating apes, rabbits (a) and dogs
with the virus, has widened our conception of the mor¬
bid processes that lead up to the development of
interstitial keratitis. The disease in question has been
produced experimentally in certain animals by the
implantation of syphilitic products. Indeed, prior to
the discovery of the treponema, P. Salmon (ref.
in Archives d’ophtalmologie, April, 1905, p. 1623)
observed iritis and keratitis thirty-three days after a
monkey had been inoculated with a syphilitic papule
from man.

We know that the tissues and organs of the syphilitic
foetus or baby are literally flooded with the treponema,
large numbers of which have been found in the placenta,
the umbilical cord, the blood of the umbilical vein, and
especially the liver. The organisms that escape the
liver are distributed by the foetal circulation to every
part of the body, where they determine this or that
syphilitic lesion. The treponema has been found in
cutaneous lesions, as pemphigus, by Levaditi and
others, in perioral ulcerations by Elizaldi and Wernicke,
in glandular lesions by Panea and Babes. That is by no
means all, for apart from definite lesions such as those
named, the treponema had been found in every internal
organ so far examined with the microscope. As
regards the eye, the findings from our present point of
view are highly suggestive. Thus, Hans Bab (Deutsche
Med. Wochenschrift, November 29th, 1906) exam¬
ined the eyes of three specific still-born babies. Pre¬
parations were treated by the silver impregnation
method, and large numbers of the spirochastes were
found in all the tissues of the eye, with the exception
of the vitreous humour and the crystalline lens. It
is important to note that the cornea contained a large
number of the organisms. Again, H. Schlimpert

(a) As long s go ss 1881 Paul Haensell (v. Grsefe's irchir. /.
Ophtalmologle, XXVII, III, p. 93) showed that syphilitic virus
could be successfully Inoculated into the Iris and oornea of the rabbit.

Dec. 25, 1907.

(Ibid, 1906, p. 1942) succeeded in discovering the-
treponema in various parts of the eyes of syphilitic
foetuses. Lastly, spirochastes have been demonstrated
in the tissues of seemingly unaffected eyes of syphilitic
foetuses and babies by some other observers, including
Peters, Gierke and Stock and myself.

It would thus seem probable that if the child survive,
these micro-organisms (possibly in some different
morphological form) fie dormant in the tissues of the
eye, more especia^y in the ciliary body and the cornea.
They cause no mischief until some exciting cause,
of a local or general nature, lowers the resistance of
the part, and allows the treponema to come into action.
The result is an attack of interstitial keratitis.

In this view we can explain an observation made-
by many surgeons—namely, that a slight injury to
the eye may precipitate an attack of parenchymatous
keratitis. I well remember the first case of this kind*
that happened in my practice. A girl. zet. 11. was-
admitted to the Ophthalmic School, Hanwell, for
trachoma, pannus, and lead opacities of each cornea,
in consequence of which the child was almost blind..
Her syphilitic diathesis was attested by (1) notched
central incisors of the upper jaw ; (2) scars radiating
from the mouth, the so-called ” Fournier's cicatrices”;
(3) ‘‘epithelial denudations” (a) about the skin of
the upper lip and nose ; (4) slightly enlarged lymphatic
glands ; and (5) cicatrices about the anus and buttocks.,
the so-called ‘‘Parrot’s cicatrices.” On March i6th„
1897, under cocaine, the metallic incrustations were
more or less scraped away from the right cornea by
means of a small, sharp scoop. The little operation,
somewhat to my surprise, was followed by redness
of the eye, and by increased haziness and vascularity
of the cornea—in a word, by the clinical appearances
of an ordinary parenchymatous keratitis. On May 4th
—that is, forty-nine days after the operation—the
condition was typical of interstitial keratitis. In view
of etiology, the case was an interesting one, and so on
June 16th, the operation was repeated on the other
eye. I am bound to add that the second intervention
was not followed by interstitial inflammation. Be
that as it may, the association between slight injury
to the eye, on the one hand, and parenchymatous in¬
flammation, on the other, is far from uncommon, as
will be obvious from the fact that I possess notes of
fifteen such cases.

Interstitial keratitis may supervene during the
course of illnesses, such as influenza and typhoid fever.
Here are one or two cases in point:—

Ellen W., aet. 11, was admitted to the North-Eastern
Hospital for Children under my colleague, Dr. James-
Taylor, on account of typhoid fever. On the seven¬
teenth day of the fever (approximately) the left pupil:
was noticed to be contracted and the cornea of the left
eye rather dull. When seen by me five days later,
there could be no doubt that the case was one of paren¬
chymatous keratitis. The girl had suffered from
periostitis of the right tibia for several weeks. Three-
months after the first eye had been attacked, the other
cornea went through a much milder attack of kera¬
titis. Florence G-, aet. 8, a child who presented

rhagades at the angles of the mouth, a caff an lait
complexion, and suspicious incisor and molar teeth,
in addition to slight deafness, was brought to the Eve¬
lina Hospital on March 15th, 1905, for a relapsed
interstitial keratitis of her right eye. The history was-
to the effect that three years before, about a fortnight
after her discharge from an Asylums Board Hospital,
where she had spent three months on account of enteric
fever, both eyes became inflamed, one soon after the-
other. The condition had slowly improved until a
relapse a few weeks before the child was brought to me.

I have also seen interstitial keratitis follow a whitlow
so closely as to suggest a connection between the two*
affections.

It is now, I think, generally recognised that inter¬
stitial keratitis may relapse—or, more correctly.

(a) The expression “ epithelial denudation " I apply to those super¬
ficial cicatrice*, whose favourite site Is at the junction of the ala nast
with the upper lip. Their significance and diagnostic value is lb»
same as Fournier's cicatrices.

oogle

Dec. 25, 1907.

ORIGINAL PAPERS. _ The Medical Pre ss. 687

recur—in one and the same patient. Manasse, in 50
cases had 8 recurrences, or 16 per cent., and v. Hippel,
among 87 cases, 15 recurrences, or 17.25 per cent.
The proportion in my own cases, many of which re¬
mained under observation for long periods of time, was
somewhat higher, namely, 22 per cent. As to the
explanation of recurrences we must assume that spiro-
chaetes have remained dormant in the tissues of the
cornea as a sequel of the primary attack. I believe
that recurrences are commoner in cases originally
treated without than with mercury, and I am confident
that, as a rule, they are more difficult to manage than
that original attack.

Experimental Keratitis. —Bertarelli (Presse Midicale ,
August 22nd, 1906) obtained a positive result by in¬
oculating the cornea of rabbits with an emulsion of
human chancres. The animals’ corneae showed numer¬
ous spirochaetes, and, in addition, a pronounced leu¬
cocytic infiltration, which extended into the seemingly
unaffected parts of the cornea. Scherber and v.
Benedek (Munch. Med.: Wochenschrift, June 14th,
1906) produced nodular iritis and interstitial keratitis
by inoculating the anterior chamber of rabbits with
syphilitic virus. Most suggestive experiments were
reported during the course of 1906 by Greeff and
Clausen (Bericht der Oph. Gesellschaft, Heidelberg,
1906), who inoculated the eyes of apes and rabbits
with syphilitic material, and after the lapse of some
weeks, observed the development of a kind of paren¬
chymatous keratitis. In the earlier cases, numerous
spirochjetes could be demonstrated, but the organism
could not be found in the more advanced cases. The
authors concluded that the corneal opacity was the
outcome of a leucocytic invasion, which attacked and
eventually destroyed the micro-parasite;

In a second communication (Deutsche Med. Wochen¬
schrift, 1906. No. 36), Greeff and Clausen concluded that
the pathogenic agents of syphilis multiplied in the
cornea, and thus caused an invasion by leucocytes,
which finally exterminated the micro-organisms,
Lastly, Hoffmann and Bruening (Deutsche Med.Wochen-
schr ft April 4, 1907) produced keratitis by the inocu¬
lation of a rabbit’s eye with a morsel of a human
chancre, and obtained a somewhat similar result when
an emulsified chancre was introduced into the anterior
chamber. Smears from the diseased cornea, when
stained by Giemsa’s method, showed the spirochaeta
pallida, thereby proving the essentially syphilitic
nature of the keratitis.

Panas (Archives d’ophtalmologie, 1871* p. 577)
taught that interstitial keratitis was a dystrophic
symptom, the indirect cause of which was to be sought,
not only in ancestral syphilis but also in lymphatism,
scrofula, gout, and arthritism. It is now suggested,
mainly as the result of experimental and histological
researches, that it is, in reality, an infection of the
tissues of the cornea with this or that specific organism,
the most important of such being the treponema palli¬
dum, the tubercle bacillus, the B. influenzae, the plas-
modium malaria;, and the parasite of trypanosomiasis.

In brief, it can nowadays scarcely be doubted that
syphilitic interstitial keratitis is due to the presence in
the parenchyma of the cornea of the causal agent of
syphilis. The treponema, however, has yet to be de¬
monstrated in that structure. The hiatus on this vital
point is not to be wondered at, since eyes are seldom,
if ever, removed during the height of parenchymatous
keratitis, nor do patients usually die during the course
of that affection. Speaking for myself, I have failed
to find the spirochaete in scrapings from eyes affected
with keratitis ; but, then, superficial parts only were
removed. Despite the known difficulty of recognising
the treponema in tertiary syphilitic lesions, it is safe
to predict that sooner or later the organism will be
discovered in the tissues of the cornea. The chain
of evidence, which still lacks one link, will then be
complete.

Aphorisms Respecting Interstitial Kera¬
titis.

1. Interstitial keratitis is not a primary affection of
the cornea, but is probably in every instance secondary
to changes in the anterior part of the uveal tract.

2. The disease is nearly twice as frequent in females.

1 as in males.

j 3 - Four-fifths of the cases occur between the ages of
five and fifteen years.

4. The disease can be shown in about two-thirds of
all cases to be associated with signs of inherited
syphilis, of which the commonest are the dental, facial,
and ocular stigmata. Other important causes of the
disease are tuberculosis, acquired syphilis, influenza,
malaria, and sleeping sickness.

5. Given a predisposing cause, the affection may be
excited by almost anything that lowers resistance,
local or general.

6. Ulceration of the cornea occurs in a notable per¬
centage of all cases.

7. The ailment is bilateral in three-fourths of the
cases. The interval between the two eyes being at¬
tacked may, however, run into several years.

8. Recurrences occur in perhaps one-fifth of the cases,
are commoner in cases treated without than with,
mercury, and are often very difficult to manage.

9. The disease is due to the lodgment and multi¬
plication in the cornea of the treponema palliduiru
derived primarily from the uveal tract.

10. Interstitial keratitis does not form more than.
1 per cent, of the cases met with in a special depart¬
ment for diseases of the eye.

ON EYE STRAIN, (a)

By HERBERT C. MOONEY, B.Ch., F.R.C.S.,

Ophthalmic Surgeon to the Children'* Hospital, Dublin.

In the short paper which I am about to read to you,.
I have brought together some symptoms of neuroses
which one meets with in eye work, and which, al¬
though varying very much in their severity and dis-
tribution, are generally grouped under the term “Eye
Strain.”

Although it is a long time since Donders described!
the errors of refraction of the eye, and since Weir
Mitchell wrote articles in which he brought forward
the part played by the eye as a cause of headaches,
yet it would appear that the relation which errors of
refraction bear to heachaches and other neuroses is.
not as generally appreciated as it should be.

When we consider the condition of affairs when the
eye is provided with an imperfect refractive system,
it is not surprising that some evil results therefrom.
Take the simplest case, that of hypermetropia. Here,
in order that the retina may be provided with perfect
images the ciliary muscle must be kept in a constant
state of tension from morning till night. With the
exception of the circulation and respiration, is any
other system expected to do a9 much? Even the
stomach, which stands a fair amount of ill-treatment,
breaks down, I believe, when subjected to a constant
call on its functions. When the refractive error is
one of astigmatism we have a stronger reason for
nervous exhaustion, for in this case there is an in¬
equality in the refraction of the principal meridians of
the eye, with a result that the images presented to-
the retina for its elaboration are not alone blurred,
but they are also distorted images of the object looked
at. No effort on the part of the ciliary muscle can
correct this condition completely, whatever it may
accomplish in reducing the distortion, so that the
work of the retinal elements and the visual act ai
a whole is considerably increased, with a resulting
fatigue somewhere.

Many patients who complain of headaches will not
believe that their eyes have anything to do with the
trouble, because they are satisfied (and rightly so)
that they can see as well as the best. A patient of
mine, a Queenslander, complained of headaches.
Without glasses the vision of each eye came up to
our normal standard. With corrective cylinders of
-r i D this acuity of vision equalled 5 / 2.5— i.e.,.
twice as good as the accepted standard. But
it must be remembered the visual act is not con-

fa) Road at the Medical Section of the Royal Academy of Medicine-
In Ireland, December 6th, 1907.

by Google

688 The Medical Press.

ORIGINAL PAPERS.

Dec. 25, 1907.

fined to focussing images on the retina. There is the
fusion of these images of the two eyes to be accom¬
plished by the six pairs of extrinsic muscles. So
that, with two emmetropic eyes and a complete accom¬
modative system, we may have some irregularity or
want of symmetrical action between the various pairs
of the extrinsic muscles. Those which are concerned
most with vision for different distances are the lateral
recti, and these are the muscles which we find most
at fault. But even these recti may possess a moderate
degree of a symmetrical action without producing
symptoms, but a very small degree of defect in the
action of the elevators or depressors of the globe
usually produces a discomfort of a marked degree,
and is often the cause of the most distinct symptoms
of eye strain. Having thus briefly viewed the possi¬
bility of the intrinsic or extrinsic muscles, acting in¬
dividually, being a cause of strain, or asthenopia, we
must recognise that when they come to work together
in cases where there are not only errors of refraction,
but errors of different kinds in the two eyes, the
source for eye strain is much widened. It is in cases
of marked difference in the refraction of the two eyes,
or want of balance in the extrinsic muscles, that we
find cases of migraine occurring which are relieved by
glasses.

Now to refer to the symptoms associated with eye
strain. Of these headache is the most common. The
pain may be across the forehead or at the root of the
nose. It is usually bilateral, .or may affect one side
of the forehead or one temple. The pain may be re¬
ferred to the vertex, a not uncommon site, or more
rarely to the occiput. The pain varies very much in
character, from being a constant dull ache to one
which may lie described as darting or neuralgic in
character. The headache may be constant or inter,
mittcnt, or noticed only when the eyes are applied to
close work or, perhaps, may have no relation to the
amount of near work performed.

In addition to the headache the patient may com¬
plain of apathy, giddiness, and sleeplessness.

The gastric symptoms sometimes met with take
various forms, ranging from slight dyspeptic symptoms
to nausea and vomiting. I aan not anxious to work
out the reflex path in such cases as these, but there
would seem to be a connection between the nerves of
the eye and the pneumogastric, for in cases of acute
glaucoma, where pain and vomiting are the prominent
symptoms, the real cause of the trouble may be over¬
looked, and a bilious attack diagnosed, with rather
bad results to the vision of the affected eye. I have
seen a very weak solution of eserin act sufficiently on
the ciliary muscle to produce such giddiness and
nausea, that the patient had to remain lying down for
about six hours.

As already mentioned, migraine, with all its typical
train of symptoms, is capable of being relieved, if not
cured, by the suitable corrective lenses. These cases
are usually found where the error of refraction is in
■one eye only, or where it differs in the two eyes From
my own experience I am satisfied that I have seen
cases of migraine relieved by the use of glasses. What
I mean by relieved is, that the attacks become much
less frequent. In one case in particular, where th$
pain was migrainous, but there were no characteristic
scotomata or blind spots, and in which the attacks
were frequent (one every eight or ten days), the use
of glasses for reading brought about a reduction of
the number of attacks to about one every month or
six weeks, although the refractive error was very
marked and differed in the two eyes, this lady would
not wear her glasses constantly, as, of course, she
should have done.

Children, as a rule, do not complain of headache,
but they very often have hypermetropia or some form
of astigmatism imprinted on their eyelids, as for
example sties, chronic conjunctivitis and blepharitis,
twitching and blinking of the lids. I have had an
opportunity of seeing a good number of cases of
ocular headache amongst the boys of one of our
large schools. Their ages varied from 11 or 12 to 14
or 15, and their grievance was that the incandescent
gas was too bright. Well, nearly all these cases, 9
per cent, of the whole school, had one form of
astigmatism or another, so that I do not consider the

quality or quantity of the illuminant had so much to
do with the headaches as the astigmatism. I may
remark here that I believe many of those who wear
coloured or smoked glasses (in the absence of in¬
flammatory affections of the eye, of course) would be
able to discard the disfiguring glasses if they had
their astigmatism corrected, for even the low degrees
of astigmatism will produce an irritability or hyperaes-
thesia of the retina which renders the eye intolerant
of ordinary diffuse day light.

As to treatment, I need not go into minutiae.
Suffice it to say, that each case must be carefully and
deliberately examined by the various methods at our
disposal, not refraining from the use of atropine or
homatropine ‘n certain cases. The routine resting
of the balance of the extrinsic muscles with Maddox’s
rod and prisms should be adopted, for I have men¬
tioned that the refraction of the eye may be quite
normal, but the muscle balance faulty. It is well not
to ignore the small degrees of astigmatism, such as
.25D., for much may be done by the wearing of the
weakest cylinders.

In conclusion, I would like to warn you against
being put off your guard by the patient who wears
glasses, who may complain of headache, telling you
that his glasses are right because ordered by an ex¬
perienced oculist. Very often in ordering cyl:nders
it is right not to give the full correction, and such
glasses will afford relief for two or three years, j cr-
haps, but then the patient may have a return of his
headaches, which will be probably cured by order¬
ing the full cylindrical correction. In young
persons the amount and axis of astigmatism are liable
to alter, and, finally, persons who do not wear their
glasses horizontally in front of their eyes are liable to
produce symptoms of eye strain, although the glasses
themselves may be quite correct.

When Dr. Oliver, of Philadelphia, wrote that
asthenopia is the bane of the civilised minority, I
think he was using strong language, but perhaps I
have said a little towards justifying it.

THE EFFECTS OF THE RONTGEN
RAYS ON LYMPHATICS AND
MYELOID LEUKAEMIA.

By Dr. EMIL EPSTEIN.

Poliklinlk, Vienna.

[Specially Reported for this Journal.]

In discussing the Rontgen rays, it is necessary to
explain the methods we practice in the Kienbiick
clinic, where such a wealth of material is to be
found all the year round. The present remarks
will be directed’towards the htematic system, par¬
ticularly ifour cases of leucocythemia, and the
influence of the rays on this pathological tissue.

Native preparations are made from the blood of
each patient, and the haemoglobin measured by
Fleishl instrument, while the corpuscles are
analysed and carefully counted according to Turk’s
method given in his clinical haematology. The
greatest difficulty tve have is the selection of an
eosin solution, as so many of these are now in use.
all having individual advantages of their own.
In the Kienbock clinic we have selected Zolli-
kopfer’s solution as a more stable fluid.

We use Muller’s tubes, as prepared by Reimyer,
Gebbert, Shull, etc. The ravs have three measure¬
ments :—(1) The strength of the ray; (2) the radio-
metric measurement according to Sabourand-
Noir6; and thirdly, the radiographic method
adopted by Kienbock of quantimeter. The two
latter are purely control measurements to prevent
over-dosage by the first, and thus avert burning.
Every sitting has a normal dose administered, i.e.,
the maximal dose of Sabourand-Noire, or 10 on
K-ienbdck’s quantimeter. The secondary current
is between 4 and 5 deci-milliamperes, and the focus
between 17 and 20 centimetres, or 7.87 inches.
After receiving a dose of this kind the rays would

Digitized by GoOgle

Dec. 25, 1907.

ORIGINAL PAPERS.

The Medical Press. 689

not be applied for a month afterwards. To avoid
misunderstandings in the descriptions, it might be
noted here that Turk’s terminology has been
adopted.

Case I. —A merchant, set. 44, whose mother was
always healthy and lived eighty-four years, but
father died earlier of inflammation of bowel. As
far as the patient recollects, he was in good health
till March, 1905, when he took middle ear inflam¬
mation, for which he was operated on. After this
swellings commenced in the glands of the neck,
some of which broke and discharged. Lues and
potus negative.

When received into hospital, on June 13th, 1906,
the patient was feeble, white, and emaciated. The
cerebral nerves were normal, pupil moderately
■dilated, and reaction prompt. The glands in the
region of the neck on both sides were about the
size of beans, hard, and mobile. The right supra¬
clavicular glands were the largest, while the left
sterno-cleido muscle was hard with infiltration, over
which ran a red inflamed line 5 centimetres long
and 2 broad, with a granulating ulcer and surround¬
ing ulceration. This was in the region of the beans on
both sides, but movable, while those of the axilla
were larger, particularly the left side, and as hard
as stones. On the other hand, those of the cubitals
were not enlarged. The inguinals, however, were
large and hard, but could be moved in the direction
of the lymph ducts, while those on the inside of the
leg and knee were the size of peas.

The spleen was very large, commencing at the
normal Hne above, or ninth rib, and extending far
beneath the ribs, and running forwards and in¬
ternally to within two centimetres of the median
line of the body below the level of the umbilicus.
The heart was healthy and the lungs perfectly
clear on percussion, though a few fine rAles could
be detected at the apex of the left.

On the first dav of treatment the blood was exa¬
mined, with the following result : —

Haemoglobin by Fleischl’s instrument, 65%

Number of red blood corpuscles, 4,900.000.

Colour index, 0.66.

Number of white blood corpuscles. 24,300.

Small lymphocytes, 19.400 = 79.9 %\ _ - 0 /

Large lymphocytes, 1.900= 7-8%/ /,//0

Polynuclear leucocytes = 12.8%

After completing this examination, the rays were
applied to the left leg on June 13th.

On June 15th the blood was again examined,
■with the following result : —

Number of white corpuscles, 24.400.

Small lymphocytes, 20,500 = 84.0%) _ g „/
Large lymphocytes, 960 = 3.9 %f ~ 7,9 /0
Polynuclear leucocytes. 2,930 = 12.0%

On this date the right leg was irradiated. On the
16th both thighs were done, and on the 18th the
right arm.

On June 19th the blood was again examined :—
Total white corpuscles, 18,430.

Small lymphocytes, 13.070 = 70.9 %\ 0/

Large lymphocytes, 1.130= 6.1 %) = 77,5/0
Polynuclear leucocytes, 4,230 = 22.9%

On this date the right arm was irradiated.

On July 20th blood examined gave :—

White blood corpuscles, 9,860.

Lymphocytes. 7,630.

Small lymphocytes, 6,870 = 69.7 %) _ 0 ,

Large lymphocytes, 760 = 7.8 %J “ 77> * /0
Polynuclear leucocytes, 2,230 = 22.5%

On this date the right arm was exposed to the rays.
The spleen was exposed on the 21st and 22nd, as
well as the supra-clavicular glands on the latter
rate, while the axillary glands were irradiated on
4 he 23rd on both sides.

On June 25th the blood was again examined

Total white corpuscles, 9,130.

Small lymphocytes, 5,730 = 62.7 %\ _ 0/

Large lymphocytes, 800 = 8.7 % f 7 /o
Polynuclear leucocytes, 2,600 = 28.8 %

The reddening over the left supra-clavicular
region is reduced to 3$ centimetres, the infiltration
less, and the ulcer healing.

On June 26th the inguinal glands were exposed.
On June 27th the blood was examined :—

Total number of white corpuscles, 8,280.

Small lymphocytes, 5,570 = 67.2%\ „ 0/

Large lymphocytes, 880 = 10.6% J 77% /o

Polynuclear leucocytes, 1,830 = 22.2%

About this period reddening and itching of the
skin commenced, and the left hypochondrium was
exposed. June 28th a fresh ulcer with infiltration
apeared in the supra-clavicular space. June 30th
the right hypochondrium was exposed with the
anterior side of the liver. On July 2nd the spleen
had receded to 5$ centimetres from the median
line and i centimetre upwards. On July 2nd, 3rd,
and 4th the lower bones of the legs were exposed.

July 6th the patient felt very unwell, and com¬
plained of sharp pains. The left supra- and infra-
clavicular spaces were hard and tender, while the
cervical and axillary glands are unchanged. Not¬
withstanding, both clavicular regions were exposed.
On July 12th the left infiltrated supra-clavicular
region began to discharge, but the axillary gland
remained as before. June 19th the spleen was ex¬
posed in front and on the right; on the 20th the left
was done, and repeated on the 21st. The ulcera¬
tion of the infiltrated left supra-clavicular space
was found healed on August 3rd. In the neck
only a few of the glands could be found on the left
side, while the right had a few hard glands about the
size of beans. In both axillae the glands were large.

The spleen (from the beginning never exceeded its
normal position upwards, but downwards and in¬
wards was enormously increased at first, but was
now greatly reduced. It was now a hand’s breadth
from the median line and four finger breadths
below the ribs; the low pole was now on a level
with the umbilicus. This viscus was again ex¬
posed on the 3rd : (a) Front, and (b) on the right
side. The lower portion of the left leg was irra¬
diated on the 4th, and the blood examined on
August 6th :—

White corpuscles, 11,100.

Small leucocytes, 5,170 = 47 % J
Large leucocytes, 1,500 = 13.5% /

Polynuclear leucocytes, 4,430 = 40.3%

August 14th the right leg was irradiated, and on
the following day two sittings were given to this
limb; on the 16th both arms; on the 17th same
limbs were repeated ; and on the 18th the spleen was
exposed fore and aft.

The patient was now allowed to go home and
return in three months’ time for further treatment.
About the beginning of September, after he went
home, he suffered from severe headache which did
not keep him from sleeping, and disappeared about
the end of the month. Subjectively at this time he
felt much better.

On his return, November 13th, he appeared
greatly improved, but the face still retained that
yellowish-white colour that was present early in the
disease, although it had now increased by a reddish
infiltration; the pupils reacting promptly, cervical
and supra-clavicular glands were less hard and
more mobile; one of these lying over the cucularis
was very tender. The skin everywhere over the
glands was movable, and no ulceration as at the
commencement. About the middle of the clavicle in
the infra-clavicular space a few of the glands were
verv painful and swollen about the size of hazel-

Google

Diqitiz

ORIGINAL PAPERS.

Dec. 35, 1907.

690 The Medical Press.

nuts, while those in the axillae were the size of
walnuts. In the upper third of the arm several
were 2 centimetres long, spindle-shape, but not
painful. The inguinal glands on both sides were
about the size of beans; both lungs and heart were
normal. The lower point of the spleen in the
axilliary line was slightly below the costal arch
and still tender.

On November 13th the examination of the blood
gave the folowing :—

Haemoglobin, Fleischl, 87%

White blood corpuscles, 8,66o.

Small lymphocytes, 5,260 = 60.7%

Large lymphocytes, 3 - 4 %

Polynuclear leucocytes, 3,110 = 35.9%
Transformation forms, 0.7%

After this followed another series of irradiations.

On November 14th the right cervical glands were
exposed ; on the 19th the left infra-clavicular glands
were treated; on the 20th and 21st the inguinal
glands, both left and right, were exposed. On
November 22nd the blood gave :—

Total number of white blood corpuscles, 7,780.
Polynuclear leucocytes, 5,330 = 4.29%

After this examination the spleen was irradiated,
and two hours after the sitting the blood examina¬
tion gave :—

White blood corpuscles, 10,300.

Polynuclear leucocytes, 41 %

The patient felt heavy and unwell after this ex¬
posure. On November 23rd the total number of

, White blood corpuscles were 7,560.

Polynuclear leucocytes, 3,560 = 47%

The spleen was again irradiated for two days, but
an unfortunate circumstance called the patient
home suddenly, which prevented further treatment.

The diagnosis mav now be conclusively stated as
a case of benign chronic sublymphaemic lympho¬
matosis or pseudo-leukaemia, according to Pinkus.
The supra-clavicular ulceration must be considered
as a secondary infection, which was accompanied
with great pain, infiltration, and abscess formation,
succeeded by a rapid retrogression.

A NOTE ON

tuberculosis as a factor in

THE IRISH DEATH-RATE.

By \V. R. MACDERMOTT, M.B.

In 1871, of 1,000 deaths occurring in Ireland,
156 were due to tuberculosis; we would therefore
say that the disease as a factor of the mortality
had the value 15.6 per cent. Again, taking the
average for 35 years, 1871-1905 the same value
was 14.9 per cent. But is this a true value—or, in
other words, did tuberculosis determine the death-
rate year by year? This may be put by asking
whether the general rate and the part of it due 10
tuberculosis varied together, and in what way ?

Tuberculosis being a principal cause of death, it
might seem d priori that in any year a high mor¬
tality from it would correspond to a high general
rate. There is certainly a relation between the
variations of the two rates, but it is not so simple
as this ; the deviations of both from their means
are different, both in magnitude and •time. The
highest death-rate in the 35 years is 20.0 (1879),
the lowest 16.4 (1871); the highest tuberculosis
rate is 16.1 (1899), the lowest 13.5 (1879). Con¬
trary, therefore, to what might be expected, the
lowest tuberculosis death-rate coincides with the
highest general rate. In the ten years, 1871-80,
the average G rate, as we will call it for brevity, is

18.3, and the average T rate 14.3; but the maxi¬
mum T rate, 15.6, coincides with the minimum G-
rate, 16.4, and this is the rule for the twenty quan¬
tities to a significant extent.

In the next ten years the highest G rate, 19.2,
coincides with the lowest T rate, 14.3; and the
higher T rates, 15.4, 15.6, and 15.2, with the lower
G rates. The same rule applies with but few ex¬
ceptions for the last 15 years, 1891-1905, and to the
whole period of 36 years; the G rate for the first
ten years being 18.3, the T rate 14.3—they are for
the last five years 17.6 and 15.7. The necessary-
inference to be drawn from the variations in detail
is that the general death-rate falls as the part of it
due to > tuberculosis rises. The thing might be-
worked out more exactly by Karl Pearson's statis¬
tical methods, but anyone who glances at the
figures in the last report of the Irish Registrar-
General will think the problem itself sufficiently
perplexing.

Tuberculosis in some of its manifestations is a
very obscure affection, even under the conditions of
the more refined means of diagnosis. There is,
however, less liability to error where death is
assigned to pulmonary phthisis. In the ten years
1871-80 the average yearly number of deaths was
96,674.5, of which 10,352.8 were due to phthisis.
For the five years 1901-5 the corresponding
numbers were 77,747.4 and 9.511.4. Thus, while
the number of deaths declined by about 20 per
cent., the number due to phthisis fell by only 8 per¬
cent. Comparing the average for the five_ years
with that for the 35 years 1871-1905, the fall is oniy
5 per cent. Thus a practically constant death-ra:e-
for phthisis has concurred with a fall of 20 per
cent, in the total number of deaths. The variation
from year to year of the phthisis rate is relatively
very small compared with that of the general
death-rate, but that of itself shows that the latter
is not determined by it in proportion to the relative
magnitude of the two rates. No matter whether
the total number of deaths is 105,000 or 75,000. the
number due to phthisis always remains somewhere
about 10,000, and, of course, for this reason
appears a minimum when the total is 105,000, and
a maximum when it is 75,000. We cannot say that
the variation in the total is due to a term falling
under the total when that term remains very nearly
a constant. Nor is it reasonable to conclude that
what remains a constant under a vast variety of
circumstances can be changed by means which
may affect the true variable.

There are reasons, of course, why the number
of deaths from phthisis remains constant relatively
to the total as a variable, but it does not appear to
me that there is any use at the present time in
giving them. The position that the number is a
constant is a statement of fact which is worth keep¬
ing to; it may be, of course, one applying only to
Ireland. In general, however, if 10,000 deaths
from phthisis occur, whether the total deaths are
105,000, 95,000, 85,000, or 75,000, it is evident that
such number stated as a percentage of the total
deaths is misleading. It is even more so stated as
a percentage of the living, less the number dying
in a year; both the general and phthisis mortality
vary "according to age distribution independently.
I have not studied the remarkable fall which has
occurred in the English death-rate from tuber¬
culosis with sufficient care to venture any opinion
on its nature and causes worth giving. It seems
to me, however, that at no period can the English
and Irish rates be compared except subject to cor¬
rections difficult or impossible to make. Registra¬
tion of deaths did not come into operation in
Ireland until 1864, and for ten years at least it was
imperfect. Both in England and Ireland certifica¬
tion of death by medical men is imperfect, and in*

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Dec . 25, 1907.

TRANSACTIONS

aiiany cases impracticable. Judging, however,
from intrinsic evidence, I believe the Irish statistics
■are more reliable than the English; the constancy
•of the Irish death-rate from phthisis is probably a
lair indication of its exactitude.

In the last four decennia the English death-rate
has fallen by 15 per cent., but bv 33 per cent, for
the age period 1-5. As the English population,
32,527,843. was constituted to the extent of
.3,716.708 by those in that age-period, this means an
accumulation of life in the higher age-periods
which by mere increase of mass would give an
apparent rise in the mortality occurring in them.
But in the four decennia the tuberculosis rate fell
by 38 per cent., a percentage not reflected in the
general death-rate. The mortality from any cause
is, cceneris paribus, as the mass it operates on. In
England the mortality from phthisis has shifted in
a remarkable manner to the higher age periods,
and therefore is determined by a rapidly decreasing
mass. Thus at 25 the mass would be 2,824.509,
and at 45 1,573,188; so that, no other cause inter¬
vening, the maximum mortality in rising with age
would diminish pro rata as the mass affected. In
Ireland the age-period 25-35 gives a decided maxi¬
mum ; in England the maxima are given by 35-45
and 45-55, ar| d therefore characterise a relatively
much smaller mass. It is probable that, if this were
taken into account, what is a constant for Ireland
would appear also as a constant for England.

The Irish is predominantly a rural community,
the English an urban. Concurring with a reduc¬
tion of 38 per cent, in the tuberculosis death-rate,
the purely rural English population has declined
even more than the Irish—that is, the element in
which the phthisis mortality is highest has greatly
Increased; that in which it is lowest decreased.
The urban mortality in England is to the rural as
the numbers 1,493 ant * >.292. We are being told
just now, or it is suggested to us. that the decline
in the tuberculosis death-rate in England is due to
Improved sanitation, and, as usual, that country is
set to us as an example. I am sufficiently well and
long acquainted with it and Ireland to know that,
though both are open to improvement in sanitary
Tind other matters, the improvement that has actu¬
ally occurred in both has been relatively much
greater in the latter than in the former country.
The assumption that the conditions of life of the
rural Irishman arc worse than that of the urban
Englishman is one which should not be allowed
to prejudice the consideration by medical men, at
least, of difficult and complicated questions. Tuber¬
culosis as a disease is one thing, as a cause of death
another. So is scarlatina. The mortality from
scarlatina has fallen in England in the proportion
of 890 to 158, but the explanation of that is not
that the disease has disappeared or that the infec¬
tion has been “stamped out”—14,539 cases of it
were treated in London hospitals alone in 1901 —
but that the disease is one thing in itself, another
ns a cause of death. The increased aggregation
of the English people in great cities has favoured
experience of the tuberculosis infection, but in ail
probability careful study and freedom from precon¬
ception would show that where tuberculosis, the
disease or infection, is a maximum, the mortality
from it is a minimum. The mortality is not as the
disease, but as the susceptibility to it. In the pre¬
sent state of our knowledge, however, though the
grounds for dissenting from the views expounded
to uncritical audiences are clear, they do little more
than suggest to us that the subject is one not
adapted for popular exposition. It is admirable
to give popular lectures on hygiene and sanitary
science, but the pathology and causation of tuber¬
culosis should be strictly kept ns a preserve sacred
to the professed votaries of /Esculapius.

OF S OCIE TIES. The Medical Press. 691

TRANSACTIONS OP SOCIETIES.

ROYAL SOCIETY OF MEDICINE.

Obstetrical and Gynecological Section.

Meeting held Thursday, December 12TH, 1907.

The President, Dr. Herbert Spencer, in the Chair.

THE SUPPORTS OF THE PELVIC VISCERA.

Dr. \V. E. Fothergill read a paper on this subject.

The writer considers that the current teaching of
gynaecological anatomy, while correct in a general
sense, lacks that accuracy which is essential if the
student is to have a real grip of his clinical work. It
is generally assumed that the urino-genital organs are
partly suspended by the so-called ligaments of the
uterus, and partly supported from below by the pelvic
floor. But the perinaeum and the pelvic diaphragm
are often seriously impaired by injury or loss of tone,
without any consequent change in the position of the
pelvic viscera, which shows that support from below
is not essential. Again, during abdominal operations
the ligaments of the uterus are seen to lie loose and
slack upon the subjacent structures, and to have no
supporting action whatever. The operation of vaginal
hysterectomy affords confirmation of these observa¬
tions, and reveals to the clinician the fact that the
uterus is really supported by the sheaths of its blood¬
vessels, which attach it firmly to the sides of the
pelvic diaphragm. In the same way the vagina and
the bladder are held in position by the sheaths of
their blood-vessels, the rectum having an independent
attachment to the back of the pelvis. Thus lengthen¬
ing and laxity of the sheaths of the blood-vessels is the
one constant and essential factor in the causation of
prolapse of the pelvic viscera.

The writer considers that while gynaecologists are
well aware of these facts they refrain from teaching
them, because they borrow their anatomical state¬
ments from the writings of professed anatomists. He
therefore goes on to show, by quotation from recent
papers by anatomists of the first rank, that descriptive
anatomy has changed in a way exactly parallel to that
in which clinical gynaecology has moved.

The uterosacral ligament is a mere peritoneal fold ;
the broad ligament is simply a mesosalpinx and
mesovarium. The round ligament is a vestigial
structure, the homologue of the gubernaculum testis,
which pulls down the ovary and uterus in early foetal
life, and by no means supports them during post¬
natal life.

The superficial perineal muscles derived from the
primitive sphincter cloacae have a sphincteric and not
a supporting action.

The muscles of the pelvic diaphragm are vestigial
structures, being the degenerated representatives of
the powerful tail-moving muscles of lower vertebrates.
Their muscular action is largely lost: but, by virtue
of their position, they, with their fascial coverings,
form the funnel-shaped musculo-membranous struc¬
ture known as the pelvic diaphragm. This could not
support the plastic pelvic viscera, either by its shape
or its muscularity, if the pelvic viscera were not firmly
attached to its sides.

The conception of the pelvic fascias as independent
and definite structures must be given up, and the
fascis must be regarded simply as the connective
tissue-coverings of the muscles, the viscera, and the
blood-vessels.

The vessels and their sheaths, together with the
ureters, nerves, and lymphatics, form masses of tissue
which extend between the sides of the pelvis and the
lateral aspects of the uterus, bladder, and vagina, and
which hold these structures in position. The rectum
is independently attached to the back of the pelvis,
and lies loose in a channel between the vessels of the
right and left sides. It is free from the urino-genital
organs, and does not descend with them in prolapse
unless the anterior rectal wall is pathologically
adherent to the posterior vaginal wall.

The Fresident (Dr. Herbert Spencer) thanked the

Dec. 25, 1907.

692 The Medical Press. TRANSACTIONS, OF SOCIETIES.

author for the interesting and lucid communication he
had brought before the Section. Although the question
of the support of the pelvic viscera was one to be
settled by anatomical research, anyone who had per¬
formed total abdominal hysterectomy and had noticed
the “ligamentura transversale colli ” which lay at a
lower level than the uterine artery and was very
dense in structure, would find it difficult to accept
the statement that it was the sheath of the vessels
which kept the uterus in place. Also how could the
bladder be kept up by the sheath of the vessels which
were small in number and size.

Dr. Amand Routh congratulated the author on his
lucid and excellent discourse, and felt that it would
be greatly to the advantage of both students and
gynaecologists if the antiquated views so long held on
the subject of the uterine supports were replaced by
those now elaborated. He thought that the author
had succeeded in proving his contention that the
uterus was mainly supported by the perivascular con¬
nective tissue bundles above the pelvic floor. He had
put into words much of the scepticism which gynaeco¬
logists have held as to the acceptance of -the orthodox
views. No one who is in the habit of opening the
abdomen and of seeing the flaccid broad ligaments
and the redundant circuitous round ligaments could
hold the view that these structures support the uterus,
whatever might be thought of the functions of the
utero-sacral ligaments. He had long held the view
that the connective tissue in the bases of the broad
ligament and utero-sacral folds (which really unite and
form one common connective tissue bundle at their
junction with the supra-vaginal cervix) were very im¬
portant agents in holding down the uterus to the
floor of the pelvis. If in amputating the cervix per
vaginam, these bundles are cut through, the freed
uterine body can not only be easily drawn downwards
by traction, but will be spontaneously elevated behind
the pubes, if not held down by vulsella forceps. He
thought, therefore, that the bundles of connective
tissue grouped round the vessels and the ureters served
rather as anchors to fix the uterus down to the pelvic
diaphragm, preventing undue mobility both upwards
and downwards. The normal anteversion of the
uterus is doubtless maintained, according to Dr.
Fothergill’s views, by the perivascular sheaths suspend¬
ing the supra-vaginal cervix from a direction upwards
and backwards (in the erect position) much in the
same way as the utero-sacral folds have been hitherto
supposed to act. He hoped Dr. Fothergill’s views
would receive general attention and acceptance.

Dr. R. H. Paramore disagreed with what had been
said by the author of the paper. In determining the
position of the uterus and the maintenance of this
position in the pelvis we had to consider not only
the structures which united the uterus to the pelvic
wall and the pelvic floor itself, but also the intra-
abdominal pressure which had a definite influence
upon the position of the pelvic viscera. The intra¬
abdominal pressure depended upon the capacity of the
abdomen, the volume of the abdominal contents, and
upon the condition of contraction of the muscles which
enclose and form its boundaries. Dr. Matthews
Duncan had laid stress on the retentive power of the
abdomen, and drawn attention to the fact that the
uterus does not alter its position as a result of com¬
plete rupture of the perinaeum alone, but if prolapse
occurred, other factors had come into play. In women
with an undamaged pelvic floor, and in whom the
intra-abdominal pressure was much increased by a
deposit of fat in the omentum or mesentery, the uterus
was often found high up owing to the activity of the
levator ani. If in such cases the pelvic floor was
damaged by child-birth, an inevitable prolapse
resulted.

Dr. Briggs believed that too much was attributed
to ligaments. The muscular and tendinous and other
fibrous tissues around a joint controlled its security
and mobility, and produced its stiffness. The liga¬
ments of the pelvic viscera were insignificant com¬
pared with the mass of the muscles and their fascia,
the fibrous packing between, and the fibrous envelopes
of the viscera and canals.

Sir Arthur Macav said that the importance of the

pelvic connective tissue was pointed out years ago by
W. A. Freund, and more recently a firm band in the
lower part of the broad ligament at each side of the
cervix had been differentiated by Kocks.under the
name “ Pars cardinalis lig lati.” The effect of taking
away the support from below could often be observed
clinically in cases where prolapse of the anterior
vaginal wall followed rupture of the perineum. As
the vaginal wall prolapsed it drew the cervix down¬
wards and forwards, which produced backward dis¬
placement ot the fundus, and finally prolapse. Pro¬
lapse of the uterus is also met with in old women,
due to senile atrophy of the pelvic connective tissue,
removing the natural support of the pelvic organs.
The strength of the support from below was, be
thought, well shown by the resistance the pelvic floor
offered to the expulsion of the child’s head during
labour.

The following specimens were shown:—

Dr. C. Hubert Roberts, “A cancerous uterus and
glands removed by Wertheim's method.”

Dr. Peter IIorrocks, “Tuberculous disease of the
cervix.”

Dr. James Oliver.. “A somewhat unique tubal
gestation. ”

Dr. A. H. N. Lewrrs, “Sarcoma of the ovary com¬
plicated by carcinoma of the body of the uterus;
operation.”

SOCIETY FOR THE STUDY OF DISEASE IN
CHILDREN.

Meeting held December 13TH, 1907.

Dr. George E. Shuttleworth in the Chair.

Mr. R. Clement Lucas opened a discussion on

INHERITED SYPHILIS.

This paper will be published in a future number.

Mr. Sydney Stephenson’s communication was
based upon an analysis of 101 cases of interstitial
keratitis. Associated signs of inherited syphilis were
present in 69.3 per cent., and of tubercle in 9.9 per
cent, of the patients. The series included four
examples of keratitis due to acquired syphilis, one of
which was in a child, 12 years of age, who had
suffered in infancy from a chancre of the eyelid;
61 per cent, of Mr. Stephenson’s cases were in females,
as against 38 per cent, in males. Four-fifths of the
cases occurred between the ages of five and fifteen
years, so that interstitial keratitis W 3 s essentially a dis¬
ease of childhood, although cases had been met with
at 38 years of age. The symptoms were apt to be
atypical when the disease occurred in very young sub¬
jects. In one of Mr. Stephenson’s patients an interval
of seven years had elapsed before the second eye was
attacked. Ulceration of the cornea had been noted in
four of the author’s cases. Stress was laid upon the
influence as a determining factor of keratitis of any
condition, local or general, capable of lowering the
patient’s resistance. The name “interstitial keratitis”
did not correspond with the pathology of the con¬
dition, which was essentially one of inflammation of
the ciliary body. An account was given of the experi¬
mental production of keratitis, caused in syphilitic
cases by the lodgment and multiplication of the tre¬
ponema pallidum in the tissues of the cornea.

Mr. George Pernet said he considered the features
of importance in a discussion of this kind at the pre¬
sent moment were heredity and the treponema palli¬
dum. As to heredity proper, we knew little about it.
But he desired to emphasise the fact that the usual
English designation, congenital syphilis, though not
biologically correct, was preferable to the employment
of the term hereditary syphilis of Continental writers.
All the evidence available pointed to ihe fact that
there was no congenital syphilis of the child without
syphilis of the mother. The subject was a complex
one to deal with in so short a time, but there were
various reasons against the infection of the ovum bv
means of the spermatozoa, notwithstanding the experi¬
ments of Finger with the sperm of syphilitics, experi¬
ments which, by-the-bye, had not been confirmed by
Erich Hoffmann. Mr. Pernet referred to a case men¬
tioned by Jullien of a syphilitic man with super-

feed by Google

Dec. 25, 1907.

TRANSACTIONS

numerary fingers who had infected his wife; she had
borne a syphilitic child with supernumerary fingers.

the man’s mistress gave birth to a perfectly healthy
child, also with supernumerary fingers. There could
be very little doubt as to the paternity here. Tt was
known, tco, that a man with florid syphilis did not
necessarily infect his wife. Again, there could be no
doubt that Collcs's law was a law ; the exception to
it could not hold water, various conditions, such as
pemphigus neonatorum, Jacquet’s erytheme erosif, and
so forth, having been taken erroneously for syphilis
in the child. In conclusion, he desired to insist on
the maternal origin of congenital syphilis, and on the
reliability of the observations of Ab.-aham Colies and
of Baumes.

Dr. H. G. Adamson made some remarks on the

DIAGNOSIS OF THE SKIN ERUPTION OF CONGENITAL
SYPHILIS.

This was a matter which did not receive the atten¬
tion which its importance demanded, and errors were
often made, especially in regard to certain common
non-specific eruptions of 'he napkin region, which
were frequently wrongly diagnosed as congenital
syphilis, with obviously serious consequences. The
eruptions which might be mistaken for those of
syphilis were:—

(1) Streptococcic impetigo.

(2) Seborrhoeic dermatitis.

(3) Simple infantile erythema (of Jacquet).

The speaker showed diagrams illustrating the
features and distribution of the eruptions in con¬
genital syphilis, and in these three types of simple
eruptions.

Streptococcic impetigo produced red, raw areas, with
phlyctenular margins in the flexures, or occupying the
whole napkin area, with crusted or bullous lesions on
other parts.

Seborrhceic dermatitis also attacked the flexures (or
the whole napkin region), and the areas had a
yellowish red, granular surface. The eruption was
associated with seborrhoea capitis in the child and in
the mother.

Simple erythema, on the other hand, attacked the
prominent convex surfaces of the napkin region, of
the calves and of the heels in a marked manner,
leaving out the flexures. There were three stages:—

(a) Erythematous ; (£) papulo-erosive ; (c) ulcera¬

ting.

The two latter were especially liable to be confused
with syphilitic eruptions, but were distinguished by
their affecting only prominent convex surfaces and by
absence of other signs of syphilis. The syphilitic
eruptions were characterised by disc-like coppery red
patches, which might be erythematous, papular, scaly
or crusted, and which attacked both flexures and pro¬
minent surfaces alike. A special point was that the
palms and soles were the seat of these lesions. Other
symptoms of syphilis were often present—namely,
fissured lips, mucous patches at the anus, snuffles,
hoarse cry, and muddy complexion.

Mr. A. H. Tubby discussed the

BONE AND JOINT LESIONS IN INHERITED SYPHILIS.

The cranial signs might be localised or general.
Local manifestations took the form of bosses which
were most marked on the frontal bone. The enlarge¬
ment of the parietal eminences might exist alone or
in conjunction with enlargement of the frontal
eminences. Excessive overgrowth of the external
occipital protuberance occurred occasionally, but it
was a rare condition. The most striking of the lesions
in the long bones was that producing syphilitic
pseudo-paralysis. It occurred in infants before the
fourth month, usually during the second month. The
limb became useless, and then a swelling appeared in
the neighbourhood of the epiphysis, associated with
effusion into the neighbouring joint. Separation of
the epiphysis might occur, and pus might form with
necrosis of the entire epiphysis.

Dr. George Carpenter said that chronic snuffles
was not always self-evident, and that it was important
to recognise a postrhinal form with discharge by the
posterior nares. Craniotabes was, he said, most usual
in the second and third months of life, and whenever
he detected it, the probability of syphilis occurred to

OF SOCIETIES. The Medical Press. 693

him. Craniotabes was not a rickety manifestation*
and Parrot’s nodes were evidence of syphilis, not of
rickets. He did not believe that syphilis produced
rickets. During the first six months the majority of
enlarged spleens were syphilitic. From the ninth to
the thirtieth month, the rickety age of life, some cases
were syphilitic, others could not be explained in that
way, and although cases of sple.io-megaly did arise
in rickety children, they occurred infrequently, and
spleno-megaly was a coincidence, not a svmptom. Of
syphilitic nephritis in infants he gave examples, and
pointed out that on several occasions he had been
able to diagnose the condition during life. He said
that all cases of cirrhotic kidneys were not syphilitic,
that in some cases the disease commenced in intra¬
uterine life, and that the contracted granular kidneys
of children and adults could be of either syphilitic
or simple, and certainly of infantile origin.

Dr. Leonard Guthrie sad that there were two kinds
of nephritis attributed to inherited syphilis—acute and
chronic. Both were essentially interstitial in character,
though in both parenchymatous conditions might be
present. Acute interstitial nephritis was sometimes
£ongential, or occurred shortly after birth in un¬
doubtedly syphilitic infants. The symptoms were
usually gastro-intestinal at first, and ended in uramia ;
oedema was rare in purely interstitial nephritis. The
urine was scanty and albuminous, with or without
the presence of casts. The kidneys post-mortem
showed little that was abnormal to the naked eye, but
microscopically interstitial cellular infiltration, forma¬
tion of new connective tissue, with a varying degree
of catarrhal exudation in the tubules. Syphilitic
infants might succumb to this within the first few
weeks or months of birth. Chronic interstitial
nephritis appeared to be the result of the acute form.
Clinically and pathologically it was indistinguishable
from the chronic interstitial nephritis of adults.
Whether the two forms were essentially syphilitic was
a matter for discussion. It was certain that in a
small proportion of cases congenital syphilis had
been recorded, but, on the other hand, no personal
or parental history of syphilis was forthcoming in
the majority of both acute and chronic cases cf inter¬
stitial nephritis in infancy and childhood. Dr.
Guthrie concluded that a certain proportion of cases
might be due to congenital syphilis, whilst others were
of septic origin.

LIVERPOOL MEDICAL INSTITUTION.

Meeting held Thursday, December 5TH, 1907.

The President, Mr. Frank T. Paul, F.R.C.S., in the
Chair.

Amongst a large number of clinical cases shown
were the following:—

Dr. T. R. Bradshaw showed three patients, adults,
suffering from acute anterior poliomyelitis. (1) A
man, aet. 53. Sudden onset, hands giving way while
patient was sitting on a gate. The paralysis was at
first attributed to the fall. Characteristic paralysis,
with wasting affecting forearms and thighs. (2) A man,
aet. 28. Ill two days with what was supposed to be
influenza, and then found to have paralysis of one
arm. Condition characteristic. These two cases
occurred within a week of one another, and the
patients lived in the same district, suggesting an in¬
fective source for the disease. (3) Woman, aet. 35.
Two years ago sudden paralysis of right leg, slightly
of left. At present foot-drop, with coldness and blue¬
ness of feet.

Dr. R. J. M. Buchanan showed a child who had
suffered from tubercular meningitis, and recovered.
After an illness of four weeks, and coma for eight
days, lumbar puncture was performed, and 20 c.c. of
cerebro-spinal fluid removed, containing lymphocytes,
but no meningococci were found. The symptoms
were classical. An inoculation of 1-4,000 mg. new
tuberculin was given. The child showed immediate
signs of improvement, and gradually recovered con¬
sciousness. Three weeks later the above treatin'- •

Digitized by GoOgle

Dec. 35, 1907.

694 The Medical Press. TRANSACTIONS

was repeated, after which the child made an unin¬
terrupted recovery, is now quite intelligent and able
to run about. Calmette's tuberculin reaction on the
conjunctiva was positive.

Dr. Buchanan also showed photographs, and
•described a case of chloroma in a child of 4$ years.
The symptoms commenced with anaemia in July, right
facial paralysis with pain in the right ear in October,
and exophthalmos followed. The orbital growth is
.proceeding rapidly. Characteristic blood changes are
present, the leucocytosis increasing from 25,000 to
250,000 per c.mm. in a few days.

Dr. J. Lloyd Roberts showed:— (i) A case of
chancre of the scalp, caused by the patient butting
his head in a scuffle against the teeth of a man who
had secondary symptoms of syphilis. (2) A case of
lead paralysis, which improved rapidly under
treatment with iodipin, after potassium iodide had
been tried for some time without apparent benefit.
<3) A case of transverse myelitis, which improved to
a certain extent under potassium iodide and mercury,
and was now making more rapid progress with iodipin.

Dr. Percy Marsh showed:— (i) A boy, iet. 1 year
g months, who was admitted into the children’s in¬
firmary on November 5th with a history of having had
meningitis, with retraction of the head, seven weeks
previously. On admission he had marked “intention
tremors ” of all the parts of the body. The cerebro¬
spinal fluid was turbid, reduced Fehling, and showed
a large number of polymorpho-nuclear leucocytes ; a
growth of staphylococcus aureus was obtained. There
was no optic neuritis, nor atrophy of the disc, (a) A
girl, ast. 8, with insular sclerosis. Symptoms
were first noticed four years ago after a fall on the
head. She now had typical intention tremor, with
nystagmus and seaming speech. There was no optic
atrophy, and the cerebro-spinal fluid was normal.
<3) Two cases of lymphadenoma— (a) the ordinary
type, with a lymphocytosis varying from 48 to 60 per
cent., with a normal blood count; ( b ) sub-lymphatic
type. Calmette's ophthalmo-reaction negative. Marked
improvement under full doses of arsenic and X-rays.

Mr. R. C. Dun :—(1) General thyroid enlargement
in a girl 12 years old; tremors and rapid heart’s
action, but no exophthalmos. (2) Lymphadenoma.
<3) Meningocele and accessory auricles. (4) Congenital
deformity, of hand (two cases), showing syndactylism,
microdactylism, and congenital lateral deviation of
the fingers. (5) Congenital deformity of lower ex¬
tremities (two cases). (6) Ischaemic contraction of
muscles of forearm following fracture of the humerus.

Dr. H. Leslie Roberts showed the following:—(1)
Rodent ulcer of nose of two years duration cured
by X-rays. (2) Lupoid gummata covering the whole
of the front of the neck and a portion of the nose
and upper lip. The resemblance to lupus was extra¬
ordinary, but the disease was of only one year’s
duration. (3) Tubercules in a woman, aet. 47, in¬
volving the right upper eyelid, the cheek and upper
lip, of 3$ years’ duration. A sister died of con¬
sumption, and the patient had had more than one
“haemorrhage.” The lesions were multiple, discrete
uniform in their objective characters and their mode
of evolution. Each lesion presented the appearance
of a slightly elevated convex spot of bluish red colour.
At the centre of each spot a slight amount of fluid
exudate preceded quiet necrosis, the loss of tissue
being followed by a minute depressed scar. (4)
Acquired syphilis in a girl, ast. 12. The intoxication
rash covered most of the body. The chancre was on
the lip, and resembled impetigo. (5) Multiple lupas
in a boy, and complicated by secondary inoculations.

Dr. Stopford Taylor and Dr. Mackenna showed
the following cases of skin disease:—(1) Enchondroma
cutis in a female child, aet. 15 months. She is the
fifth child in a family, all of whom are healthy. In
the skin on the outer side of the left thigh, the front
•of the chest, the back, the left side of the scalp, and
the left forearm just above the wrist, are plates of
cartilage varying in size from ij in. to the size of a
split pea. Over these deposits the skin has a peculiar
violaceous hue, and shows here and there a pearly
deposit. The cartilaginous nature of the plaques has
been confirmed microscopically, and at points the car¬
tilage which is lying in the true skin shows signs of

OF SOCIETIES.

ossification. So far as is known, this is the first case
of the kind that has been shown in England, (jj
Psorospermosis follicularis vegetans (Darier's dis¬
ease) in a young woman ast. 32. The disease alfects
chiefly the neck, the upper part of the chest and back,
and the arms. It had lasted for seven years. 13,
Ichthyosis nigricans—a very severe case in a boy
of 11. (4) Cases of lupus showing Calmette's

ophthalmo-reaction. (5) Follicles of the fingers and
hands of 13 years’ duration in a young woman. The
tubercular nature of the disease was confirmed by the
presence of tubercular glands in the neck. (6) Case
of severe papular syphilis. (7) A Case of hypertrophic
lupus of six months’ duration (8) A series of 40 wax
casts taken from patients suffering from different forms
of skin disease.

Mr. J. Bark showed cases of the complete mastoid
operation, and Heath's conservative method. The
patients had been the subjects of foetid middle ear
suppuration of from 3 to 12 years’ duration. The
results were excellent, and the hearing after Heath’s
operation was most marked.

Cases were also shown by Dr. N. Raw, Mr. C. T.
Holland, Dr. F. H. Barendt, Dr. K. Grossmin, Mr.
R. J. Hamilton, Mr. A. M. Walker, Mr. T. Guthrie,
Dr. McDougall, and Mr. K. W. Monsarrat; an
operating table by Dr. Blair Bell; radiographs by Dr.
D. Morgan.

WEST LONDON MEDICO - CHIRURGICAL
SOCIETY.

Meeting held December 6th, 1907.

The President, Mr. Richard Lake, F.R.C.S., in the
Chair.

Dr. Mansell Moullin read a paper on the
treatment of uterine fibroids,
advocating early operation in all cases giving rise to
symptoms. The troubles arising from these tumours
were, he remarked, so grave and so varied that,
considering the brilliant results now attained by sur¬
gery, it seemed worse than folly to allow a woman
to spend years of her life as a chronic invalid, exposed
to all these risks, when the remedy was at hand—a
remedy which might, and often did, become a matter
of necessity at a later date. He described the tech¬
nique of hysterectomy, and advocated the supra¬
vaginal operation in the very great majority of cases.
He had lost but one case in 78 operations. The danger
of the operation had been reduced to a minimum, and
need not deter one urging radical treatment when
called for.

Mr. Sampson Handley read a paper on
CHRONIC APPENDICITIS IN WOMEN.

The study of chronic appendicitis had been retarded
by two causes—firstly, by the erroneous belief that
an appendix free from adhesions is necessarily a
healthy appendix ; secondly, by the divorce which in
England exists between the practice of general surgery
and that of gynaecology. The most striking symptoms
of chronic appendicitis were located in the female
pelvic organs. Of these the most constant and im¬
portant was dysmenorrhoea. The history of a painful
menstrual period precipitated (or brought back after
its cessation) by what appeared to be an attack of
acute indigestion, was very characteristic of chronic
appendicitis. But the main object of his paper was 10
show that chronic appendicitis in women is frequently
accompanied by a definite physical sign. This sign
was an enlargement of the right ovary up to double
its normal size owing to the congestion and lymphanc
stasis produced by the near neighbourhood of an in¬
flammatory focus in the appendix. In such cases the
diagnosis of chronic ovaritis was usually made, and
futile gynaecological treatment was often carried out
for long periods. In one of his own cases appendec¬
tomy cured a patient who had submitted without
benefit to douching, blisters, tampons, and local
applications to the cervical canal, over a period of five
years. The appendix was free from adhesions, and
its lumen contained a small collection of pus.

gitized by GoOgle

Dec. 25, 1907. CORRESPONDENCE. The Medical Press 695

BRITISH BALNEOLOGICAL AND CLIMATOLO¬
GICAL SOCIETY.

Meeting held December iith, 1907 ,
at Hanover Square, London.

The President, Dr. W. J. Tyson (Folkestone), in the
Chair.

Dr. Edgecombe (Harrogate) read a paper on
BLOOD PRESSURE IN SPA PRACTICE,
the purpose of which was to show the utility of making
observations of blood pressure as an aid to diagnosis,
and as a guide to hydro-therapeutic treatment. After
pointing out that most cases going to spas suffer from
chronic diseases of nutrition, in which blood pressure
changes afford some indication of the state of tissues
nutrition, he discussed the following conditions in
relation to blood pressure: arterio-sclerosis, hyper-
pyesis, gout, fibrositis, heart disease, anaemia, and the
menopause, giving cases in illustration of his views.
He concluded with a plea for the routine examination
of blood pressure in spa practice as affording more
precise information than could be obtained by the
■digital method.

Dr. Leonard Williams, in support of Dr. Edge¬
combe's views, strongly deprecated the pretensions of
those who claimed to be able to estimate the degree of
Blood pressure by digital examination alone. He re¬
called Professor Clifford Allbutt’s dictum to the effect
that it was a3 absurd to discuss blood pressure in the
.absence of an instrument as it was futile to discuss
temperature in the absence of a thermometer. In
further support of Dr. Edgecombe’s views he insisted
upon the existence of high blood pressure as a
functional manifestation which was altogether inde¬
pendent of granular kidney or other structural disease
except in so far as its continuance tended to produce
these conditions. He discussed the spa and climatic
treatment, and concluded that such benefits as were
peculiar to this form of treatment resided rather in
the greater readiness of patients to obey orders at
health resorts than in any properties inherent in the
waters, more especially at British spas.

Dr. George Oliver (Harrogate) discussed the blood
-pressure in gout and the menopause, and gave an out¬
line of his recent observations on the diagnostic value
of the armlet method in arterio-sclerosis. He demon¬
strated his improved haemomanometer, provided with
a supplementary method, which serves as a check
-against arterio-sclerosis.

Dr. Harry Campbell contended that it was possible
-to estimate the radial blood-pressure by the finger. He
referred to the function of the muscular media in
preventing vascular stretching.

The discussion was adjourned to January 29th, 1908.

CORRESPONDENCE

PROM OUR SPECIAL CORRESPONDENTS
ABROAD.

GERMANY.

Berlin. Dec. igth 1907.

At the Verein fur Innere Medizin, Hr. Bleich-
Toeder showed a six to seven months' foetus that had
been sent to him for examination. The autopsy
showed a diaphragmatic hernia, with sac complete, on
the left side, the sac containing all the abdominal
viscera. Herniae of the diaphragm were mostly on the
left side in a proportion of 6 to 1. It was a disease
of development due to patency of the ductus com¬
munis. Below the diaphragm was a horse-shoe kidney
-with three ureters, one of which was in a state of
hydronephrosis.

Hr. Benno Levy remarked that he had shown a
similar case some years ago, in which, however, there
was almost complete absence of the diaphragm, and
the child had been carried to full term. It was not
-clear to him why the child shown had died so early.
"The hernia of the diaphragm could scarcely have been
the cause of death.

Hr. Klebs showed a guinea-pig that had been in¬
fected with

Human Tuberculous Sputum
120 days before, and became affected with widespread
tuberculosis. He had now brought about its recovery
by injections with his own serum. During this process
of recovery the tubercle bacilli had been led to the
glands, and enormous swelling of the bronchial glands
was seen in the preparations. The animal through
accident had died.

Hr. Erich Schlesinger spoke on

The Treatment of Neuralgias by Injection.

He recommended the use of isotonic + O 0 solutions
of salt. Formerly strong narcotic solutions were made
use of; then it was found that weak solutions did as
well, and now we thought we saw that the chief thing
was the mechanical action of the injection, and that
the simple isotonic saline solution was sufficient, so
long as a larger quantity was injected than formerly.
The speaker had obtained brilliant results, especially
in the treatment of sciatica, that obstinate complaint.
The injection should not be passed into the nerve
itself, but into the adjacent tissues.

Hr. Peritz was of opinion that occasional successes
had been obtained with ail kinds of injection material.
It was known that a saline solution was generally
sufficient. Alcohol injections were specially recom¬
mended for old trigeminus neuralgias. The speaker
had laid stress on his success in chronic sciaticas. All
cases of so-called chronic sciaticas were myalgias,
and not sciatica. How long had he observed his cases ?
That a saline solution of 0 ° was given was scarcely
possible.

Hr. Remak observed that sciatica cases ran very
different courses. Some yielded to any treatment,
some to none at all. Salt water injections were harm¬
less, at any rate. That could not be said of other
injections, as paralyses were not unfrequently seen to
follow injections of alcohol in consequence of paren¬
chymatous neuritis, and just as much as from the in¬
jections of ether formerly employed. One could not
always avoid injection into the nerve; it got there
sometimes without intending it.

Hr. Kraus said that chronic sciatica was known to
be the crux medicorum. Whatever treatment was
used, complete recovery was rare. It was a great
advantage when a method of treatment made patients
fit for work. Regarding injections of saline solutions,
he could express himself rather more favourably than
Peritz. Chronic sciaticas were favourably influenced
by it. They had tried everything in his klinik. From
his own experience he should recommend blister
plasters.

Hr. Rothmann, jun., thought success was obtained
by suggestion, and not by injection.

Hr. Alexander said that good results were obtained
by saline injections before now. Chronic sciaticas,
however, had their seat in the muscles, as the result
of acute sciatica. In the latter the muscles were kept
in a certain position in which the pain was least felt.
This fixed position, by constant tension of the muscles,
led to myositis. We therefore found points that were
painful on pressure in chronic sciatica that had nothing
to do with the nerve trunks, but the terminals of the
nerves which were compressed by the muscles. By
the injection of larger quantities of fluid the terminals
were relieved from pressure, and the cause of the pain
removed.

At the Ophthalmological Society, Hr. Adam showed
a female with pulsating exoptnalmos. Nine years
before she had been operated on for an orbital tumour
that was either a sarcoma or an enchondroma, and
for a year and a half there had been exophthalmos that
could be pressed back with some force. There was
no arterio-venous aneurysm; it could not be a solid
tumour; it could be only a vascular tumour. To
determine whether it was arterial or venous, the
patient was examined with the head hanging down,
and forced to one side, whilst the jugular was com¬
pressed. No increase of the exophthalmos took place,
so the cause was probably not penous. Considering
that it took not a little force to press the eyeball back,
it was one with a very free vascular supply, most
j probably an angio-sarcoma.

Digitized by GoOgle

CORRESPONDENCE.

Dec. 25, 1907.

696 The Medical Press.

AUSTRIA.

Vienna, Dec. 2and, 1907.

Ischialgia and Infiltration.

At the Gesellschaft, Bum presented six patients
whom he had treated with salt injections for chronic
ischialgia. All of them had suffered for more than
two years with an excruciating pain in the ischial
nerve. Bum injected an “isotonic” solution of table
salt, under high pressure, with a canula, into the upper
part of the thigh. Bum does not insert the canula, as
Grossmann, Lange, Kellermann do, into the gluteal
muscle, but prefers inserting at the junction of the
long head of the biceps femoris and the gluteus
maximus, where no wounding of muscles or large
vessels can take place. This injection or infiltration
of the nerve distends the sheath into a spindle shape,
acting mechanically on the neurilemma, and subse¬
quently producing adhesion of the sheath with its sur¬
roundings. The action is therefore at first an intense
distension, followed by an active contraction of the
nerve.

The six patients presented had been free from pain
for seven to fourteen months since the operation,
although all of them had suffered from pain and been
disabled for work for two years preceding the opera¬
tion, but are now quite fit for duty. He had now
similarly operated upon 81 cases, with 63 per cen<t.
perfectly cured, and 21 per cent, greatly relieved. This
infiltration treatment is contra-indicated where the
cause is neuritis at the root of the nerve, advanced
arterio-sclerosis and hysteria. It need not be added
that the infiltrating fluid should be perfectly aseptic.

Noorden was quite convinced that Bum's method
was the most preferable and free from the dangers
that the other methods were subject to, and Laudler
was of the same opinion.

Embolism of Pulmonary Artery.

Stoerk exhibited preparations of embolism of the
pulmonary artery and branches that had occurred
eight days after an operation for umbilical hernia. The
ascending aorta and arch were perfectly closed, while
the foramen ovale was open. The arteries of the right
kidney and the finer branches to the spleen were also
closed by emboli. Eiselsberg, who performed the
operation, said that the patient was perfectly well on
the following day after the hernia was replaced, and
no complication threatened. Suddenly, however, on
the third day progressive paralysis commenced.
Trendelenburg’s method of dealing with such cases
was immediately discussed, which is that after four or
eight hours, when death threatens, the right heart
should be opened and the embolus aspirated from the
pulmonary artery. Eiselsberg could not decide on this
heroic treatment, and the patient died. After exam¬
ining the heart, it was concluded that the operation
would have been of no avail owing to the open foramen
ovale.

Bier's Suction Treatment.

Jerusalem pointed out a new indication for Bier's
suction treatment in the after-effects of appendicitis.
From the beginning he applies Bier’s instrument with
curved edges for 20 to 30 minutes over the right side
of the abdomen. After this is done it is less sensitive
and resistant, while the cicatrix becomes soft and the
pain much less. The applications vary between 6
and 20. He also finds that Bier’s treatment has a bene¬
ficial effect on alleviating pain in the abdomen and
hastening absorption in perityphlitis, particularly where
the infiltration is subcutaneous. He also finds it of
much advantage in healing fistulae, and after laparo¬
tomy.

Lead Poisoning.

Teleky briefly related the history of several lead
poisoning cases in shoemakers, where the extensor
muscles were affected by rubbing a white cream into
the leather. Another case was a locksmith with severe
encephalopathia saturnia, with extensors also paralysed,
the latter being due to the use of a paste. Another
was a hatter with thickening of the inner surface of the
fingers and thumbs, due to the colophonium or dark
resin used in the trade.

FROM OUR SPECIAL
CORRESPONDENTS AT HOME.

SCOTLAND.

The Late Professor Annandale.— The news of
Professor Annandale’s tragically sudden death on
December 20th was received in Edinburgh with the
most profound regret. It is hard to believe that, with¬
out any warning, so well-known a figure has been
snatched from our midst. Professor Annandale was
apparently in his ordinary health on the day before
his death. He had performed his ordinary day’s work
at the Infirmary, and dined at home a9 usual. The
next morning he was found dead in his bed by the
servant who went to arouse him. So little was" Pro¬
fessor Annandale deemed to be ailing, much less
seriously ill, that he was looking forward to being
present on the 21st at the prize presentation of the
Royal Garrison Artillery, of which regiment his son-
in-law, Mr. Norman Mitchell James, is one of the
officers. Professor Annandale was a native of New¬
castle, but spent the greatest part of his life in Edin¬
burgh. He assisted Professor Lyme, and in 1877 was
appointed Regius Professor of Clinical Surgery, and
had thus been for thirty years a conspicuous figure
in the University and social*life of the city. His death
was totally unexpected, and the deepest sympathy is^
felt for his family in their great and unlooked-for
bereavement.

The Treatment of Incipient Mental Disease in
the Edinburgh Infirmary. —Dr. Clouston has written
to the Scotsman a second letter advocating this scheme,
and giving the results of a postcard plebiscite among
the practitioners of Edinburgh. He sent to each of
the 379 medical men resident in Edinburgh and Leith
the query, “Are you in favour of the establishment of
psychiatric wards in the Royal Infirmary for the treat¬
ment of early* suitable and transient forms of mental
disease?” Two hundred and fifty-eight replies were
received; 212, or 82 per cent., answered “Yes"’; 26,
or 10 per cent., answered “No”; while conditional
answers, merely approving the principle, were received
from 20. There is thus a very large degree of unani¬
mity in the minds of the profession in favour of Dr.
Clouston’s proposals. The chief objections put for¬
ward aire that there are more urgent matters awaiting
solution by the managers; that the institution has not
the funds to carry out the scheme ; that such patients-
might be a source of danger and annoyance to the
other patients ; that there is no room within the present
Infirmary grounds for such wards; and that there
would be legal difficulties and risks. Dr. Clouston's
general answer to most of these is, that such wards are-
successful elsewhere.

Falkirk Fever Hospital. —The Local Government
Board inquiry into the charges of maladministration
was opened at Falkirk on December 16th. The charges-
of mismanagement were made by the Rev. N. \Y.
Miskimmin in the course of his campaign in the recent
municipal election. The complaints came under four
categories:—(t) Irregularities having occurred’ at the-
hospital; (2) charge of professional negligence; (31
charge of neglect; (4) a charge of extravagance. Mr.
Black, on behalf of the complainers, asked that the
inquiry be adjourned in order that they might have
adequate time to prepare their case. The object of
the inquiry was to restore public confidence, and unless
it was thorough and effective that would not be
achieved. He suggested that thev might lodge a written
statement of their case, and the Town Council be asked
to answer their charges. Mr Allan, for the Town
Council, concurred in the request. Statements had
been made against the hospital, and the people had
been appealed to not to allow their children or relatives
to be taken there. Sheriff Fleming and Sir Henry
Littlejohn, who have been appointed to investigate the
case, decided, however, to take Mr Miskinmrin's
evidence before adjourning. The rev. gentleman stated
that he had heard complaints, and that these had been
substantiated by other persons. The convener of the
Public Health Committee used conveyances belonging
to the hospital very much longer than was reasonable.

, There was extravagance in the provision of liquor and

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Dec. 25, 1907.

CORRESPONDENCE.

The Medical Press. 697

foodstuffs, and laxity in ordinary goods. A child of
eight had been ill-treated in hospital. According to
one order, 72 lbs. of tobacco had been procured, and
all this had not been consumed in the hospital, but
some had been carried away. Reflections were also
made on the quarantine methods during the recent
smallpox epidemic, and on the internal administration
—card-playing, concerts, organ-playing, late at night.
He wanted to see changes both in the convenership of
the Public Health Committee and in the Medical
Officership. The inquiry was adjourned until
January 15th.

The Medical and Dental Defence Union of
Scotland. —The fifth annual report records substantial
progress in the affairs of the Union. The membership,
now 966, has increased by 112 new names during the
year. The financial position of the Union is satis¬
factory. After writing off the last instalment of the
preliminary expenses, a balance of ^271 has been trans¬
ferred from the revenue account to the balance-sheet,
so that the Union now has ^929 9s. to its credit. The
Union has done a great deal of useful work in advising
and assisting its members, adjusting disputes, obtain¬
ing apologies, etc. The annual subscription is only
10s.—a mere trifle, considering the advantages of
belonging to the Defence Union.

LETTERS TO THE EDITOR.

THE BRITISH MEDICAL ASSOCIATION.

To the Editor of The Medical Press and Circular.

Sir,—Y our editorial references to the British
Medical Association are invariably couched in terms
of kindness and sympathy, and your note this week
forms no exception to the rule. Full of goodwill
as we may be to the Association, and alive as we may
be to the uselessness, and often the unfairness of mere
fault-finding, it is unnecessary to disguise the fact that
widespread discontent with the management of the
Association exists among large sections of the members.
This discontent helps to explain the fact that the
membership of the Association numbers less than
20,000 all told—that is about half the numbers eligible
in these islands, and within the British Empire. The
Association boasts of an enormous income, but of
this the greater part is absorbed in the production
of the journal, and there are only meagre funds left
for activity in other directions. The matter was
well put by a correspondent in your pages some time
ago. He said the B.M.A. is in reality at present
solely a co-operative society for the publication of
a journal enormously costly to produce, but certainly
supplied to the members at a cheap rate. The journal
is too big. In every direction, and, particularly in the
editorial department, it could be reduced, and with
advantage, to about one quarter of its present bulk.
The scientific contributions could also be compressed
easily, and to the benefit of the readers, to almost the
same extent. The circulation would still command
the advertisers, whilst a few thousands a year would
be saved for objects now untouched for lack of money.
The Association is doing some small thing towards
the promotion of scientific research ; but if it were
able to speak in the name of the majority of the
profession, and possessed the organisation necessary
to make that voice heard, it might do much more,
not only towards the advancement of science, but to¬
wards those reforms of so much more vital importance
to the bulk of the profession which you, Sir, are so
well doing your part to promote.

I am, Sir, yours truly,

Member B.M.A.

December 20th, 1907.

QUACKERY OF QUACKS.

To the Editor of The Medical Press and Circular.

Sir,—I am pleased you have opened your columns
for a discussion of the all-absorbing and important
question of quackery. I think we might look at our

own profession and see if any quackery exists among
ourselves. Let me make a few suggestions for your
many readers to explore and report their experiences
upon. Commencing at the top of the tree, consul¬
tants, so-called, in many cases, really self-glorified
G.P.’s, Let me ask your readers to record their
experiences. Then among the G.P.’s. let me cite one
case, and I could cite more. Dr. A. was treating a
lady with cardiac dropsy with digitalis. The lady
being dissatisfied with her progress called in Dr. B.,
who remarked to her, no wonder you are not pro¬
gressing. Dr. A. is treating you quite wrongly. The
patient died about a month afterwards, and the
family then employed Dr. B. I regard Dr. B. as a
quack of the worst order.

Let me glance at the nursing profession. I attended
a lady in her confinement, and who employed a trained
nurse to nurse her. I ordered an aperient. The
nurse remarked I always order salts for my patients,
you see they act upon the liver. I dealt with this
nurse very promptly and effectually. I ask. if a nurse
will address a doctor like this, what will her con¬
versation be like, in the absence of the doctor ? I
shudder to think of it ?

I think that many of your readers can give their
personal experience upon the subject of midwives.
Quackery of the rankest description thrives here.
Then we have massage nurses. A patient was suffering
from peripheral neuritis, and a nurse was employed
to massage the lower extremities. The patient asked
me, what is the potential of muscle ? The nurse
had remarked to her that the potential of her calf
muscles was low. I replied, the potential of a muscle
is a meaningless term employed by the ignorant to
cover their ignorance.

Quackery such as I have mentioned means when
referring to the consultant’s and G.P.’s. that we have
failed to act as gentlemen. When we come to the
nursing profession and midwives we must ask our¬
selves the question, W ho is to blame ? Surely, our¬
selves. We have the teaching and examining
of them ; and we do not sufficiently impress upon
them that the superficial knowledge of anatomy,
physiology, etc., which they learn, is merely to enable
them to take an intelligent interest in their nursing
work, and that their duty when nursing a case is faith¬
fully to carry out the instruction of the medical man
who is attending, and is alone responsible for the
case.

I leave your readers to amplify these remarks. I
am sure much practical advantage would accrue from
such a discussion.

I am, Sir, your truly,

Bedford, Dec., 18th, 1907. S. j. Ross.

THE BROWN DOG INCIDENT.

To the Editor of The Medical Press and Circular.

Sir,—I had not intended, as I said, to trouble you
further, but you have apparently entirely missed my
points as to your extraordinary assertion that “ animal
experimentation had provided the children of Battersea
with the only means ” of coping efficiently with an
attack of diphtheria.

At this moment I am not concerned to either endorse
or deny an assertion that diphtheric serum is a very
efficient remedy. That is not the point. I again repeat
that your assertion is in direct contradiction of estab¬
lished facts on the ipse dixits of authorities at least
as high as the Editor of The Medical Press, which
is no doubt very great. I have read all your articles,
and, fortunately, a very great deal besides, or I might
take a more narrow and prejudiced view, and fall into
the making of so untenable an assertion as the one
I have challenged.

I am, Sir, yours truly,

George W. F. Robbins,

| Battersea, London, S.W., Secretary.

December 20th, 1907.

[This letter surely requires no comment We have
given Mr. Robbins plenty of room in our columns,
and if this letter represents the best he can do, we
think it may appropriately wind up the discussion.—
Ed. M. P. and C.l

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REVIEWS OF BOOKS.

Dec. 2 $, 1907-

698 _

OB ITUA RY.

REGIUS PROFESSOR OF SURGERY THOMAS
ANNANDALE.

The close of the year has been sadly marked and
mourned by the profession in Edinburgh, owing to
the sudden death of two of its greatest surgeons, the
death of Regius Professor Thomas Annandale occur¬
ring on Friday last, and that of Sir Patrick Heron
Watson on Saturday. Professor Annandale was Sur¬
geon to H.M. the King’s Bodyguard for Scotland,
Surgeon to the Royal Infirmary, and Consulting Sur¬
geon to the Royal Hospital for Sick Children. Edin¬
burgh. Time precludes us giving more than this brief
announcement of the sudden death of these distin¬
guished surgeons. We hope to present a fuller account
of their careers in our next.

SIR PATRICK HERON WATSON, M.D., F.R.S.,etc.

We regret to announce the sudden death, from heart
failure, of Sir Patrick Heron Watson, who died at his
residence in Charlotte Square, Edinburgh, on Satur¬
day last.

Sir Patrick, who was born in 1S32, was Surgeon-in-
Or din ary to the late Queen Victoria, and Surgeon-in-
Ordinary to the King in Scotland. He was a past
President of the Royal College of Surgeons of Edin¬
burgh, and at the time of his death held the post of
Consulting Surgeon to the Royal Infirmary and to
Chalmers’ Hospital, Edinburgh, receiving the honour
of Knighthood in 1903.

JOSEPH LLEWELYN WILLIAMS, M.B., C.M.Ed,,
M.R.C.S., J.P.

We regret to record the death, on December 13th,
of Dr. J. LI. Williams, J.P., of Wrexham. He was
63 years of age, and was married to a daughter of the
late Mr. Edward Evans. Dr. Williams graduated at
Edinburgh, and, after being at St. Bartholomew’s Hos-

S ital, London, and having obtained the degrees of
LB., C.M., and M.R.C.S., London, he was appointed
house surgeon at the Liverpool Northern Hospital.
Subsequently he became first Medical Officer of Health
for Wrexham, and last year he was appointed Medical
Referee under the new Compensation Act. About three
weeks ago Dr. Williams was seized with heart trouble,
and death was due to cardiac failure. Dr. Williams
had an extensive practice in the Wrexham district, and
for the past six years had been in partnership with
Dr. S. Edwards Jones.

REVIEWS OF BOOKS.

THE PREVENTION OF INFECTIOUS DIS¬
EASES (a).

The title of Dr. McVail’s last book, “ The Prevention
of Infectious Diseases,” led us rather to expect a work
on the subject which broke new and interesting ground,
for it cannot be said that much is generally known
about the prevention of infectious diseases, at any rate
as regards the common infectious diseases of this
country. But we find veiy little in it beyond the usual
hardy perennials—isolation, disinfection, vaccination,
and so on—and these are merely described as we are
accustomed to seeing them described. The reason of
the somewhat platitudinous character of the book is
that it is a reprint of the Lane Lectures which Dr.
McVail gave last year at the Cooper Medical College
at San Francisco, and presumably the facts which
sound in our ears like a thrice-told tale were to the
Pacific audience both novel and interesting. True it
is that Dr. McVail has embellished the ordinary run
of the narrative with incidents drawn from his own
experience, and that here and there we get extracts
from reports and registers which do not usually come
our way; but, after all said and done, the book is
more likely to be of service to the student working for
the D.P.H. and to the intelligent layman than to the

(a) "The Prevention of Infectious Diseases." By John C.
McVail, M.D., County Medical Offloer for Stirlingshire and
Dumbartonshire. London: Macmillan and Co., Ltd. 1907.
8 s. 6d. net.

medical officer of health hungering for fresh tips and
pastures new. For instance, in a book of this kind,
dealing solely with the prevention of infectious dis¬
eases, we should have expected a full and satisfactory
statement of the arguments for and against hospital
isolation in scarlet fever; but the author, after a few
general remarks, dismisses the subject by saying, ' I
am not going to attempt to argue out this question of
hospital influence in scarlet fever.” Then, too, with
regard to return cases, we hoped to find a full dis¬
cussion of that lively and disquieting problem, but it
receives a bare half-page, and even in that no figures
are set out. Now we should have thought questions of
this kind deserving of space which is actually occupied
with such matter as descriptions of the diphtheria
plague, and tubercle bacilli, which are to be found in
every text-book; but this brings us back to the point
that the work before us is really an elementary one,
and that it was brought out for a special purpose and
written ad hoc. The views are all of an orthodox
character, and pleasantly conveyed.

FUNCTIONAL NERVOUS DISORDERS IN
CHILDHOOD (a).

Dr. Leonard Guthrie, in the preface to his
“Functional Nervous Disorders in Childhood,” anti¬
cipates that there may be critics and reviewers so
churlish as to say, with Merlin—

“None can read the text, not even I.”

Let us hasten to assure him that there is one reviewer
at least who not only has read the text but whose
pleasure it will be to place it in that select corner of
his bookcase over which is written (metaphorically).
Non legendi sed lectitandi. For this is no ordinary-
book of scissors, paste, and midnight oil. embellished
with extracts from the case-book, and triumphant vin¬
dications of the author’s theories by reference to suc¬
cess in individual instances which no one else has the
opportunity of verifying. It is, on the contrary, an
unusually original treatise, dealing with a dark corner
in medicine which it illumines with the skill of a saga¬
cious physician, the elegance of a fastidious scholar,
and the wit of a consummate man of the world. We
do not know whether to praise more the sound learning
it reveals, or the brilliance of the style in which it is
written; both axe admirable. One conclusion that is
irresistibly borne in on us is that Dr. Guthrie himself
must have been a neurotic child, for not otherwise
could he have experienced those poignant sensations
which he describes with such fidelity in the first ten
chapters, and only personal suffering could have helped
him so justly to trounce the unthinking cruelty of
pastors and masters towards highly-strung, emotional
and shy children. We sttongly suspect that some of
the excellent stories of childhood’s woes, and even
shortcomings, are put impersonally on the same prin¬
ciple that die fourth evangelist writes of “the other
disciple.” But this intense dramatic sympathy with
objects of his solicitude does not cany the author into
mild and indulgent advice to parents and medical
men ; on the contrary, nothing could be more measured
or more sane than his views of child management gene¬
rally, and nothing distinguishes him so much as his
aversion to faddism and ecstaticism. If the over¬
doing of good causes could be killed by satire, the
thick-and-thin advocates of intemperate “temperance
teaching,” the total abolitionists of juvenile smoking,
the excusers of vice on the “ uric acid ” hypothesis, and
similar excellent and ardent people, would find their
activities vastly curtailed. We would that this book
might fall into the hands of many of our nascent
school hygienists, for they would be bound to recog¬
nise that, whilst the author is a master of his subject
and an intimate friend of children, he is no partisan
of wild experiments of the doctrinaire type which so
many enthusiasts are so keen on instituting. Through¬
out the book, both in the first ten chapters and in the
last eleven more strictly clinical ones, Dr. Guthrie
shows in a dozen ways his faculty for original
observation. In the chapter on “The Fears
of Neurotic Children,” Dr. Guthrie 1 penes about

(a) "Functional Nervous Disorder* in Childhood.” By Leonard
G. Guthrie. M.A., M D., F.B.C.P., 8enior Physician to Padding**
Green Children's Hospital. London: Henry Frowde, Oxford
University Press. Hodder and Stoughton. 1907.

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O

Dec. 25, 1907.

OPERATING THEATRES.

The Medical Press. 699

gloomy religious teaching:—“Although we may enter¬
tain doubts ourselves as to the immortality of moles
and p$t canaries, there is no occasion to allow our
reservations to distress our children.” And again:—
“ The same remark applies to the teaching of all moral,
social, and political questions. Exaggerated state¬
ments and extreme and biassed views on any topics
such as the evils of drink, tea, and tobacco, the land
and poor law questions, are in the highest degree in¬
jurious to neurotic children.” The assertion that
smoking in children stunts growth meets with criticism.
“ It is doubtful whether the most inveterate non-
smoker can add an inch, much less a cubit, to his
stature,” and the sexual purist who has a keen nose
for “ pollution ” is told that “ a child who suffers from
habit spasm, or happens to be dreamy, shy, and
miserable, is not necessarily addicted to secret sins.”
It is, however, hardly fair to give extracts apart from
the “atmosphere” of the book, and that atmosphere
we can commend as having tonic qualities seldom
found in the literary climatology of medicine.

DIAGNOSIS OF ORGANIC NERVOUS
DISEASES, (a).

Since the first edition of this well-known book 15
years ago the progress of neurology has, of course, been
very great, and Dr. Clark had a heavy task in attempt¬
ing to bring the book up-to-date. He has performed
this in an excellent manner without altering the
original form of the book, or disturbing the order of
subjects that was so characteristic and practical a
feature in the first edition. The eight chapters deal
respectively with: The Structure and Functions of the
Nervous System, the Symptomatology of Nervous Dis¬
orders, the Diagnosis of the Position of the Lesion,
the Diagnosis of the Nature of the Lesion, the Diagnosis
of Clinical Types, the Distinction of Functional and
Organic Disease, the Examination of the Patient,
Illustrations of Diagnosis. On the whole the revision
is most creditable, and an account is given of the most
recent advances, including a short description of
lumbar puncture. There are certain exceptions to
this, however; for instance, the section on cerebellar
localisation is poor, and at least twice as much
practical and precise knowledge could have been put
in the same space. While, as said, these lapses are
exceptional in the main section of the book, the same
cannot be said of the chapter (pp. 556-601) on Func¬
tional Diseases, which is extremely poor and shows
an ignorance of all modern work on the subject. When
the first sentence on hysteria contains the statement
that the affection consists in a primary derangement of
the highest cerebral centres—a statement entirely un¬
founded on any evidence whatever, and contradicted
by all our present knowledge of the subject—we are not
surprised to find later on the hackneyed errors dating
30 years back, such as that the face is never involved
in hysteria! hemiplegia, that there is never ankle clonus
on the paralysed side unless there is great contracture,
that the onset of the hemiplegia is never accompanied
by loss of consciousness, etc.

With the omission of this chapter, however, the
book is exceedingly good, and to be warmly recom¬
mended as one of the most useful and valuable books
on this difficult speciality that we possess at the
present day.

OPERATING THEATRES.

ROYAL FREE HOSPITAL.

Tumour of the Breast.—Mr. James Berry operated
on a middle-aged woman, aet. 47, who had noticed for
a few weeks a small lump in her left breast. This
was as large as a hazel nut, smooth, firm, and evi¬
dently in the breast tissue, although quite close to the

“DlagDosiiof Organic Nervous Diseases." By Christian Herter,
MJ). Revised and enlarged by Pierce Clarke, M.D. Pp. 690. New
York and London: Putnam's Bona. 1907. Price 12s. 8d. net.

skin. The latter, however, was in no way adherent
to the lump, nor did the nipple show any signs of re¬
traction. No definite enlargement or infiltration of
the axillary glands could be felt. With the exception
of some heart disease, the patient’s health was other¬
wise good. Mr. Berry pointed out that the diagnosis
in such a case lay between an involution cyst and a
malignant tumour. The short history, the smoothness
and close proximity of the tumour to the skin without
involving the latter were all in favour of a cyst. On
the other hand, the mere fact that a hard lump existed
in the breast of a middle-aged woman was sufficient
to raise a strong suspicion of malignancy in the absence
of definite signs to the contrary. If there were the
least doubt, the proper course to pursue, he said, was
to remove such a tumour locally, and then if it proved
to be malignant to at once proceed with the larger
operation of removal of the whole breast, pectoral
muscle, and axillary glands. He thought it better to
excise the piece of breast containing the tumour before
cutting into the latter, as a better view of the surface
of the growth could thereby be obtained. He con¬
sidered it excessively rare for a surgeon of any experi¬
ence not to be able to tell at once by naked eye exam¬
ination of the cut section whether he had to deal with
a malignant or an innocent tumour. Occasionally, but
very rarely, it happened that under such, conditions
uncertainty still prevailed, and it might be necessary
to have a microscopical section cut on the spot before
a definite diagnosis could be made. He strongly depre¬
cated the practice of cutting into a doubtful tumour,
and then, if it proved to be malignant, postponing for
a few days the performance of the larger operation
of removal of the whole breast, etc. Such a proceed¬
ing favoured general dissemination, and distinctly
lessened the prospect of ultimate cure. The tumour,
together with a small portion of the breast, was there¬
upon removed, and it was found to be a firm, non-
encapsuled, solid growth, of the colour and consist¬
ency of a raw potato—in other words, a typical
scirrhous carcinoma. The larger operation of com¬
plete removal of the whole breast, together with the
pectoral muscle and axillary glands, was then carried
out, special care being taken to remove plenty of the
skin because of the close proximity of the tumour to
it. It was noticeable that the axillary glands,
although not appreciably affected clinically, never¬
theless were found to be distinctly affected when the
axilla was opened, and some of them on section pre¬
sented distinct traces of carcinomatous deposit. Mr.
Berry said that the great points in regard to naked
eye diagnosis of the tumour were : its non-encapsula¬
tion and its firmness. Chronic inflammatory lumps in
the breast might contain a good deal of fibrous tissue,
but they were usually somewhat elastic, and lacked
the firm, dense consistency of carcinoma. As the
patient had fortunately been operated upon in an early
stage of the disease, and the removal had been a very
complete one, he thought the prognosis might reason¬
ably be considered a good one. He, like most other
surgeons, had many patients on whom he had per-
I formed similar operations several years ago, and who
I had remained quite free from the disease. He also
; drew attention to the insertion of a large drainage tube
I at the lower and back part of the axilla. He con-
' sidered it much safer in cases of cancer to allow the
; serum and other secretions of the wound to drain away
in the first few hours after the operation, rather than
to leave them to be absorbed from the wound. The
! drainage tube should be removed at the latest on the
J day after the operation.

The patient made a normal recovery, and will be
j sent back to her doctor in the country in a week after
I the operation.

Digitized by G00gle

WEEKLY SUMMARY.

Dec. 25, 1907.

700 The Medical Press.

Weekly Summary of Medical Literature,
English and Foreign.

Specially compiled for Thb Medical Press and Circular.

RECENT PATHOLOGICAL LITERATURE.

Calmette's Ophthalmo- Reaction to Tuberculin.—

Boyd ( Scottish Medical and Surgical Journal , Decem¬
ber, 1907) reports a few cases in which he has tried
Calmette's ophthalmo-reaction to tuberculin, a diag¬
nostic test to which there have not been as yet many
references in English. The test is extremely simple.
If a drop of a 1 per cent watery solution of tuberculin
is placed in the eye of a tuberculous patient, a definite
reaction ensues. Within a few hours there is a con¬
gestion of the conjunctiva, which soon passes into
definite conjunctivitis. The pupil also becomes dilated.
The reaction is at a maximum in 12 hours, and has
completely disappeared in a couple of days. The in¬
convenience to the patient is trifling. No reaction
occurs in the eye of a non-tuberculons patient. In
the carrying out’of the test ordinary tuberculin should
not be used, as it is usually suspended in glycerine,
which may interfere with the accuracy of the test by
irritating the conjunctiva. Calmette advises a pre¬
paration of dry tuberculin, which can be dissolved in
distilled water before use. He claims that the reaction
has a high diagnostic value, and his results have been
supported by other observers, including Boyd. If the
method should stand the test of time, it will be of
great help in diagnosis, as it furnishes an easy method
of recognising obscure tuberculous lesions. R.

Fat Embolism. —While fat embolism is only in rare
instances a cause of death, it is in itself a frequent
occurrence. Graham ( Journal of Medical Research ,
July, 1907! publishes the history of a fatal case, and
gives a critical summary of the literature of the sub¬
ject. He concludes : (1) Two lesion complexes may be
found in fatal cases of fat embolism. The first con¬
sists of an extreme blocking of the pulmonary vessels,
together with less marked involvement of those of the
beart. There is only a negligible blocking of the
■vessels of the general circulatory system. The second
involves widespread embolism of the vessels, and the
pulmonary lesion is overshadowed by lesions of the
heart, kidney, and central nervous system. (2) Death
occurs in the first class of cases from asphyxia, and
follows closely upon the trauma or disease leading to
the entrance of fat into the vessels. In the second
class of cases it depends upon multiple cerebral em¬
boli, associated with embolism and fatty degeneration
of the heart. In such cases death follows only after
the lapse of some days. (3) The dividing line be¬
tween fatal and non-fatal amounts of fat is ill-defined,
and individual susceptibility seems to vary. (4) An
amount of fat, which would be fatal if suddenly gain¬
ing entrance into the blood stream, produces no un¬
favourable symptoms if it enters the circulation in
divided doses separated by intervals of several days.
Such fat is gradually eliminated through the kidneys
and by the phagocytic action of the leucocytes. (5)
Fatty degeneration of the heart in fatal cases is often
accompanied by similar changes in the diaphragm, the
skeletal muscles remaining unaffected. These dia¬
phragmatic changes may in part account for the
respiratory disturbance always observed. R.

Tuberculin Treatment in Children. — Riviere
(British Medical Journal , October 26, 1907) publishes
the results of his experiences of tuberculin treatment
in children. As vaccine treatment in general has
hardly yet received the support it deserves, we call
attention to his paper. Riviere is, on the whole, a
disciple of Wright’s, and he hardly ventures on any
independent criticism. He believes that during
treatment the opsonic index should be carefully
watched, though he permits treatment without opsonic
control where the latter is impracticable. The all-
important point as regards success of treatment is

dosage, and the discouraging results obtained by some
observers have been due to over-dosage. In Riviere'-:
own experience he finds 1-12,000 to 1-8,000 mg. a suit¬
able dose for a child of one year, 1-4,000 mg. for a
child of five years, and 1-3,000 for a child of 10 or 12
years. With regard to localised tuberculosis, he find?
tuberculin, “in suitable doses, an almost certain
remedy.” The improvement following on treatment 1-
shown not only by local healing, but by improvement
in general health, bodily and mental. Among the
cases treated were dactylitis, superficial abscess, tuber¬
culous glands and joints. General tuberculosis
should, in Riviere’s opinion, also be treated by tuber¬
culin. The opsonic index is thereby steadied, and
the general symptoms alleviated. He makes reference
specially to phthisis and tuberculous peritonitis. The
condition he regards as most unpromising for success
is marked wasting. Riviere also believes that the in¬
jection of tuberculin in some way gives protection
against secondary infections. The opsonic index to
other organisms seems to bear a certain parallelism to
the tuberculo-opsonic index. Riviere closes with a
strong plea for a wider use of tuberculin. R.

The Aunmia of Ankylostomiasis.— Boycott yBritish
Medical Journal , November 9th, 1907) describes the
points of contiast between the anaemia of ankylosto¬
miasis and idiopathic pernicious anaemia. (1) \>
regards the histology of the blood-film in pernicious
anaemia, many of the cells are large and contain much
haemoglobin, whereas in ankylostomiasis the majoritv
of the cells are small, and contain a small quantitv of
haemoglobin. In other words, the colour index of per-
nicious anaemia is high, that of ankylostomiasis low
Moreover, the more severe the anaemia, the greater the
contrast on this point. (2) As regards the volume of
blood and its oxygen-bearing capacity, the contrast is
equally marked. In ankylostomiasis the volume of
blood is nearly twice the normal, and therefore,
although the haemoglobin percentage is only 45 per¬
cent. of the normal, the total oxygen capacity is hardlv
diminished at all. In pernicious anaemia, on the other
hand, there is a real diminution in the total quantitv
of haemoglobin in the body, and therefore in the
oxygen-bearing capacity of the blood. In severe cases
the oxygen-bearing capacity is reduced by a half.

R.

Pelvic Inflammation in the Female.— Wilson ( Journal
of Obstetrics and Gynacology, July, 1907), in the course
of a general paper on pelvis inflammation, gives some
bacteriological findings of interest. In the case of
twelve recent puerperal infections, micro-organisms
were found in every case, the distributions beine as
follows:—Streptococci alone, 4; streptococci with
staphylococcus aureus, 2; streptococcus with other
organisms, 4; other organisms, 2. It is not so stated,
but we gather that the cases referred to were examined
on the post-mortem or operation table, and were there¬
fore cases of great severity; hence the high proportion
of streptococcal infections. In 43 cases of sub-acute
or chronic suppurative pelvic inflammation, no germ*
were found in 10 cases; in 10 streptococcus was found
alone; and in association with other germs in 4:
staphylococcus aureus was found in 2 ; staphylococ 'll-
albus in 1 ; and mixed staphylococci and pneumococci
in 1 ; bacillus coli was found in 1. With regard to
pyosalpinx, of 13 cases examined, 4 were found to be
sterile; 1 contained streptococcus, 1 staphylococcus
albus; 1 staphylococcus and pneumococcus; 1 gono¬
coccus ; and 5 various saprophytes. R.

The Cancer Problem.— Skerrett (British Medical
Journal , November and, 1907) makes an ingenious sug¬
gestion bearing on the nature and treatment of cancer.

Digitized by GoOgle

The Medical Press. 7 qi

MEDICAL NEWS IN BRIEF.

Dec. 25,_ 1907!

Starting with the facts that the essential characteristic
of the cancer cell is its apparently unlimited power
of reproduction, and that reproduction is governed by
Ihe cell-nucleus, he asks whether it is possible so to
act on the nucleus as to inhibit this power of excessive
reproduction. He then refers to the observation that
acute inflammations seem to exert a retrogressive in¬
fluence on cancerous growths. He suggests that it is
possible that the pabulum for the excessive nuclear
.growth in cancer is supplied by an influx of leuco¬
cytes to the part, and that the effect of inflammation
is to starve the tumour by depriving it of its leucocytic
supply. Would it then be possible, he asks, to modify
nuclear growth by diminishing in the food the supply
of the materials necessary for the formation of
nuclein—or so to act on nuclein as to alter its func¬
tional activity? In reply to the latter question he
■suggests the possibility of supplying arsenic with the
food, so that the nuclein molecule might possibly take
up that metal instead of phosphorus, and thereby
-undergo some change in its functional activity. He
suggests, therefore, that the results of taking a nuclein-
free diet while arsenic is administered internally
should be observed. K-

Medical News in Brief.

Contamination of Town Milk.

Dr. G. Trew Cattell, one of the medical officers
of health for Berkshire, has just issued a report
■dealing with his inspection this year of the dairies
and milkshops. In taking samples of milk fresh from
the cow, and kept in a covered vessel for a certai 1
period of time, and also taking samples which had
Leen exposed in large open porcelain bowls for a
like period to the ordinary conditions prevailing in
the main street of a town, he found the number of
micro-organisms from the one so exposed to be enor¬
mously increased as compared with the covered
sample. The dust of the streets of a town was mixed
largely with the dried excreta of animals and human
expectoration, and very frequently contained germs of
disease. The bacilli of scarlet fever, of tuberculosis,
and of enteric fever specially throve in milk. It was
quite possible that many epidemics of the form-r dis¬
ease which had begun in a mysterious manner and
whose cause had never been accurately determined,
might be traced to the accidental contamination of the
milk supply in the manner indicated. The habit which
consumptive people had of constantly expectorating—
a habit which, from the nature of their disease, it
was difficult to prevent—constituted a serio as danger.
The sputum, generally swarming with tuberculous
bacilli, quickly became dried on the pavement or road¬
way, and was blown about in the form of dust, and,
should this settle on the milk, there was a grave pos¬
sibility of children being brought into contact with
rtuberculous infection, to which they were peculiarly
susceptible. He suggested that greater care was neces¬
sary in the way that milk was handled before sale,
■and that it should never be allowed to be exposed in
uncovered vessels. It would, he added, be an advan¬
tage if all authorities in the county adopted one set of
.'egulations, thus securing unanimity of action.

Teaching of Midwifery in Ireland.

A meeting of Masters, Assistant Masters, and ex-
Assistant Masters of the Dublin Maternity Hospitals
was held in the Royal College of Physicians, Dr.
Hastings Tweedy, Master of the Rotunda Hospital, in
the chair. The following resolution was proposed by
Dr. R. D. Purefoy, ex-Master of the Rotunda Hospital,
and seconded by Dr. Gibson, Master of the Coombe
Hospital, and passed unanimously‘ That this meet¬
ing, consisting of the Masters and Assistants, past and
present, of the Dublin Maternity Hospitals, is unani¬
mously of opinion that the proposed shortening of the
course in practical obstetrics from six to three months
would seriously interfere with the work of the
matemitv hospitals ; that it would increase, rather than
lessen, the difficulties in providing each student with

the required number of cases; and that, at the same
time, it would materially diminsh his opportunities of
obtaining practical instruction.” It was then proposed
by Sir William Smyly, ex-Master of the Rotunda Hos-

S ital, seconded by Dr. A. J. Horne, Master of the
National Lying-In Hospital, and passed unani¬
mously :—“That, in the opinion of this meeting, it is
most desirable that the recommendations of the
General Medical Council with regard to a Clinical and
Practical Examination in Obstetrics and Gynaecology,
be adopted, especially as the meeting has been assured
that the Masters of the Maternity Hospitals will further
the scheme by every means in their power. ”

Infantile Mortality In Poplar. | • j

In reporting upon the desirability of appointing a
female health visitor in Poplar, the Public Health
Committee of the Poplar Borough Council state that
last year in the borough 822 infants under one year
of age died, and of these 188 were under one month
old. The total number of births in the year was 5,363.
Upon inquiries at 26 factories in Poplar, where a total
of 5,641 women are employed, it was found that 769
were married, or 13.6 per cent. The Local Government
Board have asked the Poplar Council what action they
propose to take upon the information of births to be
received under the Notification of Births Act with a
view to the reduction of infant mortality. The Public
Health Committee will recommend the Council to agree
to the principle of the appointment of a health visitor.

The Coombe Hospital, Dublin.

A special meeting of the directors of the hospital
was held on December 17th to elect a Master in place
of Dr. Thomas G. Stevens, whose period of office had
expired. There was a large attendance of Governors,
the Right Hon. the Lord Mayor presiding. The can¬
didates were: Dr. M. J. Gibson, M.A., M.D., B.Ch.,
B.A.O., Dub. Univ., and Dr. Thomas Neill, B.A.,
M.B., B.Ch., B.A.O., Dub. Univ., both having occu¬
pied the position of Assistant Master in the hospital.
A ballot having been taken, the Lord Mayor declared
Dr. Gibson elected by n votes as against 5 for Dr.
Neill. The newly-elected Master was then notified by
the Chairman of his election to the responsible posi¬
tion, and Dr. Gibson having thanked the Board for
the confidence they had placed in him, the proceedings
concluded.

PASS LISTS.

Royal Colloge of Surgeons, Edinburgh.

At a meeting of the College held on the 16th inst.,
the following gentlemen were elected Fellows :—Bryan
Foster, M.B., Ch.B., Melb. ; William James France,

L. R.C.S.E. ; Henry Goodwyn, L.R.C.S.E. ; Henry
John Lotz, M.R.C.S.Eng., L.R.C.P.I.oud., D.P.H.
Camb. ; Raymond Herbert Price, M.B., C.M.Edin. :
John Fordyce Robertson, M.D.Edin. ; Cyril Shellshear,

M. B., C.M.Syd. ; Fred Stoker, M.B., Ch.B.Durh. ;
Herbert Pank Thompson, M.D.Edin. ; Walter Wood-
word White, M.D. ; C. M. McGill, L.R.C.S.E. ; David
I’ercival Dalbreck Wilkie, M.B., Ch.B.Edin. ; and
James W'ilson, M.B., Ch.B.Aberd.

Apothecaries’ Hall, Londo <

The Society of the Apothecaries of London has
granted the L.S.A. Diploma to the following candi¬
dates, entitling them to practise Medicine, Surgery,
and Midwifery :—R. Beesley and E. S. Cooke.

The Salford Board of Guardians recently decided
that public vaccinators should receive half-a-crown for
each case of successful primary vaccination and re-
vaccination performed by them at the surgery, and
that the fee for each case after the twenty-ninth
should be one-and-sixpence.

The Daily Mail Year Book having now attained the
eighth year of its existence, has become more or less
familiar to readers. It contains the usual vast store¬
house of information of a manifold kind. One in¬
teresting feature is the brief biographies of men and
women of our time. The price of this 1908 compen¬
dium of reference for the writing desk is only sixpence.

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702 THE Medical Press. NOTICES TO CORRESPONDENTS.

Dec 35. 1907.

NOTICES TO
CORRESPONDENTS, ffc.

W* OoRjutaroNDixn requiring a reply in this oolumn are par¬
ticularly requested to make tue of a Distinctive Signature or
Initial, and to avoid the praotioe of signing themselves
" Reader,” "Subscriber," Old Subscriber," eto. Muoh con¬
fusion will be spared by attention to this rule.

SUBSCRIPTION*.

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each year begin on January 1st and July 1st respectively. Terms
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Spink and Co., of Calcutta, are our officially-appointed agents.
Indian subscriptions are Bs. 15.13.

ADVERTISEMENTS.

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Quarter Page, £1 6e.; One-eighth, 12s. 6 d.

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Small announcements of Praotioes, Assistances, Vacancies, Books,
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Original Articles or Letters intended for publication
should be written on one side of the paper only and must be
authenticated with the name and address of the writer, not
nxessarily for publication but as evidence of identity.

Contributors are kindly requested to send their communica¬
tions, if resident in England or the Colonies, to the Editor at
the London offloe; if resident in Ireland to the Dublin offloe, in
order to save time in reforwarding from offloe to office. When
sending subscriptions the same rule applies as to offloe; thsss
should be addressed to the Publisher.

Eastern. —The Siamese certainly are going ahead, and have
a good appreciation of European medicine. As the result of a
visit reoently paid by the King of Siam to the Virchow Hospital
in Berlin, a contract has been placed for the whole equipment of
a similar hospital for the oity of Bangkok. The building mate¬
rials are to a large extent to be shipped from Germany, and
there will be an installation of apparatus, not only for carrying
out operations in major surgery, but also for bacteriological
work. An ambulance department has already been Inaugurated
in the Siamese defensive services, the Geneva Red Cross being
adopted with a vernacular emblem, and the King of Slam is
desirous of conferring upon his subjects the full advantages of
modern progress. The sum to be rzpended, including buildings
and the expenses of the staff, cannot be less than £25,000.

THE INDEX FOB 1907.

The Index for the present Tolume, of which this number is the
last, will appear in our next week's issue.

Mr. J. Watson.—T he question of priority in the discovery of
the infection of Malta.Fever is fully discussed in our issue for
November 6 th, 1907, page 510.

THE NEW TREATMENT.

Away with judge and jury, pray I

For oourt and gaol have had their dry,

No more shall law 3 oontrol us;

We shall, immune, from every ill,

Cure murderers by a little pill
And burglars by a bolus.

If draughts, not of the sort he likes.

Effect no cure in Mr. Sikes,

Then careless what 'twill cost us,

Our Btom prescription, I profess.

Shall, while we look for swift success.

Be “ Repetatur haustus!"

If he, however, grow and grow
In crime and vicious habits, though
To virtue we still urge on.

Aware what treatment beet befits
His fell disease, we'll call for its
Removal by the surgeon.

Our grateful praise then, I insist.

Is what the skilled pathlologist
Shall—what reward’s like that?—earn.

For soon “ the mixture as before ”

Shall make our gaol-birds more and more
To all mankind a pattern. M. S.

—Daily Chronicle.

Westbalian.— There are several Post-Graduate centres in Lon-
ion, offering various facilities for study. Apply to the Dean of
the West London Post-Graduate College, Hammersmith Road, W.,
or to the North-East London Post-Graduate College, Prince of
Wales’s Hospital.

Subscriber, M.D.—We have carefully considered the matter
and laid the facts—impersonally, of oourse—before a member of
the profession, who is well acquainted with suoh problems. His
advioe, in which we oonour, is that you would do well not to
accept such an appointment under present oiroumstanoes. The
advantages that might aoorue would be more than counter¬
balanced by the risks involved.

£ppohtinunt0.

Devane, J. F., M.B., B.Ch., D.P.H., House Surgeon at the
County Infirmary, Limerick.

Gunnino, C. J. H., M.R.O. 8 ., L.R.C.P.Lond., Clinical Assistant
to the Ophth&lmio Department at St. George’s Hospital.
Hawthorne, 0. O., M.D.Glasg., M.R.C.P.Lond., Examiner in
Medioine and Clinical Medicine in the University of Glasgow.

Morrison, J. T. J., M.B.Cnntab., F.R.C. 8 .Eng., Examiner is
Medical Jurisprudence at the University of Glasgow.

Nicol, J. H., M.B., M.S.Glasg., Examiner in Surgery at the
University of Glasgow.

Robb, D. M., M.B., Ch.B.Edin., Senior House 8 urgeon at tie
Clayton Hospital, Wakefield.

Sloan, Samuel, M.D., M.S.Glasg., Examiner in MldwiferT «t
the University of Glasgow.

UataitcuB.

St. George’s Union.—Second Assistant Medical Officer at their
Infirmary, Fulham Road, West Brompton, 8 .W. 8 alsry, £15)
per annum, with board, residence, and washing. Applica¬
tions to the Medical Superintendent.

The Hospital for 8 iok Children. Great Ormond 8 tree*, London,
W.C.—A Casualty Medical Officer. Salary, £200 per annua,
with lunoh. Applications to Stewart Jones, Secretary. (See
Advert.)

Parish of Bermondsey Infirmary.—First Assistant Medical
Officer. Salary, £170 per annum, with rations, waahisj.
furnished apartments, and attendance. Applications to

E. Pitts Fenton, Clerk, 283, Tooley 8 treet, 8 .E.

University of Sheffield.—Demonstrator in Anatomy. Satin.

£150 per annum. Applications to W. M. Gibbons, Registrar
Birmingham City Asylum.—Junior Assistant Medical Officer.
Salary, £150 per annum, with board, lodging, and wukinf.
Applications to the Medioal Superintendent.

Huddersfield Infirmary.—Male House 8 urgeon. Salary, £100 per
annum, with board, residence, and washing. Application
to Mr. J. Bate, Secretary, Infirmary, Sheffield.

West Riding Asylum, Wadsley, near Sheffield.—Fifth Asautaat
Medical Officer. Salary, £140 per annum, with board, etc.
Applications to the Medioal Superintendent.

General Hospital, Barbados.—Junior Resident Surgeon. Salary,
£200 a year, with separate furnished quartan. First-dan
passage out provided. Applications to Sir Frederick Trem.
Bart., care of the Warden, London Hospital Medioal Collett,
Mile End. E.

The Middlesex Hospital, W.—Resident Medioal Officer. Salary,
£200 per annum, with residence and board. Applications 10

F. Clare Melhado, 8 eoretary- 8 upt.

Cardiff Union.—Assistant Medical Officer. Salary, £139 per
annum, with rations, apartments, attendance, and .washing.
Applications to Arthur J. Harris, Clerk, Union Offico,
Queen’s Chambers, Cardiff.

Kent County Asylum, Maidstone.—Fourth Assistant Medial
Officer. Salary, £175 per annum, with furnished quarter*,
attendance, 00 all, gas, garden produce, milk, and washio;.
Applications to rhe Medioal Superintendent.

tfirihs:

Angles. —On Deo. 17th, at Multan, Punjanb, India, the wife of
Captain R. L. Argies, R.A.M.O., of a son. (By oable.)
Ward. —On Deo. 13th, at Wellwood, Bloemfontein, O.R.C., the
wife of Arthur Blackwood Ward, M.B., of a son.

Dr Selincourt—Wheeler.— On Dec. 19th, at Lyndhurst Hoad
Congregational Chapel, Hugh, youngest sou of Mrs. de Seiic-
oourt, of 26, Bel 8 ize Grove, London, to Janet, youngest
daughter of Henry Wheeler, L.R.C.P.Lond., M.R.C.S.Eng, of
Norwioh.

Embleton—Botd. —On Dec. 20th, at 8 t. John’s, Hamprt»d.
Dennis, eldest son of the late Dennis C. Embleton, M.D..
M.R.O.S., L.R.O.P., of Bournemouth, and grandson of th?
late Dennis Embleton, M.D.. F.R.C.S., F.R.C.P., of New¬
castle, to Alys Faraday, daughter of Philip Boyd.
Bardswell—Mack. —On Dec. 14th, at 8 t. Margaret’s Church.
Paston, Norfolk, Noel Dean Bardswell, M.D., son of the late
Oharles William Bardswell, Recorder of Kingstou-upori
Thames, Co Monica, elder daughter of John Mack late IS.
Regiment, of Paston Hall, Norfolk.

Botan—Cattt. —On Deo. 18th, at the Church of 8 t. Joseph. New¬
bury, Staff-Surgeon John Boyan, Royal Navy, eldest #on of
Mr. Thomas Boyan, of Ratbmlnes, Dublin, to Pearl Alenin
Macdonald, younger daughter of the late Major-General
Charles Parker Catty, 46th Regiment.

Mabsden—Hannah.— On Dec. 18th, at St. Thomas’s Church.
Ashton-in-Makerfieid, Prosper Henry Marsden, Lecturer ti
Pharmacy in the University of Liverpool, to Jessie, thirl
daughter of Dr. Hannah, M.O.H., Ashton-in-Makerfleld.
Haviland—Huxley. —On Dec. 20th, at the Registrar’s, Kenstir-
ton, Heath John Haviland, son of the late Captain R. H
Haviland, of Bath, to Ellen, daughter of the late Jane?
Edmund Huxley, M.D., of Maidstone, Kent.

Hemsted—Cash. —On Deo. 18th, at The Friends’ Meeting Houw.
Torquay, John Garnet Hemsted, L.D.S., M.R.C. 8 .Eng.. of
Torquay, youngest son of Dr. Hemsted, of Whiteburr*.
Hants, to Violet Mary, second daughter of Dr. A. MidglfT
Cash, of Limefield, Torquay.

JBeath*

Comer ford. —On Dec. 2nd, at St. Vinoent’s, Ventnor. LOW-
Deputy-Inspeotor-General J. T. Oomcrford, M.D., K.N
(retire!), aged 64.

Duke. —On Deo. 12th, at 44, Northumberland Avenue, Kiiri
town, Caroline Georgina, widow of the late Fleet-Surge«
Valentine Duke, R.N.

Maitland.— On Deo. 20th, at his residence, Langdon, Bouire
mouth, Lt.-Ool. John Maitland, M.D., I.M. 8 . (retired), of
Madras, aged 55.

v”: C .?T^ v I 8.081- WEDNESDAY, DEOEMBEB 25, 1907.

SUMMARY

CONTENTS.

Editorial Notea and Comments. .. 677

Leading Article 678

Current Topics. _ „ .. 680

Personal - .681

Clinical Lecture.682

Original Papers .. - 684

Transactions of Societies.691

Correspondence: Foreign and Special .695

0 '' I Correspondence : Home ..

678 1 Letters to the Editor.

680 ! Obituary.

681 ; Reviews .

6 82 Operating Theatres.

684 Week, F Summary of Medical Literature ..
691 Medical News In Brief - _ _

695 Notlees to Correspondents; Weekly Diary As.

FOB FULL TABLE OF CONTENTS SEE NEXT PAGE.

CLEFT PALATE AND HARE-LIP:

The Earlier Operation* on the Palate.

By EDMUND OWEN, M.B., F.R.C.S.,

Consulting 8u

>on, St. Mary’s Hospital, and to tbe Hospital for Sick
ildren, Oreat Ormond Street, London.

Pp. Ill, with 32 Illustrations. Just published.
Price, 2s. 6d. net.

“ The most faoourabe time in life for operating on a
cefl palate i* between the age of two week* and three month*."

(Page 41.)

London: Bauluu, Tindall & Cox.

BT THI SAMI AUTHOR:

SURGICAL DISEASES OF CHILDREN.

Third Edition, Revised and Enlarged.

Pp. 504, with 6 Chromo-lithographs and 120 Engravings.

London: Cabbbll & Co., Ltd.

By W. AHBUTHNOT LANK, MU,

Cleft Palate and Hare Lip.

New Bdltlon, In large clear type, demy 4to, 6s.

"Mr. Lane makes out a clear case for early and almost Immediate
operation. To sum up: Mr. Lane has absolutely proved his conten¬
tion, and rendered it quite clear that early operation la the right
course on every ground, developmental and otherwise; and, farther,
that delay in performing staphylorrhaphy until the third or sixth
J,6 .* r ... u * ht with most harmful results, and should not be per¬
mitted.’ —BrUUh Medical Journal, Jan. 27th, 1906.

Operative Treatment of Fractures.

New Edition, uniform with above, 7 s. 6d,

The Operative Treatment

of Chronic Constipation.

New Edition, uniform with above, 2a. 6d.

Thb Musical Publishino Co.. Ltd.. 22) Bartholomew Close, E.C.

B.P C. NOW HEADY. Its. 6d. net. B.F.C.

SECOND EDITION, with Illustrations, royal 8vo, 10s. 6d. _ ’. ‘ o r v -

The Treatment of Lateral Curvature THE BRITISH

By BERNARD PHARMACEUTICAL CODEX:

*2 « 5HESH4KW »JL ID m or xedical

book would do something to check the nnsclentlflc and often dis¬
astrous treatment of lateral curvature of the spine by spinal supports
and prolonged rest, and this new edition ie even better calculated to

PRACTITIONERS AND PHARMACIBT8.

This volume provides the best means of flshtlng quackery, by

show the good results which may be obtained In lateral curvature by f u PPW , ig accurate Information respecting all Drug* and Medicines
posture and exercise.”—L as cit. “ common use, and removing the veil of secrecy from Chemicals and

•• There can be no doubt that good work has been done by the author Pre P“* tl0D ' under f * nc > "•««• “ exorbitant prices.

by his strong advocacy of the more rational method of treating lateral , __.. ~_ __

curvature o? the spine by exercises."— Bum sh Mxdical Journal. London: The Publisher B.P.C.', 72 Great Rueeall Street, W.C.

London: H. K. Lewis, 186 Gower Street, W.C. Mag be seen A ordered at any Pharmacy, or obtained through

--— . BooktMtr*.

NOW READY. SIXTH EDITION, 687 pages, with 240 Illustrations.

Royal Svo. Prise lie. uai.

Sixth Edition.

Diseases and Injuries of the Eye,

WITH THEIR MEDICAL AND SURGICAL TREATMENT.

By GEORGE LAWSON, FJt.O.B.

Revised and Re-written by ARNOLD LAWSON. F.R.0.8.

London : Smith, Elder A Co., 16 Waterloo Place, 8.W.

NOW BEADY, with Photograph and numerous Dlustiutions.
Third Edition enlarged. Prioe 10 s.

ON DISEASES 07 THE E7E.

By CHARLB8 RILL TAYLOR. F.B.CJ9., and M-DXdln.

Pp. xil + 108. With 42 Illustrations.
Prioe Se. net.

LATERAL CURVATURE OF THE
SPINE

AND PELVI0 DEVIATIONS.

By RICHARD BAR WELL, F.R.C.8.,

Consulting Surgeon, Charing Cross Hospital; Surgeon, Cripples’
Home.

" The book will well repay perusal."- MBDICal. Press A Circular.
"We regsnl this work ss an original effort to eolve the difficult

Fellow Medical Society, London; late Preeident of the problsfc of lateral curvatum.-- British Mbdioal Journal.

Medleal Society; Scogeon Nottingham and Midland Eye Infirmary.
London : Ragan Paul, Trejjpb A Co., Paternoster Square.

London: Bailllere, Tindall A Cox, 8 Henrietta St., Covent Gardsq.
Dublin: Hsaua A Neaie, 18 Nassau 8trset.

KMrUtnmd for Hojge usd Foreign Transmissioa

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Hie Medioal Press and Circular

Dec. 25 , 1907

Table of Contents.

Notes and Comments—

I*AUF

7

Roll of Merit

' •. 677

“ Rive ” Treatment

.. 675

Limericks and Insanity

.. 675

Notification Errors ..

.. 675

And Their Results ..

.. 675

A’HappyJHunting Ground..

.. 675

Leading Articles—

Midwives in Default .. 676

The Feeding'of School Children .. 676

Current Topics— f

A Workhouse Scandal .. .. 680

Inaccurate Prescriptions .. .. <580

An Alternative Drink for Alcohol .. 680

The Manchester Epileptic Colony.. 681

The Manchester Epileptic Col
A Public Medical Service ..
Copper in Spinach
Incriminated Kippers

Clinical Lecture—

The Serum Treatment of Typhoid.
Fever (Anti-typhoid Opsonisa-
tion). ' By. Dr. Cbanlepiease .. 682

Original Papers—

IntenditiaCKeratitis from a Modern
Stand point. By Sydney Stephen¬
son, M.B., C.M. 684

On Eye Strain. Bv Herbert C.
Mooney, B.Ch., FlR.C.S. .. 687

TliefEffecta of the Rontgen Kays
on Lymphatics and Myeloid Leu¬
kaemia. By Dr. Emile* Epstein ..
A Note on Tuberculosis as a Factor
in the Irish Death Rate. By
. W’.JR. MacDermott, M.B.

Transactions of Societies

Royal Society of Medicine..
Society for Study of Disease in
Children ..

Liverpool Medical Institution ..
West I,ondon Medico-Chimrgical
Society

British Balneological ai d Climato-
kigicul Society ..

Correspondence -Foreign —

(itrmaHy — .jg

Human Tuberculous Sputum ..
The Treatment of Neuralgias by
Injection
. A lulrta —

Ischialgia and Infiltration
Embolism oft Pulmonary Artery
Bier’s Suction Treatment
Lead Poisoning ..

Correspondence—Home—

Scotland —

The Iaite Professor Annandale..
The Treatment of Incipient
Mental Disease at the Edin¬
burgh Infirmary
Falkirk Fever Hospital
The Medical and Dental Defence
Cnion of Scotland

Letters to the Editor—

The British Medical Association .. tS7
Quackery of Quacks .. .. t»7

The Brown Dog Incident .. t*T

Obituary—

Regius Professor of Surgery
Thomas Annandale .. .. 69?

Sir Patrick Heron Watson, M.D.,

F.R.S.ft*

Joseph Llewelyn Williams. M.B.
fi.M.Ed., M.R.C.S.. J.P. ..

Reviews of Looks—

The Prevention of Infectious
Diseases .. .. .. ft*

Functional Nervous Disorders in

Childhood.. .. ..ft*

Diagnosis of Organic Nervous
Diseases .. .. ft4

Operating Theatres .. ..

Weekly Humm\ry of Pathological
Literature—

Calmette’s Ophthalnio- Reaction to
Tuberculin .. .. .. 7h>

Fat Embolism .. .. "(W

Tuberculin Treatment in Children 7«t
The Anivmia of Ankylostomiasis . 7W
Pelvic Inflammation in the Female '<**
The Cancer Problem .. .. if'

Medical News in Brief .. .. '<>1

Notices to Correa pokmihl

W eekly Diary, LRCYt**«h^AMfc
isos, Appointments, VagAmK
Births, Marriages, Dbitm^P *<•

HOMMEL’S Haematogen

CONTAINS NEITHER ALCOHOL NOR ANTISEPTICS^

A combination of AO parts purified and concentrated Hemoglobin
with 20 parte chemically pure Glycerine and Aromatic Flavouring.

The best of all the existing preparations of Hemoglobin. More efficacious than Cod-Liver
Oil or the ordinary manufactured preparations of Iron. Very strengthening both for Children
and Adults. An energetic Blood Former. Increases the Appetite. Aids Digestion.

IT- Extremely useful in Riokuta, Scrofula, Guttural Debility, Anaemia, Weak Heart,
Neurasthenia, and Convalescence from illness such as Pneumonia or Influensa.

CP* Unsurpassed as a Strengthening Reetoretire in Diseases of tho Lungs. Has a

very agreeable taste, and is taken with the utmost relish even by Children.

FRRR FROM BAOTRRIAL GROWTH. UNCHARGED BT KEEPING.

These important qualities are guaranteed by using the highest permissible temperature in the prooess
of manufacture (130° to 140° Fahr. for 24 hours).. No guarantee of this description is possible for prepara¬
tions made by a cold prooess with ether. _

w* In proscribing, always state Htsmatogon

as spurious Imitations aro"o7Ferod.

ONLY SUPPLIED IN FLUID, NOT IN CAPSULES OR OTHER FORMS.

Infants - - Take from Half to One Teatpoanful twice e day in milk.

Children - „ One or Two Dessertspoonfuls daily, either pure or mixed with any convenient liquid.

Adults - - ,, One Teblespoonful twice a dey before the two principal mesla.

fiv* SAMPLES AND LITERATURE, gratit and carriage paid, on application.

HIC0LAY A CO., 86 A 36a, ST. AIBRKW8 HILL, L0HD0H, K.C.

As« mti PM Nmtn AMsmeat LKHN • FINK, WILLIAM •TRKET, NCW YORK.

e

Dec. 26,1007

The Medical Prase and Omxilar

Bailliere, Tindall s Cox s

“University Series”

of Manuals for Students and Practitioners.

MANUAL

OF

MANU/

MANUAL

OF

MANLY

Of

MANUAL rmenc
or

MANUAL

ArPLI! - _ of

mbdic;.'. DISEAS'

ANATOMY SURGF.l/V MEDIC1N lYSIOff MIDWIFERY ^crmar.KACTERlOl • ^ WQ - (

N

BUCHANAN “OSEACAH

MONRO

STEW

JELLETT -ooktv

mu I Htv

<«naughto

TM1BD *a:

uurvEiuin

SSHJES

OH I VERS!
SUiiS

UNIYEr. r

sun.

UHIVERM,

SUUEJ

XIVER

»Ull

tnrvies

sem

tOKDO

^ifetnsuv

MMIDON
'■UAW.TODU!.

UHM.

'•ube.muui.H"-' *uuu,-. u> '"‘'

tuny.

Hswbt.n:.

BUCHANAN’S ANATOMY,

SYSTEMATIC AND PRACTICAL, net.

INCLUDING EMBRYOLOGY. O 1 /
eral Colours. Complete in I VoL, or in ** * / "

Pp. 1572, with 631 Illustrations, mostly Original and in several Colours. Complete in 1 VoL, or in
2 Vols.. price 12/6 each net.

•• It contains ample information for students preparing for examinations .”—Dublin Journal ol Medical Science.

nftcc « A ADI CCC’ CIIDPCDV sixth Edition. p P .xiv;+ 1350. with

Kllot « UAnLtOO wUllUlLllY 30 Plate* and 50a Illustrations.

(Or bound in limp leather, gilt edges, 25/- net.)
“ In spite of many rivals it is still most popular.”— Guy’s Hospital Gazette.

21 /-

MGNRO’S MEDICINE

Second Edition. Pp. xxii. + 1022. With # C
B 42 Illustrations, Plain and Coloured. B 4 J/ m

“ It will cover the syllabus of any examining board ."—London Hospital Gazette.

ATCVIflDT’O nill/CIAI Aav Fifth Edition. Pp.xviii. + 912. With 2 |C/

Q I tWAIl I W I ill vlULUU V ■ Coloured Plates and 395 Illustrations. B 1//

■ One of the most complete and useful manuals on the subject.”— Practitioner.

ICI I CTT’C iiinilfICCDV Pp.xxiv. + 1176. With 9 Plates and 467 O I J m ,

JtLLL I I W miUVfirtlfY ■ Illustrations, plain and coloured. “*/ j

•• It is quite the best of the many manuals published ."—Westminster Hospital Gazette. ,

TURNER’S MEDICAL ELECTRICITY I ' Lighteradium, 10/6

AND HIGH FREQUENCY CURRENTS. Fourth Edition. With 205 Illustrations.

“ Written by an author who is thoroughly In touch with his subject.” — lancet.

MOOR HEWLETT’S APPLIED BACTERIOLOGY 12/6

Third Edition. Pp. x. + 476. With 29 Plain and 73 Coloured Figures.

” One of the best elementary handbooks we have examined.”— Practitioner.

MACNAUCHTON-JONES’ DISEASES of WOMEN 21 /-

Ninth Edition. Po. xi. 4- 1 44, With 122 Plates and 647 Illustrations ^Ormj_Vols_ ! _22/£neM__

B AILLI ERE, TINDALL & COX, 8 Henrietta St., Covent Garden, London.

HANNA & NEALE, 18 Nassau Street, Doblin.

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MEAT EXTRACTS, MINERAL
WATERS, WINB8, OOOOA, Ac
(continued.)

Bewley A Draper.—Ginger Wine 16

Brand ACo.,—Essence ol Beef 8

Bachanau.-Black and White
Whisky. 5

Fry's Milk Chocolnte.80

CHEMICAL & MEDICAL

FOODS &c.

BOOKS & PUBLICATIONS.

CHEMICAL. A MEDICAL
PREPARATIONS, FOODS, Ac.

PREPARATIONS,

(continued.)

Wulflng, A., A Co.—Forms-

Ballliere. Tindall ft Cox :—

Barweil R.—Lateral Curva¬
ture of the Spine ..

Lindsay, L A.-Dlseasea of
the Lungs...

Owen, E.-Cleft Palate .

University Series .

Sewill -Dental Bui gery .

Walsh. D.—Rontgen Rays in
Medical Work ..

Wheeler,-W. L De Courcey—
Students' Handbook of
Operative Surgery.

Cassell & Co.

Owen, E.—Diseases of Chil¬
dren .

Abbott, G. Van A Sons—Diabetic

ment

Andrus & Andrus.—Hema-

Ziinmennann,

iKtioids

parations

Angier Chemical Co.—Angier's

Emulsion .

Allen A Hanburys. —Bynin

HEALTH RESORTS, HOTELS
HOMES A ASYLUMS.
Altadore Sanatorium ...... 18

Cannes.—Hotel Continental... 21

Own

Amara

Brin's Oxygen Co.,Ltd.— Brin’B

• Oxygen .

Bristol-Myers Co.—Sal He-

patlca .

Burroughs Wellcome A Co.—
The True Cascura Sagraila..
Christy, T. A Co.—Glyco-Thy-

Valentine Meat Juice Oo.

EDUCATIONAL.

General Nursing Association... 20

Church Stretton Asylum.

Farnham House, Finglas.

Hartfleld House, Drumcondra,

Dublin .

Hampstead — Gentlemen's Pri-

moliue

MISCELLANEOUS.

Behnke Voice Training ...

Christy, T. A Co.—Glyco-

Heroin . ly

Denver Chemical Manufacturing
Co.—Antiphlogistine. 1*

Fairchild, Bros. A Foster—
Peptogenic Milk Powder.etc.il
Fellows Medical Manutacturing

Co.—Hypopeos . 8

Grillon, E. — Tamar Indien

Urlllon . 20

Giles, Schaoht & Co.—Bisedia 10
International Plasmon, Ltd.—

vate Hospital

Btrkbeck Bank.

Fannin and Co. (Dublin)
Ormsby, Sir L. H.—Work

Highfteld — Private Hospital

Clarke A Co. .. Sup

Isaacs A Co.—Bottles.

M'Cowen. R.—Atlantic Oysters
Smith A Sheppard.Su[

for Ladies.

InnBbruck.—Hotel Tirol.21

Matlock. Bath.— Royal Hote
Neullen 8 Hotel.— Aix - la 20

Chapelle . 21

Smedleys Hydropathic Es¬
tablishment . 21

St. Patrick's Hospital, Dublin... 18

Stewart Institution . 18

The Retreat Private Asylum ... 18
Verville, Olontarf, near Dublin 18

Kogan Paul, Trench ft Go.:-
Taylor, 0. B.— Diseases ol the
..

Lewis, H. K.:—

Roth, B.—Curvature of the
Spine .

SURGICAL INSTRUMENTS AND
APPLIANCES, Ac.

Leonard A Co.—Feeding Bottle 18

Pope A Plante.—Elastic Stock¬
ings.-.*

Plasmon.

Medical Publishing Co. :—

Lane, W. A.—Works by .

Smith Elder & Go.

Lawson, G.,'Diseases of the
Eye...

The Publisher—

The British Pharmaceutical

Codex .

•Bromural

Knoll A Co.

Miol, Manufacting Co.—Miol
Newbery, F. A Sons-Warner's
Tono Suihbul .

Nicolay A Co.—“ Hommel'B

Hiematogen ”.

The Saccharin Corporation,
Ltd.—Novocain .

VACANCIES.

Hospital for Sick Childreu ..
Royal College of Surgeons in

England .

Poor-Law Medical Officers .

Medical Locum Teneus .

MEAT EXTRACTS MINERAL
WATERS,WINES, COCOAS, Ac.
-Ejculap Bitter Water Co.—

.Esculap Water . 10

Bewley A Draper—Soda Water 16

“The Food Par Excellence

Valentine’s Meat-Juice

For a Tired Stomach

III PNEUMONIA. PHTHISIS AND INFLUENZA.

Where a powerful and energetic nourishment is
required in a concentrated, rapidly assimilated form,
easily administered and readily tolerated, when other
forms of food fail, Valentine’s Meat-Juice is employed
by well known practitioners throughout the world.

Prof. Dr. M. Utten, Lecturer on Internal Medicine,
University of Berlin, and Director of the City Hospital,
Berlin, Germany. “ I have employed Valentine s Meat-
Juice with patients suffering from Tuberculosis and
observed excellent results from its use. I have also
used it with good results in the treatment of patients
with Anaemia, as well as those convalescent from
acute diseases.”

O. B. Douglas, M. D., Ex-President Medical Soci¬
ety, County of New York ; Professor Diseases of Nose
and Throat; New York Post-Graduate Medical School and
Hospital. “I have been ill with Influenza and used
Valentine’s Meat-Juice when nothing else seemed to
be relished. 1 consider this an assurance of my conti-

MEAT JUIC 1

For sale by European and American Chemists and Druggists,

VALENTINE’S MEAT-1UICE COMPANY,

Dec. 26. 1907

The Medical Press and Circular

Just Published. Pp. via. + 509. Price 10s. fid. net.

Second Edition. Enlarged and Re written.

LECTURES ON

DISEASES OF THE LUNGS,

By JAMBS ALEXANDER LINDSAY, M.D., P.R.C.P.,

Professor of Medicine, Queen's College, Belfast; Examiner in Medicine
in the Royal University of Ireland.

“ Rears on every page the stamp of practical experience ."—British
Medical Journal.

London: Bailliere, Tindall A Cox, 8 Henrietta 8 t., Oovent Garden.
Dublin : Hanna A Neale, 18 Nassau Street.

Just Published, the Fourth Edition, price 12s. 6 d. net, of 1

HEART DISEASE8,

With Special Reference to Prognosis and Treatment.

By Sir WM. BROADBENT, Bart., M.D.Lond.. F.R.S..
Physician to His Majesty the King,

AND

JOHN F. H. BROADBENT, M.D.Oxon., F.RC.P.Lond.

This new edition more than maintains the reputation which its
predecessors have won.— Edinbcbuh Medical Journal.

London: Bailliere, Tindall A Cox, 8 Henrietta 8 t., Covent Garden.
Dublin : Hanna A Neale, 18 Nassau Street.

Works by Sir LAMBERT HEPENSTAL ORMSBY,

M !>., F.B.C.8.,

Ex-President of the Royal College of Surgeons in Ireland;
Lecturer on Clinical and Operative Surgery, and Senior Surgeon to the
Meath Hospital and oo. Dublin Infirmary;

Piles and Prolapsus Recti: Causes, Symptoms, and

Treatment Price Is.

Varicose Veins: their Cause, Symptoms and Cure

Price Is.

Osteotomy for Genu Valgum. Price Is.

mosia and Paraphimosis, with a description of the Ancient Bile of
Oi r mmmeii ion. Prlos Is.

THE BEHNKE METHOD

OF VOICE TRAINING,

For Speakers, Singers, and Stammerers-

'• Pre-eminent success."—TiMRfi.

“ I bare confidence In advising speech sufferers to place themselves
under the Instruction of Mss. Behnke."—Editor, MlDICAL TOU8.

“ Mrs. Behnke is well known as s most exosllent teacher upon
thoroughly philosophical principles.'’—LANCKT.

’• Thanks to your inatruotlou, my voioa now fills the church with
perfect ease."—A Pupil.

“ STAMMERING,*' Is., poet free.

Apply to Mrs. Emil Behnke, Earl's Court Sq.. London.

An Operation Chart, giving the Instruments in

detail used In all the Major and Minor Operations In 8urgery de
signed for the use of Hospital and Infirmary Surgeons, Dressers and
Junior Practitioners. Now ready, 2nd New Edition, prlos with
Rollers, mounted on Linen end varnished, 10s. 0d. net.

Dublin : Fannin A Co. London t Bailliere. Tindall A Oox.

Fourth Edition. Pp. xU. + 622. With 281 Illustrations.

Price 10a. fid. net.

SEWILL’S DENTAL SURGERY.

Including Special Anatomy and Pathology. A Manual for
Students and Practitioners.

Edited by W. J. ENGLAND, L.D.S.Bng.; and
J. SEFTON SEWILL, L.R.C.P., M.R.C. 8 ., L.D. 8 .Eng.

“ A complete manual."—B rit. Mkd. Journal.

“ lias the charm of lucidity."—THR Lanobt.

London: Bailliere. Tindall A Cox, 8 Henrietta Street, Coveot Garden
Dublin : Hanna A Neale, 18 Nassau Street.

Now RlADT. Pp. xlL + 300. With 134 Illustrations. Price be.

STUDENT’S HANDBOOK OF
OPERATIVE SURGERY.

By W. I. Dx COURCEY WHEELER, B.A., M.D., F.R.C.8.,
Surgeon to Mercers Hospital; Ex-Demonstrator of Anatomy, Trinity
College, Dublin.

London: Bailliere, Tindall A Cox, 8 Henrietta 8 t., Covent Garden.
Dublin : Hanna A Neale, 18 Nassau Street.

NOW READY. Fourth Edition. Pp. xvtii + 434. with 172 Illus¬
trations, mostly Original. Price 15i. net.

WALSH’S Rontgen Rays in Medical
Work.

With s Section on Apparatus end Methods by LEWIS JONES, M.D.
London: Bailliere, Tindall A Cox, 8 Henrietta 8 t., Covent Garden.
Dublin : Hsnna A Neale. 18 Nassau 8 treet.

ATLANTIC OYSTERS. — Approved by Sir

Charles Cameron, C.B. •• Beds free from pollution.'* (Bee L.G.R.
Report.) Fresh front the Beds dally ; carriage paid to any station,
cash with order. 126 for 10s.; 50 for 6 s. ; 26 for 3a.—B. M'Cowen, i
Tralee.

Doctors
Should Know

that OXO is made by the original Liebig
Company, the firm who first introduced
concentrated meat foods to the world. They
have their own vast cattle farms exceeding one
million acres in extent, carrying fine pure-bred
British Hereford stock from His Majesty’s farms
at Windsor and other British breeders. It is
the possession of these farms, and the conse¬
quent complete control of raw material, that
makes the Liebig Company superior to all
other manufacturers. OXO is made from cattle
certified to be free from tuberculosis; it is
standardised, pure, free from preservatives, and
untouched by hand.

OXO

4, Lloyd's Avenue. London. E.C.

BUCHANAN’S

BLACK

WHITE

THE WHISKY OF WORLD
WIDE REPUTE

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Th« M»dloti Press and Circular

Deo. 26,1907

(WH. R. WARNER A

A Tonio that always Tones and
supports the General System.

Enriohes the Blood. Sustains the Heart

It restores tone to debilitated
nerves, is a splendid appetizer,

— .*«

* ^ and a tissue builder. It is
peculiarly adapted to the
nervousness which so many
women frequently experience.

Avoid all Substitutes. Literature on Request.

PER LARGE BOTTLE. 3/6.

WM. R. WARNER CO.,

British Depot:— F. NEWBERY & SONS (*" A £"2‘ I> ), 27 & 28 Charterhouse Square, LONDON, £A

THE TUBERCULOSIS PROBLEM.

Given the Sociological Conditions of Sanatoria and Medico-Dietetic Conditions of “ MIOL,”
there is evidence arriving daily from medical men that MIOL will satisfactorily combat
tubercular Disease.

Miol

“MIOL” IN PULMONARY DISEASE— The air passages are relieved from the
obstructive morbid secretions ; breathing is soon restored to the normal. Haemoptysis is at once
arrested, night sweats stop in about three days, the irritating cough is speedily removed.

The foul-smelling septic condition is corrected by the antiseptic action of the contained free Iodine,
and the whole series of morbid symptoms are removed.

“ MIOL ” is a nutritive tonic and stimulant promoting the functional activity of all the organs
ef the body as well as being the most active digestive of its kind known to Science.

MOST PALATABLE. CHILDREN LIKE IT.

“ MIOL ” is being rapidly established in all the principal Hospitals and Sanatoria.

Send for booklet and sample with actual Clinical Reports obtained by Medical Men from Patients.

Will the Doctor kindly—

(1) Weigh each case before taking "MIOL,” and each fortnight afterwards?

(2) Examine the sputa and blood before and after taking " MIOL " for Tubercle Bacilli ?

(3) Note temperature, sweating, appetite and digestion before and after beginning “ MIOL ”
from time to time ?

Samples and Clinical Reports on application.

• The Miol Manufacturing Co., Ltd,,

66 < 5 - 66a, Southwark Bridge Road, London, S.E.

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Deo. 26,1907

The Medioal Press and Circular

vii

-

K.UO DOUCHE TOR THE APPLICATION OF

OLVCO-TMYMOLINE TO THE NASAL CAVITIES

GLYCO-THYMOLINE

IS USED FOR CATARRHAL CONDITIONS OF
MUCOUS MEMBRANE IN ANY PART OF THE BODY

Nasal, Throat, Stomach, Intestinal
Rectal and Utero-Vaginal Catarrh

KRESS S OWEN COMPANY

210 Fulton Street, New York

Sole Agents lor Great Britain. THOS. CHRISTY & CO., 4—10 & 12 Old Swan Lane, London, E. C.

Bummed end approved by the Institute or Htoiene, 34 Devonshire St., Harley St, W., where this
preparation can be seen, and ita properties and value can be eaplained.

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Deo. 25,1907

THE ABSOLUTELY NON-IRRITANT LOCAL ANAESTHETIC.

Six tlmos I 099 toxlo than Oocalne.

Inoroaooa tho motion of Supraronln and othor Adrenal Proparallonm.

NOVOCAIN.

Manufactured by the FARBWERKE vorm. MEISTER LUCIUS 9 BRUENING, Hoechst-on-Main.

NEUTRAL. EASILY SOLUBLE IN WATER. NOT DECOMPOSED BY BOILING-

Supplied in Sterilised Solutions or Tablets (with Suprarenin borate).

A. —For Infiltration Anaesthesia. I C.—For Medullary or Lumbar Anesthesia.

B. —Anesthesia of Nerve Centres-__I E —F or D ental Purposes-

Sole Proprietor» for United Kingdom, and Colonies —

The SACCHARIN CORPORATION, Ltd., 165 Queen Victoria Street,

--- LONDON, B.C.

LITERATURE AND SAMPLES FREE TO MEDICAL MEN.

IN THE TREATMENT OF

ANJEM1A, NEURASTHENIA , BRONCHITIS , INFLUENZA . PULMONARY
TUBERCULOSIS, AND WASTING DISEASES OF CHILDHOOD, AND
DURING CONVALESCENCE FROM EXHAUSTING DISEASES,

THE PHYSICIAN OF MANY YEARS’ EXPERIENCE

KNOWS THAT, TO OBTAIN IMMEDIATE RESULTS . THEBE IS NO REMEDY THAT
POSSESSES THE POWER TO ALTER DISORDERED FUNCTIONS LIKE

“ fellows’ $yrup or hypoplwpltitcs."

MANY A TEXT BOOK ON RESPIRATORY DISEASES SPECIFICALLY MENTIONS
THIS PREPARATION AS BEING OF STERLING WORTH.

TRY IT, AND PROVE THESE FACTS.

SPECIAL NOTE .—Fellows’ Syrup ia never sold in bulk, but is dispensed in bottles

containing 8 os. and 15 os.

THU PREPARATION MAY BE OBTAINED AT ALL CHEMISTS AND PHARMACISTS
THROUGHOUT THE UNITED KINGDOM.

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Dec. 25, 1907

The Medical Press and Olroular

XV

It

ft

ITS

3 BACTERIOLOGY

The crucial test of the efficacy of an antiseptic
fluid is the bacteriological one* When we
state that FORMOLYPTOL is equal in
germicidal potency to a 1-1000 solution of
Corrosive Sublimate, without the irritant or
toxic properties of the latter drug, we base
our claim upon the results of careful lab¬
oratory experimentation with the different
varieties of germ life* Complete and conclu¬
sive reports from prominent bacteriologists
sent upon request*

ANDRUS & ANDRUS

46 Hotborn Viaduct, London, C, C«

Representing

THE PALISADE M’F'G CO., Nvw York

FORMOLYPTOL. is a palatable, fra¬
grant and slightly astringent formaldehyde
preparation. It does not stain linen or
clothes. Employed in Gynecology and
Obstetrics, Rhlno*Laryngology, Surgery
aad Dentistry. Also internally in the
treatment of Typhoid Fever, and in the
gastro-inteslinal disorders of children.

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XVI

The Medioal Press and Circular

Dec. 85, 1907

PROCESS DEVISED BY D^BEWLEY 1776 .
Iand elaborated by H.N.DRAPERfcs 18781

- q ^C\oin/\' l

SodaWater

Perfected

SOLE PROPRIETORS

Bev/Ie 9 & P/j/rp E/j Us.

This is par excellence the Soda Water for use in the sick-room.
It is prescribed by eminent medical men, and has been adopted by the
principal Dublin Hospitals. May be obtained in either Syphons or Bottles
from all first-class Chemists and Wine Merchants.

Order “Bewley 6* Draper’s Perfected SodaWater.”

FOR

TRi

BRIN’S

■ AMU.

OXYGEN

BRIN’S OXYGEN GO., Ltd^ Elverton 8L, Westminster, S.W. [Tele.—w Westminster.
BIRMINGHAM O XY GEN GO., Ltd., 8altley Works. [Tele. — 2687.] [Telegraphic Address:

MAN CHESTER OXYGEN GO., Ltd., Gt. Marlborough St. [Tele.— 2688. "Brins Oxygen London."

THE TASTELESS AND BEST NATURAL APERIENT

" Contain* the Snlphatee of Magnesium and Sodium in unusually large
qoantitiea. It ia an admirable aperient water.”—T hs Lawc*t.

" JSSCULAP ia the clearest and pnreat of all the Hungarian Aperient
Water*.”—T h* Hospital.

* Of uniform strength and free from organic impurity. ”— Edinburgh
MbDIOAL JOURNAL.

* A valuable remedial agent in atomach and inteatinal affections.”—
Gla900w Mxdioal Journal.

It ia an efficient aperient.”— Dublin Journal or Mrdioal Somci

“ It poeeeeaee the decide d advantage of being leea unpleasant to take
than many other bitter wa tors, as well as being free frbm any organic
impurity. —Th* Mrdioal Paxes.

ANALYSIS

Of the JC8CULAP SPRING, BUDAPEST.

By Prof. JOHANN MOLNAR, Government Analyst.

Salts in 10,000 Parts op Wats*.

Sulphate of Potassium

OlOi

Sulphate of Ammonia

o-oei

Sulphate of Sodium

... 189-063

Sulphate of Magnesium ...

... 172A06

Sulphate of Calcium

... 80788

Chloride of Sodium

... 29"047

Carbonate of Sodium

6*669

Carbonate of Iron ... ...

0067

Carbonate of Manganese ...

0-428

Alumina .

0948

Silicic Acid ... .

0062

Total .

... 872*894

/ESC U LAP

May be obtained from all Cbemista, Dru* •
gists. Shippers, and Mineral Watar Dealers.

THE BOTTLING AND MANAGEMENT OF THE >ESCULAP SPRINGS, BUDAPE8T, ARE
CARRIED ON DIRECTLY UNDER ENGLISH SUPERVISION.

THE fiSCULAP BITTER WATER CO., LTD., LONDON, E.C.; AND BUDAPEST-

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Dec. 26 , 1907.

The Medical Press and Circular

In all disorders of the respiratory tract in which
inflammation or cough is a conspicuous/actor. incomparably
beneficial results can be secured by theiadministration of

Glyco -Heroin ( Smith

The preparation instantly diminishes cough, augments
expulsion of secretions, dispels oppressive sense of
suffocation, restores regular, pain-free respiration and
subdues inflammation of the air passages.

The marked analgesic, antispasmodic, balsamic,
expectorant, mucus-modifying and inflammation-1
allaying properties of GLYCO-HEROIN (SMITH)
explain the curative^action of the Preparation
in the treatment of

Coughs, Bronchitis, Pneumonia,
Laryngitis, Pulmonary Phthisis,
Asthma, Whooping Cough

,and the various .disorders of the breathir^ passajesi

GLYCO-HEROIN (SMITH) is admittedly the
ideal heroin product. It is superior to preparations
containing codeine or morphine, in that it is
vastly more potent and does not beget the
bye-effects common.to those drugs.

jDos e . — “Tfie adu/t dose is one teaspoonfuf. repeated
every two or three hours. For Chi/dren of more than three
years of age, the dose is from five to ten drops.

Samples.and exhaustive literature bearing upon the preparation
’will be^sent. post paid, on request
To the Sole British Agents

Thos. Christy & Co.,

4.OLD SWAN LANE. LONDON.E.C

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*viii

The Medloal Press and Circular

Dec. 85,1807

_ PRIVATE ASYLUMS, HOMES, SANATORIA, _

ALTADORE SANATORIUM,

CO. WICKLOW, IRELAND.

Established 6 years. 750 ft. above aea level. 630 acres. Graduated walks. Shelter from N.. E.. and W. Proorietor and
Physloian, J. O. 8MYTH. M.E.C^8., LRO.P.Lond. For particular, apply Resident Puysiclan, Altadore, KUpedder. co. Wkilos
Telegraphic Address : "Altadore/ Newtownmountkennedy. Ball way Station: Greystones.
_Inclaalve Terms- 3 guineas pop week.

ST. PATRICKS HOSPITAL FOR
MENTAL DISEASES.

THE GOVERNORS OF

ST. PATRICK’S HOSPITAL, DUBLIN

(FOUNDED BT DZAN SWIJT IH 1746).

Wish to announce that they have acquired a large property, In
accordance with their Royal Charter (900 acres), and established
a Private Asylum in connection with the Hospitals at Lucan,
for the reception of patients of both sexes suffering from Mental
Disease.

A NEW VILLA has been erected at Lnoan for the accommoda¬
tion of a limited namber of gentlemen, and the entire establish¬
ment has been lighted by electricity.

The parent institution in Dublin continues its curative work,
has undergone almost entire reconstruction, receives both male
and female patients, and its recovery rate is very satisfactory.
The Governors are anxious that the Medical Profession should
be acquainted with the work of this historic institution, which
has been devoted for over a century and a half to the reception
and curative treatment of the insane of Ireland.

Urgent oases can be admitted by direct application to the
Medical Superintendent.

For farther particulars, forms of admission, km, apply to the
KxoiOTRAB, St. Patrick’s Hospital, James Street, Dublin- _

PRIVATE ASYLUMS,

Co. DUBLIN.

For Patients of the Upper Class suffering from
Mental and Nervous Diseases, and the
Abase of Drags. Established 1835.

HAMPSTEAD,

CUSNEVIN, FOR 8ENTLEIEN.

HIGHFIELD,
DRUICONDRA, FOR LADIES.

Telephone No. lOtt.

These Hospitals are built on ths Villa Syitsm, and there are also
Cottages on the demesne (1M acres), which Is 100 feet above the sea-
level, and oosnmands an utaative view of the Dublin Mountains
and Bay.

Voluntary Patiente admitted without Medical Certificate*,

For further Information apply tor illustrated prospectus. Ac., to
the Resident Medical Superintendents, Dr. Hbsrt Marcus Euraos,
Highfleld, Drumoondra, or Dr. William Nulboh Euracb, Hamp¬
stead, Glasnevln: or at the offioe, 41 Grafton Street, Dublin. Tele¬
phone 198. On Mondays, Wednesdays and Fridays, from 2 to 8 p.m.

THE ONLY ASEPTIC FEBDBB MADE

18 THE ROTUNDA FEEDING BOTTLE.

It is simple—only s pure rubber teat and bottle—no valve. It
safe—for It can be sterilised. It is cheap— 6d.

Can bs had wholesale from any Druggists’ Sundry Ho*»e, or from

LEONARD k OO., Chemists, Dublin k BelfltsL

Leonard’s Rotunda Tissue, 1/- per lb.

Leonard's Clinical Thermometers, 1 /- each.

BIRKBECK BANK.

Munimp U6i.

SOUTHAMPTON BUILDINGS, HIGH HOLBORN, W.C.

2i PER CENT. INTEREST

allowed on Deposit Accounts.

2 PER CENT. INTEREST

on Drawing Aooounts with Cheque Book.

All general Banking Business transacted.
ALMANACK, with toll particulars, FOfcT FREE.'

0. r. RAVENBOEOrr. Secretary.

STRETTON HOUSE,

Chureh-Stretton, Shropshlro.

A Private HOME for the treatment of Gentlemen
Buffering from Mental dieeases. Bracing hill country
See *• Medical Direotory,” p. 1958.

Apply to Medioal Superintendent. Telephone: 10 P.0.
Churoh-Stretton.

THE RETREAT PRIVATE ASYLUM,

Near ARMAGH.

., . , . (ESTABI.ISXZD 1824.)

Licensed for the reception of ladies and gentlemen of the upper
%nd middle classes suffering from

,tt . , “ANTAL AND NERVOUS DISEASES.

(Voluntary Boarders and Inebriates admitted.) This establish-
ment has lately undergone many struotural alterations and im¬
provements, and the walks and grounds are extensive and pie
turesque.

Great care and attention are bestowed upon the patients,
Tided indoor * ame8 ant * regular carriage exercise being pre

Golf links have reoently been added.

For further Information apply to the Medioal Superintendent,
Ur. J. Go war Allen, J.P., or Mr. Joseph Allen, Clomllfo,
ArmAffh.

STEWART INSTITUTION

roB CHILDREN, AND HOSPITAL FOR VESTAL

DISEASES, Palmerston. Chapellxod, co. Dublin.

This institution receives imbecile ohildren from all parti of
Ireland free, or by partial payment, by election. Full p»rm«t
oases at moderate rates. One vote for every 10s. fid. subscrib'd
annually. A life vote for £5 5s. donation.

The Hospital for Mental Diseases—a separate establishment—
receives lady and gentleman patients from £50 per an nan up-
wards, according to accommodation required. Management fill*
up-to-date in all particulars. Beautiful situation. Best trod)is
sanitation. Fine demesne with necessary privacy. Voluntsn
boarders received.

Resident Medioal Superintendent: Dr. F. B. Rainsford. All
particulars from Secretary at Offloe , 4 0 Molesworth Street, Dahlia

FARN HAmTh OUSE

For Oontlomon; MA&WILLE for 1*41 e*

*T FIHOIiMV, BN ED JAR DUBLIN,

Private Hospitals for Patients of the Upper Classes

surrERiNo non

NERVOUS AND MENTAL DISBA8E8, ALCOHOLISM, FTC

Telephone No. 1470. Telegram*: “Dawson, Finflii*"

Contxdting Room*: 17 Upper FittwiUiam Street, Dahlia.

These establishments, which are healthily situated in pretty
grounds upwards of 46 acres in extent, provide modern medics!
curative and palliative treatment on moderate terms. Voluntary
boarders admitted with oerfifloatee. Large staff maintained.
Up-to-date sanitation.

Prospectuses, forms, etc., on application to the Resident Medics!
Superintendent, W. R. Dawson, M.D., F.R.C.P.I., at the Instit*
tion, or at the Consulting Rooms from 3 to 5 p.m. on Mondays,
Wednesdays, and Fridays, or by appointment.

HABTFIELD HOU8K

DRUMOONDRA, DUBLIN. FOR QENTLBMEI-

Established in 1843, under the Patronage of the Most Btv.

Dr. Murray, Archbishop of Dublin. Telephone: No. 334.

Tele. Address: “ Pbopbietob, Habtfield House, Dbumcosma''

VERVILLK CLONTAKF,

NEAR DUBLIN. FOR LADIES.

Established in 1857.

Telegraphio Address: " Pbopbiktob, Vebtilix, Oi/JVTiET."

These Establishments are for the treatment and care of Ladm
and Gentlemen suffering from mental disturbanoe or mental di*»*

A limited number of Patients suffering from ailments trithf
oat of the oontinuoas abase of alcohol or drugs are received a
voluntary patients, without medioal certificates.

A Catholio Chaplain viaita regularly, and celebrates Mia °*
Sundays and Holy days.

Visiting Physician: Dr. BURKE SAVAGE, Rutland Sqn*-
Dublin. For further particulars, apply to Dr. LYNCH, or »
i. J. MAGRATH, Superintendent.

Diqiti:

.oogle

r Dec. 25. 1907

The Medical Press and Qircul&f

»1X

BBWLEY & DRAPER’S

GINGER WINE

May be obtained of all Grocers and Wine Merchants.

Mumfaoturers (-BEWLE7 & DB.APEB. LIMITED, DUBLIN*

XX

Tht Medical Press and Circular

Deo. 25, 1907

DIABETES

VAN ABBOTT'S GLUTEN BREAD, BJ8C0TTE8 & FLAIR.
V1R0CEN BREAD AND BISCUITS.

And virions other Biscuits and Bread from Bran, Almond Nut, and Meat Flour.

C. VAN ABBOTT & SONS, Baden Place, Crosby Row, Borough, SB.

Purvey o ri to H.B. naval. Military, and Principal London. Provincial and Colonial Hospitals. Establish*) Utt.
Telegraphic AddressG luteus,” Lobdoh, 8.B.

TAMAR

INDIEN

CRILLON.

H Coxatiw, Refroftiia, ud medicated Trait Cezeage.

vnr AQUKABLE TO TAKE, AMD NEVEE CAUSING IEEITATIOM.

Its physMsglsal asttsa assmo
Mm I mms eMata rettef and . . .
sffsetual ours sf.

CONSTIPATION,

HAEMORRHOIDS, BILE, HEADACHE, LOSS OF
APPETITE, AND INTESTINAL OBSTRUCTIONS

By augmenting die peristaltic movement oi the intestine without producing undue
secretion of the liquids. Unlike mils and the usual purgatives, it does not predispose
to intestinal sluggishness; and the same dose always produces the same effect— that
is to say, never needs increasing.

It is recommended by the most eminent physicians of Paris, notably Drs. Biuh and
Taedxbu, who prescribe it constantly for the above com pl ai n ts, and with the moot

marked success.

WI|olesalo—Loi|doi|: E. GI^ILLON, 67 Southwark Bridge Road, S.E.

Sold by all Chemists and Druggists. 2*. 6<L a bon, stamp in cl ude d.

THE NATURAL MINERAL WATERS OF

ICHY

SPRINGS)

LVTZOW.-Bteh bottle from the STATE SPRINGS bean a neek label with the
_ word “ VICHY-ETAT,” and the name of the SOLE AGENTS:-

INGRAM & BOYLE, Ltd., 26 Upper Thames Street, E.G.

And at LIVERPOOL and BRISTOL.

■ample# and Pamphlets fr— to Mwntura of the Modleal profession on Application.

M NO BETTER FOOD."

MATLOCK BATH.

OR. ANDREW WILSON. F.R.S.E.. As

ROYAL HOTEL AND BATHS.

FRY’S

Pure Concentrated

Cocoa

“The most Perfect Form of - ocoa.

— Guv's Hospital HnxetU

ANGO Dl BATTAGLIA *5

m attain. Halation, Neuritis, and Marvoaa Dlaardara.

Four-Cell, Radiant Heat, “ X ” Rays, &c. Massage.
AU the Bath) are in the Hotel, and are directly accessible
by Lift. Resident Physician. An IDEAL WINTER
HOME, being sheltered from north and east winds.

With the famous Thermal Spring, noted for its ant¬
acid properties and efficacy in the cure of Goat, Rheu¬
matism, and Kindred Ailments, Continental Baths in
periection, including Turkish, Nauheim, Carbonic Acid,
Vichy, Aix, &c. Electric Treatment: High Frequency,
WEIR MITCHELL TEEATMBNT.

The Hotel it conducted on the best Continental lines. It U situated
in the most beautiful and sheltered spot In Derbyshire, in grounds or
over 20 acres. Milanese Orchestra, conducted by Prof. Avanxi, plays
twice dally. Golf, Badminton, FUhing, Coaching, Billiard*. Accom¬
modation for Motor*. Full Particulars from the Manacer

MEDICAL LOCUM TENENS.

MEDICAL PRESS ft CIRCULAR, 18 Nassau Street, DUBLIN.

Gentlemen requiring s Locum Tenens would act advisedly by
oonunnnioeting with more than one applioaat and selecting the
most suitable.

Please address as followsX, 21, or X. 22 (as the esse may
be). 18 Nassau Street, Dublin.

Subscribers plsoed on Register free of charge. Non-

Subscribers charged a nominal fee to merely cover expenses.

It Is particularly requested that all appointments will b# duty
notified to the registrar.

GENERAL 6

Established 1862 at Henrietta Street, Covent Garthm.
Thoroughly experienced Hoepital - trained MPBBM

NURSING ‘TET

Also, specially-trained NURSES for Mental and Nerve Caaea.
Worked under the system of Co-operation.

JSSSL ASSOCIATION.

Telegrams: "Nutria London." Telephone,PaddingtonH.

Digitized byLjOOgle

CANNES

BOTBL OOSTTINBirTAli.

Superb Centre! Situation. Exquisite Panorama of Bar, Maude, and Mountains. Most
Comfortable Winter Home. Electrie Light In every room. Aacensew. Unquestionable
Sanitation. Moderate Term a. Special Pension Terms Not. to Jan. 10th.

Renovated thro ugho ut, and re-opened under the peraonal Management of the
new Proprietor, Mr. HENRY ROST.

INNSBRUCK.-

llluttraUd Pamphlet lent free on application,

“An Ideal Winter Home" Invigorating. Dry. Sonny. 1,920 feet Altitude
Sheltered from North and Baft Wind*. Equable Temperature. Free from fogs
For Health. Pleasure, and Bdncatlosal Advantage! this Town la Unique.
University ; Schools; Medical College ; English Ctiuroh : Theatre; Military Mnslo and
Balls; Skating-Rink; Curling; Tobogganing ; Sleighing ; Numerous Excursions.

HATVI TIDAf- _Breir Home Comfort Electric-Light. Lift Bath. Conversation.

UV1CI/ linVL, Reading and Smoking Salons. CARL LANDBKE, Proprietor.
Very moderate Pension Terms for Families and lor Winter Residence.
English Church Services.

89CE:

HYDROPATHIC ESTABLISHMENT,

MATLOCK, DERBYSHIRE.

Established 1863.

Piuiiwnu/C. R. HABBIN80N. M.B., B.Ch., B.A.O. (R.U.I.)
FAynmntj^ Mac lrllAnd. MJ)., C.M. (Edin.)

A complete snlte of Baths, including separate Turkish and Russian
Baths for Ladles and Gentlemen, wnioh are specially adapted In
ventilation and otherwise to the requirements of Invalids; Alx
Douche, Vichy Douche, and an Electric Installation for Baths and
Medical Purposes. Dowsing Radiant Heat D’Arsonval High Fre¬
quency. Rontgen X Rays. Fango (Mud) Treatment. Nauheim
Baths. Special Provision for Invalids. Mila from own Farm. Large
Winter Garden and extensive Pleasure Grounds commanding lovely
views. American Elevator. Electric Light Night Attendance. As
a Winter Residence this place is specially adapted, affording warm
and well-ventilated Pnblic Rooms, Bedrooms, and Corridors. Mas¬
sage and Welr-Mitehell Treatment. A large staff (upwards of 60) of
Trained Male and Female Nurses, Masseurs, and Attendants.

Matlock Golf Links, 18 holes, within about fifteen minutes’ walk.
Prospoctns and fall information on application to the
Managing Director.

Telegram t: " Sued ley’s, Matlock Bask." Ttlephone No. 17

Oftho HlghMt Renown.
In Boat Position.

Entirely Comfortable.

Fixed Frioea.

•• NUEL.LE.NS HOTEL ”

Opposite the EUseabrunnea. Completely Renovated.

AIX-LA-OHAPILLK (Aaohon).

It HEM ML, Proprietor.

Uadar seme management and In conjunction with 0 Bath Hotels
and Dependences—

Kilserbad Hotel, Henbad Hotel. Qnirinnsbtd Hotel.

Rooms from S marks, and in Ddpendanoe from 2 marks.
Psnslon. 1 Deluding rooms, from S marks, and in Dtpendanoa
from <| marks.

Putin Ratii i i ft edition of “Murray’s

PlMIIRUlBt I ICT edition of “ Murray's

. u,r 1 ■ Handbook":—

fir lleotrloLight “This boUl, fa

na.tr*! Hoe*mm **" b< * 1 situation,
finaafa Central Heating, y reoommended as

Klr-SUVllS. Large Cardan, capital.’’

The combination of these four splendid Hotels in one pr op rietor-
ship guarantees to visitors unrivalled advantages.

Extract from Ulh
edition of "Murray’s
Handbook" :—
“This hotel, fa
the best situation,
la reoommendod as
capital."

ROYAL COLLEGE OF SURGEONS OF

ENGLAND.

The Office of Conservator of the Museum of the College having
become vacant, the Council invite Candidates for the appointment to
transmit to the Secretary of the College, on or before the 1st of
FEBRUARY, 1908, their applications acoompanled by a statement of
their qualifications.

Pat tlculars relating to the appointment may be obtained on appll-
tion to the Secretary.

8. F0RRE9T COWELL,

20th December, 1907. Secretary.

IpOR Varicose Veins A Weakness, ./

* SURGICAL ELASTIC STOCKINGS and Av. J
KNEE-CAPS, pervious, light In texture, and IN- »/ ^

EXPENSIVE, yielding an efficient and unvarying
support under any temperature, without the trouble
of lacing or Bandaging. Likewise a strong low- vpn
priced article for Hospitals and the Working Classes. .1 1

ABDOMINAL SUPPORTING BBLT8, ttioe# for f r-1

Ladles' use, before and after aooouchement, an 1 /
admirably adapted for giving adequate support with l §
xxTBUMi LiQHTHBSS'-a point hitherto little attended I)—i

to. X* 1

Instructions for Measurements and prtoes on an- X \\
plication, and the art Idea sent by poet from thi^L i ~ f
Manufacturers, "

m > j V.

Vs't V 3

Telephone 99*7 Mayfair,

Hosiers by appointment to the late Queen Victoria,

42 OLD BOND 8TREET, LONDON. W

The Profession, Trade, and Hospitals are supplied.

DISPENSING BOTTLES.

THE HOSPITAL FOR SI0K CHILDREN,

GREAT ORMOND STREET, LONDON, W.C.

A CASUALTY MEDICAL OFFICER is required on the 3rd of
January, 1608. Candidates must be registered practitioners, w
invited to send in their applications, addressed to the Secretary,
accompanied by not more than three testimonials given speolally for
the purpose, on or before 12 o'clock, on Wednesday, the 1st January,
1906. Tne appointment is made for one year, but may be held subject
to annual re-election for a period of not more than three years. The
appointment is non-resident. Salary, £200 per annum, with lunch.
All candidates must appear before the Joint Committee at their
meeting on Thursday, the 2nd January, 1008, at 6 p.m. precisely.
Forms of Application and opyof rules may be obtained from the
Secretary.

By Order of the Committee of Management,

11th December, 1907. STEWART JOHNSON, Secretary.

POOR LAW MEDICAL OFFICERS-LOCUM

TENKNS.—Medical Officers seeking temporary substitutes, or prac¬
titioners willing to act aa such, are requested to make application to
tbe Locum Tenons’ Registrar, Dublin Office of tbe M9M0AL Press,
18 Naswu Street, Dublin,

■peolssl Motlow, Hednoed Pvloes,

S and 4 ounoe, plain nr graduated, 7s. fid. per gross.

• and 8 I. j, ,■ 8a. fid. ,, ,,

The above can be bad washed and Coxfeed. ready for use, la. per
gross extra. They are the Improved shape with rounded edgee.

PLEASE NOTICE.—We now make a New Improved 8bape Dispens¬
ing Bottle. We call them “ The City Shape.” A sample sent free on
application.

White MeeMed Phials, Plata ar Bradaated Teaapeena

i ounoe and under.Is. 9d. per gross.

1 „ ..4a. 3d. „

i* » ••• ~ . £}’ ” *»

2 if see see see see W. W- It It

Superior Quality Corks (we Import them direct from Spain) for 8
and 8 ounoe bottles, lOd per gross; for vials, 9d. per groes.

I. ISAACS A CO., Blau Battle Manofaetnrers

106 Midland Road, St. Futons, London, N.W.

Established 80 Yean.

SAL HEPATICA

EFFERVESCENT SALINE LAXATIVE.

URIC ACID SOLVENT.

A combination of tbe Tonic, Alterative
and Laxative Salts similar to the celebrated
Bitter Waters of Europe, fortified by the
addition of Lithia and Sodium Phosphate.

It stimulates the liver, tones Intestinal
glands, purifies alimentary tract, improves

digestion, assimilation, and metabolism.

Especially valuable in Rheumatism,
(lout. Bilious Attacks, Constipation.

Most efficient in eliminating toxic pro¬
ducts from intestinal tract or blood, and
correcting vicious or impaired functions.

Write for free sample.

BRISTOL-MYERS CO.,

977-079 Orsons Avsnus.
j Brooklyn. Now York, U.I.A.

On sale by Jobbers and Thomas Christy A
Co.,4, io * is, Old Swan Lane, Upper
Thames St„ Loudon, Eng.

Google

CX11

Trie Medical Press and Circular

Dec. 26,1907

37, LOMBARD STREET, LONDON.

L'nitep bTATts : — Niagara falls, N.V.
Canada :— Gcrrard St. East, Toronto.

Australasia:— Bridge Street, Sydney.
South Africa Castle St., Cape Town.

___ J—

■ ted for tf»« Propnetot. and Published every Wednesday morning by ALBKitT ALfHKD Tindall, 8 Henrietta Street, Cov*®t°* rt

Dublin: Hanna <fe Neale, 18 NssaanStreet,

Digitized by LrOOgTej

A Sample Bottle will be sent Free to Medical Men on request.

ALLEN & HANBURYS Ltd.,

B YNIN-AMARA is an analogue of Easton’s Syrup, in which the
sugar is replaced by an active Malt Extract. This affords a far
better vehicle than syrup, as it is actively digestive and nutritious,
and there is not the likelihood of the sugar crystallizing out, and carrying
down in the crystal the alkaloidal principle.

As a digestive tonic therefore BYNIN-AMARA is not only safer
to take than Easton's Syrup, but is of greater value both in aiding and
strengthening the powers of assimilation.

It has been found very effective in neuralgia and similar nerve
troubles.

COMPOSITION

Quinine Phosphate - - - U grains.

Iron Phosphate 2 ,,

Nux Vomica Alkaloids equal to

Strychnine - - - jV, ,,

Bynin, liquid malt ... 1 ounce.

Dose for Adults. —One table-spoonful suitably diluted.

a-